Recommended Strategies to Reduce Sodium Intake and to Monitor Their Effectiveness
This chapter identifies strategies to address the goal of reducing the intake of sodium to levels consistent with recommendations in the Dietary Guidelines for Americans. The primary strategies focus on the U.S. food supply as defined and described earlier. The strategies are predicated on the understanding that (1) a majority of Americans’ sodium intake is derived from processed and restaurant/foodservice foods, making reductions in the overall sodium content of the food supply needed to facilitate meaningful reductions in intake, and (2) a broad effort carried out as a gradual and stepwise process will be most successful. Consumers must be assisted in playing a role to reduce their sodium intake, but their ability to meaningfully reduce it will be limited without changes in the food supply.
Further, these primary strategies are based on the recognition that a significant amount of sodium in the American diet is contributed by foods eaten in restaurants and other foodservice operations, thereby requiring a combined effort focused not only on the processed foods purchased by consumers, but also on foods offered to consumers by restaurant/foodservice operators. The strategies address salt (sodium chloride) added to foods by food manufacturers and restaurant/foodservice operators, as well as other sodium-containing compounds added to foods. Interim strategies are also identified and are intended to assist with efforts to reduce the sodium content of the food supply during the time needed to implement the primary strategies.
While efforts to reduce the sodium content of the food supply can result in considerable progress toward reducing sodium intake, supporting strategies are needed to ensure that consumers achieve current recommendations.
Supporting strategies target a range of stakeholders and serve to underpin and augment the primary strategies. Strategies related to monitoring and surveillance are also included so that essential data about sodium intake, salt taste preference, related consumer knowledge and attitudes, and the sodium content of the food supply are available.
RECOMMENDATION 1: The Food and Drug Administration (FDA) should expeditiously initiate a process to set mandatory national standards for the sodium content of foods.
Strategy 1.1 FDA should modify the generally recognized as safe (GRAS) status of salt added to processed foods in order to reduce the salt content of the food supply in a stepwise manner.
FDA should expeditiously undertake regulatory activities to establish conditions of use for salt in processed food to assist in achieving population intakes of sodium that are consistent with the Dietary Guidelines for Americans. The justification for modifying the GRAS status of salt is based on changes in the body of evidence for the health effects of salt that have emerged since it was first recognized as GRAS in 1959.
Reductions in the levels of salt added to foods under the modified GRAS provisions should be accomplished in a stepwise manner to allow time for adaptation of consumer taste preference for salt added to foods and for industry to deal with technical challenges. Moreover, specific and extensive ongoing monitoring is needed to further inform the stepwise process. Implementation of new provisions for the GRAS status of salt should include initial analysis and data gathering by FDA in collaboration with stakeholders. The decisions made should be transparent and science-based. The available array of options for implementation should be considered; special labeling/disclosure statements or informational labeling regarding sodium content, if appropriate, should be incorporated into the implementation process.
Strategy 1.2 FDA should likewise extend its stepwise application of the GRAS modification, adjusted as necessary, to encompass salt added to menu items offered by restaurant/foodservice operations that are sufficiently standardized so as to allow practical implementation.
The significant contribution to sodium intake made by restaurant/foodservice menu items warrants targeted attention to this sector of the food supply. The strategy is based on the application of the Federal Food,
Drug, and Cosmetic Act to foods whose components have moved in interstate commerce, thus making the food item subject to the same standards relevant to processed foods. The implementation activities outlined for modification of the GRAS status of salt for processed foods, as well as the process for determining the modification, should apply equally to standardized restaurant/foodservice operations.
Strategy 1.3 FDA should revisit the GRAS status of other sodium-containing compounds as well as any food additive provisions for such compounds and make adjustments as appropriate, consistent with changes for salt in processed foods and restaurant/foodservice menu items.
Given that sodium can be added to foods in ways other than by the addition of salt, it is important for FDA to consider these other sources of sodium, take into account their approved conditions of use and function in food, integrate their presence in the food supply into the considerations for modifying the GRAS status of salt, and adjust as necessary the GRAS or food additive provisions for these sodium-containing compounds.
