July 2010 Issue

Salt Talk — Experts Call for Acceptable Sodium Levels in Foods
By Maggie Moon, MS, RD
Today’s Dietitan
Vol. 12 No. 7 P. 32

As one of the most pervasive ingredients in products today, salt is the subject of much scrutiny. Public health-minded professionals will be interested to learn about strategies to minimize intake.

Any dietitian worth her salt knows the public health community is abuzz about, well, salt. It’s long been recognized that excessive salt intake is linked to high blood pressure and associated chronic diseases, a scenario that is all too common in the United States. According to Jane E. Henney, MD, chair of the Committee on Strategies to Reduce Sodium Intake at the Institute of Medicine (IOM), some analysts estimate that reducing sodium intake across the population could prevent more than 100,000 deaths annually. That’s why healthcare professionals, including RDs, have been working for years to help Americans lower their salt intake. What’s new is the recent momentum for prioritizing national, public health-minded initiatives to cut back on salt consumption.

“The evidence that Americans are consuming far too much sodium has been strong for at least four decades,” said Michael F. Jacobson, PhD, executive director for the Center for Science in the Public Interest, at the 2010 Nutrition Summit in Washington, D.C. “What's new is that industry's failure to voluntarily reduce sodium over that four-decade time span has become abundantly clear to everyone. Also, Congress and [the] Obama administration are sincerely concerned about public health (as well as reducing healthcare costs).”

In April, the IOM’s Food and Nutrition Board released a consensus report that was two years in the making: Strategies to Reduce Sodium Intake in the United States. That same week, New York City’s Department of Health and Mental Hygiene, one of the oldest and largest health agencies in the world, marked a milestone in its National Salt Reduction Initiative (NSRI), announcing final sodium targets for 2012 and 2014 and the 16 companies that have committed to meeting those targets.

On the heels of these two announcements, leaders from both projects provided context and insights into their work at the Nutrition Summit, cohosted by Health and Human Services (HHS) and the USDA. Attendees included RDs, medical doctors, researchers, academics, policy makers, and others from federal, state, and local government, private organizations, and industry.

RDs can leverage the goodwill and groundswell of support for sodium-reduction efforts to create and expand opportunities to do what they do best: help people eat more healthful diets.

IOM Report
In 2008, after four decades of less-than-successful voluntary efforts by food companies, Congress asked the IOM to recommend strategies for reducing sodium intake to levels in line with the Dietary Guidelines for Americans (ie, no more than 2,300 mg/day for people aged 2 and older, or about 1 tsp of salt per day) or even lower (to 1,500 mg/day for the 70% of adults who are older than the age of 40, are black, or have high blood pressure). In stark contrast, the average American consumes more than 3,400 mg/day of sodium, nearly 50% more than is recommended. Henney acknowledged that “it has to be very challenging for RDs to guide even their most motivated clients to cut the salt knowing what they’re up against in the food supply.”

Henney explained that the Committee on Strategies to Reduce Sodium Intake faced unique challenges in critiquing salt’s presence in the American diet. While salt has a beneficial role in a food’s flavor, safety, shelf life, texture, and functionality, its presence in the food supply is inescapable. For example, your clients may be surprised to learn that even foods that don’t taste salty, such as muffins and other bakery items, can have high levels of sodium. Henney noted that the biggest concerns about cutting salt content were altering a product’s taste profile and affecting its acceptability, major factors in the committee’s decision to recommend gradual changes.

Given the unique challenges and the chasm between recommendations and actual intake, the IOM committee’s call to action involves setting government standards for acceptable sodium levels in foods. “Dietitians and their organizations should support the Institute of Medicine's recent call for mandatory limits on the sodium contents of various categories of foods,” suggested Jacobson.

The IOM report emphasizes that to be effective, efforts among manufacturers, restaurants, and foodservice operators to reduce sodium levels must be coordinated so that all sources in the food supply are involved and consumers’ taste preferences can adapt over time to the lower amounts of salt in food. RDs know that individuals can adapt to lower sodium levels in their diet, so having the food industry gradually reduce the sodium content of foods in a way that is acceptable to consumers is a win-win.

The following are the IOM’s recommended strategies to reduce sodium intake:

• The FDA should set mandatory national standards for the sodium content in foods.

• The FDA should modify the Generally Recognized as Safe status of sodium compounds added to processed foods and set a threshold for a safe amount.

• Changes should be made gradually to allow for palate changes and acceptability.

• The efforts must be coordinated among stakeholders, including public health and consumer organizations and the food industry.

• Leadership at the national level should come from the HHS secretary in cooperation with other government and nongovernment groups.

• Additional influential players should include government agencies, public health and consumer organizations, health professionals, the health insurance industry, the food industry, and public-private partnerships.

• Sodium intake should be monitored so progress can be tracked and evaluated, with adjustments made along the way as needed.

Where the Rubber Hits the Road
One concrete idea discussed at the Nutrition Summit was a proposal to update the Daily Value (DV) for sodium used on the standard Nutrition Facts panel by setting it to the Adequate Intake of 1,500 mg/day. Adjusting the DV would mean changes to the standards for related FDA-approved claims such as “low sodium,” shifting the baseline of what those claims mean to a better, lower level of sodium across the food supply. In addition, experts suggested that Congress eliminate the labeling exemption for restaurant and foodservice foods.

The IOM report also identified areas of future research, which may offer research RDs an opportunity to contribute their skills and expertise. The research areas include understanding how salty taste preferences develop throughout the life span; developing innovative ways to reduce sodium in foods while maintaining palatability, physical properties, and safety; and developing a better understanding of what influences consumer awareness and behavior related to sodium reduction.

Concurrent with other efforts, the IOM recommends a national education campaign for consumers, another area in which RDs can get involved. Dietitians are well versed in the focus areas of the educational efforts, including behavior changes to reduce the risk of hypertension, promoting the benefits of normal blood pressure for all ages, helping clients become aware of the ubiquity of sodium across the food supply, and putting sodium in the context of an overall healthy diet. 

As the IOM report states, to be successful, there will be a role for coordination between the IOM, HHS, the Centers for Disease Control and Prevention, the National Institutes of Health, and the USDA as well as healthcare professionals, health insurers, schools, and the food industry. RDs in business and industry have a great opportunity to drive changes in the food supply. “RDs working in the industry have an incredibly important role to play,” added Henney. “Companies rely on the RD’s expertise and guidance to help their products fit the guidelines, so it’s important for dietitians to stay engaged and knowledgeable in this issue.”

Interim Strategies
The IOM assessment is that voluntary programs have not been effective in the past, which is why the committee is recommending a mandatory program to create a level