Voluntary approaches cannot serve as the main focus of future strategies, but may be useful until regulatory approaches can guarantee sustainable strategies. There are questions as to the levels of success that might be achieved in the interim on a voluntary basis. But given impending regulations and heightened attention to sodium reduction, interim strategies may achieve some success and inform the regulatory process.
RECOMMENDATION 2: The food industry should voluntarily act to reduce the sodium content of foods in advance of the implementation of mandatory standards.
Although the regulatory strategies identified above should be initiated immediately, as a practical matter the process of rulemaking requires time. The committee has therefore identified voluntary strategies that could achieve some reductions in sodium intake ahead of the implementation of mandatory standards for the levels of salt added to foods. While identifying these voluntary strategies as important interim steps, the committee underscores that experience would indicate that voluntary standards have not been sufficient to provide adequate breadth and sustainability to the reductions and do not offer the level playing field that is important to realizing meaningful sodium reduction in the food supply.
Strategy 2.1 Food manufacturers and restaurant/foodservice operators should voluntarily accelerate and broaden efforts to reduce sodium in processed foods and menu items, respectively.
Some food manufacturers and restaurant/foodservice operators are currently working to reduce the sodium levels in their food products and menu items. The pace and scope of such voluntary efforts should be continued and accelerated during the time mandatory standards are being established. Further, food manufacturers (including retailers with private label brands) and restaurant/foodservice operators who have not initiated such activities are encouraged to do so.
Such voluntary efforts at this time will help to ease the eventual transition to mandatory standards and also offer the opportunity to explore options and new technologies as soon as possible. Experiences gleaned from such activities can help to inform regulatory decision making as it progresses.
Strategy 2.2 The food industry, government, professional organizations, and public health partners should work together to promote voluntary collaborations to reduce sodium in foods.
Voluntary efforts operating under the auspices of government authorities as well as public health organizations are currently focusing on initiatives intended to reduce the levels of sodium in foods, often in concert with the food industry. Such public-private partnerships should continue during the time mandatory standards are being established. Again, the experiences gleaned from such public-private partnerships can inform the process of setting mandatory national standards.
RECOMMENDATION 3: Government agencies, public health and consumer organizations, and the food industry should carry out activities to support the reduction of sodium levels in the food supply.
The committee has identified strategies useful to supporting and enhancing the effort to reduce the sodium content of the food supply through modification of the GRAS status of salt. These strategies are directed to a range of stakeholders.
Strategy 3.1 FDA and the U.S. Department of Agriculture (USDA) should revise and update—specifically for sodium—the provisions for nutrition labeling, related sodium claims, and disclosure/disqualifying
criteria for sodium in foods, including a revision to base the Daily Value (DV) for sodium on the Adequate Intake (AI).
The current provisions for nutrition labeling, related claims about sodium, and disclosure/disqualifying criteria for sodium on the labels of food products were established at a time when less was known about how consumers effectively interpret and use label information and about relevant technologies and potential unintended consequences related to reducing sodium levels in foods. Overall, the existing regulatory provisions would benefit from review and updating as appropriate in order to provide useful information to consumers and to enhance the food industry’s motivation to reformulate foods relative to sodium content. It is anticipated that such activities would be undertaken through notice-and-comment rulemaking in a timely fashion. USDA should move forward with proposed nutrition labeling regulations for single-ingredient, raw meat and poultry to ensure that the sodium content—as would be relevant in the case of meat and poultry enhanced with sodium solutions—is made known to consumers. Similarly, FDA should review its approach to seafood labeling. Further, given a 2005 report from the Institute of Medicine that identifies an AI for sodium—a reference value that had not been established at the time the current regulations for nutrition labeling were finalized—the AI should serve as the basis for the Daily Value for sodium, a component of the Nutrition Facts panel on foods. The AI, from the perspective of public health, provides a truer picture for the consumer of the contribution of the particular food in assembling a healthful diet and is preferable to use of the Tolerable Upper Intake Level (UL). To avoid unintended consequences and disincentives to the food industry given this recommendation, the basis for claims related to “low sodium” and “very low sodium” is worthy of review.
Strategy 3.2 FDA should extend provisions for sodium content and health claims to restaurant/foodservice menu items and adjust the provisions as needed for use within each sector.
The Nutrition Labeling and Education Act established a framework for providing information about the nutrient content of packaged foods, but its provisions for nutrient-related food label claims were not specifically limited to packaged foods. However, in implementing the act, FDA limited its claims regulations to packaged foods. FDA should now undertake activities to provide for sodium content claims (e.g., low sodium, reduced sodium) and related health claims (e.g., “diets low in sodium are associated with a low prevalence of hypertension”) on menu items offered by restaurant/food-service operations that are sufficiently standardized for implementation to be practically accomplished. There will be a need for preliminary activities
to gather data and background information about restaurant/foodservice operations and to carry out the stakeholder dialogues that will be necessary to develop, and then implement, workable regulations for claims to be used in such operations.
Strategy 3.3 Congress should act to remove the exemption from nutrition labeling for food products intended solely for use in restaurant/foodservice operations.
Currently, U.S. law1 exempts products intended for restaurant/food-service operations from bearing nutrition labeling. If small as well as large restaurant/foodservice operators are to be encouraged to take part in efforts to reduce the sodium content of their products, information about the sodium content of the foods they acquire from their distributors is critical information.
Strategy 3.4 Food retailers, governments, businesses, institutions, and other large-scale organizations that purchase or distribute food should establish sodium specifications for the foods they purchase and the food operations they oversee.
Groups that purchase large volumes of food products that in turn are either sold to others or served as part of a restaurant/foodservice operation can wield a powerful tool when they set the specifications for products they will purchase and foods served by operations under their authority. Specifically, the nutrition specifications for foods procured are likely to provide incentives for food manufacturers to develop or offer lower-sodium foods, especially given the high levels of procurement expenditures. Further, specifications for the use of sodium in foods served can ensure that foodservice staff will not add excess sodium. Federal, state, and local governments all have the potential to create sodium specifications for foods purchased or served in their facilities or through their programs. Relevant programs include the federal school lunch and breakfast programs as well as the military. To some extent the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) may also be useful to drive change through the use of incentives for participants to purchase lower-sodium food products. State and local governments are also large-scale procurers of foods and can be instrumental in this strategy. Further, food retailers can assist in
lowering sodium intake through their procurement and product display practices.2
Strategy 3.5 Restaurant/foodservice leaders in collaboration with other key stakeholders including federal, state, and local health authorities should develop, pilot, and implement innovative initiatives targeted to restaurant/foodservice operations to facilitate and sustain sodium reduction in menu items.
Past sodium intake reduction efforts have placed limited focus on restaurant/foodservice operations compared to the processed food industry. Further, consistent with Strategy 1.2, it is not likely that all restaurant/foodservice operations will be subject to mandatory standards for the addition of salt to menu items. While the entire restaurant/foodservice industry will be positively impacted by the advent of mandatory standards, there is a need for additional initiatives to broadly assist the industry in reducing sodium. Since few attempts have been made to reduce sodium in restaurant/foodservice menu items, restaurant/foodservice leaders working in public-private partnership should introduce pilot programs designed to assist operators in reducing the sodium content of menu items, which, in turn, could be widely implemented when shown to be effective. Such programs may include training of both existing and new restaurant/foodservice personnel, support for menu and recipe reformulation, programs to encourage social responsibility, the introduction of voluntary standards, and, as appropriate, local regulations for salt use or sodium labeling. Outreach may be particularly needed to reach independent restaurant/foodservice operators whose foods may not be fully reached by the GRAS modifications detailed in Strategy 1.2, and whose resources for educating workers and menu development activities may be limited.
RECOMMENDATION 4: In tandem with recommendations to reduce the sodium content of the food supply, government agencies, public health and consumer organizations, health professionals, the health insurance industry, the food industry, and public-private partnerships should conduct augmenting activities to support consumers in reducing sodium intake.
It is important to implement strategies targeted to consumers that will result in sustainable, diet-related behavioral changes through selection of lower-sodium foods, portion control, and other healthful food choices by
(1) increasing the consumer’s understanding of the value of reducing sodium for health throughout the lifespan because all groups are at risk; (2) increasing the consumer’s understanding of the ubiquitous nature of sodium in the food supply and the importance of supporting government and industry activities to reduce sodium in foods; (3) changing consumer attitudes toward, and perception about, lower-sodium foods; and (4) facilitating consumer understanding of the role of sodium reduction as part of an overall healthful diet for all life stage groups. While activities targeted to reducing the overall sodium content of the food supply will be primary in reducing the intake of sodium, they are unlikely to be sufficient by themselves. Consumers must also take personal action to reduce sodium intake. The consumer’s role in reducing sodium intake requires support through education, the development of tools to assist consumers, and the identification of strategies that lead to behavior change. Such efforts to reach consumers must be carefully planned with consistent overall messages that can also be tailored to the specific interests and dispositions of various subpopulations (including those at greater risk for developing hypertension, ethnic/cultural groups, and a range of life stage groups).
The following two strategies are key to accomplishing these goals.
Strategy 4.1 The Secretary of Health and Human Services (HHS) should act in cooperation with other government and non-government groups to design and implement a comprehensive, nationwide campaign to reduce sodium intake and act to set a time line for achieving the sodium intake goals established by the Dietary Guidelines for Americans.
A coordinated nationwide campaign to implement, manage, and sustain programs to reach consumers is a valuable component of the overall effort to reduce sodium intake among the U.S. population. While this campaign should be targeted to consumers, it is expected to be complementary to the activities to reduce sodium in the food supply and should include a focus to enlist consumer support for government and industry activities to reduce the sodium content of foods. Vesting specific authority and accountability for such activities at a high level within the federal government would result in the national leadership needed to reduce sodium intake and also foster linkage to health messages related to the Dietary Guidelines for Americans.
Moreover, it would be important to ensure that an informed, coordinated process is put in place to establish initial time lines and goals for the overall reductions of sodium intake and for carrying out the implementing tasks that are separate from those for reducing sodium in the food supply. In turn, there must be an active process and responsible authorities to monitor the goals and adjust them as needed while making efforts to maintain
consistent vocabulary, focus, and messages to avoid consumer confusion. This activity ensures that the goals remain viable and serves to stimulate the process by making implementers accountable. This activity should be done in close collaboration with FDA so that the overall time line for reducing sodium intake takes into account the regulatory approach and its related time line for reducing sodium in the food supply.
Strategy 4.2 Government agencies, public health and consumer organizations, health professionals, the food industry, and public-private partnerships should continue or expand efforts to support consumers in making behavior changes to reduce sodium intake in a manner consistent with the Dietary Guidelines for Americans.
The following programs and entities have the potential to reach consumers about sodium and hypertension and have the potential to be effective, especially through the use of public-private partnerships.
USDA: revision to the MyPyramid Plan for consumers to include sodium as an area of focus.
Centers for Disease Control and Prevention (CDC): expansion of the State Heart Disease and Stroke Prevention Program to address sodium intake reduction.
National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI): enhancement of the National High Blood Pressure Education Program to elevate the importance of sodium reduction in its professional and public education efforts and to emphasize research on informing and motivating consumers to reduce sodium intake.
Food industry (including manufacturers, retailers, and restaurant/foodservice operators): activities to support and distribute consumer educational materials about sodium intake and selecting diets lower in sodium.
Restaurant/foodservice operations: activities to improve the availability of sodium content information at point of purchase or point of consumption.
Public health, health profession, and consumer associations: activities to support and promote policy initiatives to reduce sodium intake among consumers.
Education for health professionals: training of new and experienced health professionals on the relationship between sodium intake and health and tools for reducing sodium intake as part of higher education curriculums and continuing education courses.
Health practitioners: commitment to incorporate guidelines on sodium intake into prevention messages and standards of care.
Health insurers: incorporation of key messages and efforts to change behavior into their disease management and health and wellness programs.
Schools: incorporation of messages on sodium and health into nutrition education curriculums.
RECOMMENDATION 5: Federal agencies should ensure and enhance monitoring and surveillance relative to sodium intake measurement, salt taste preference, and sodium content of foods, and should ensure sustained and timely release of data in user-friendly formats.
The importance of immediately beginning activities to determine the baseline levels of sodium intake through measurements of nationally representative 24-hour urine collections, to track the sodium content of processed foods and menu items through the creation of relevant databases, and to monitor changes in salt taste preference cannot be overemphasized. Current monitoring mechanisms are inadequate to track the progress of the recommended strategies and are not sufficient to satisfactorily elucidate the nature of the problem. Without access to reference data and data summaries in a timely and user-friendly manner, such monitoring and surveillance approaches cannot be checked or adjusted as needed. Additionally, as described in Chapter 10, research is needed to provide better tools for relevant monitoring and surveillance.
Strategy 5.1 Congress, HHS/CDC, and USDA authorities should ensure adequate funding for the National Health and Nutrition Examination Survey (NHANES), including related and supporting databases or surveys.
An adequate budget including resources to ensure enhanced design and content of the major federal dietary and nutrition surveys is important to the process of implementing and tracking strategies to reduce sodium intake.
Expanding and Enhancing Monitoring
Strategy 5.2 CDC should collect 24-hour urine samples during NHANES or as a separate nationally representative “sentinel site”-type activity.
Currently, collection and analysis of 24-hour urine provides the most accurate estimates of sodium intake and should be a component of national monitoring. Its inclusion in the national surveys will require pilot testing and innovative techniques. In addition, these surveys should continue to collect estimates of dietary sodium intake by multiple 24-hour recalls.
Strategy 5.3 CDC should, as a component of NHANES or another appropriate nationally representative survey, begin work immediately with NIH to develop an appropriate assessment tool for salt taste preference, obtain baseline measurements, and track salt taste preference over time.
Change in salt taste preference on a population basis is an important goal. However, salt taste preference has not been measured or tracked for the population. It is important to immediately initiate activities to develop and, in turn, incorporate these measurements into national surveys to establish baseline measures and to conduct ongoing monitoring.
Strategy 5.4 CDC in cooperation with other relevant HHS agencies, USDA, and the Federal Trade Commission should strengthen and expand its activities to measure population knowledge, attitudes, and behavior about sodium among consumers.
Monitoring changes in consumers’ (1) understanding of the importance of reducing sodium intake, (2) ability to estimate sodium intake, (3) intention to reduce sodium intake, and (4) related attitudes and behaviors is needed to evaluate the effectiveness of health communication strategies and to make the necessary adjustments in the related national initiatives to reduce sodium intake.
Strategy 5.5 FDA should modify and expand its existing Total Diet Study and its Food Label and Package Survey to ensure better coverage of information about sodium content in the diet and sodium-related information on packaged and prepared foods.
Continuous and systematic market basket and labeling studies of the food supply that incorporate approaches relevant to sodium are important and efficient components of monitoring sodium content and the related labeling of foods.
Strategy 5.6 USDA should enhance the quality and comprehensiveness of sodium content information in its tables of food composition.
The accuracy, detail, and timeliness of food composition databases are essential for measuring sodium intake from dietary studies.
Strategy 5.7 USDA in cooperation with HHS should develop approaches utilizing current and new methodologies and databases to monitor the sodium content of the total food supply.
Current databases should be enhanced to more completely assess and track the sodium content of products in the food supply, including processed foods and restaurant or foodservice menu items; they should also be updated with sufficient frequency to allow monitoring and assessment of the stepwise process.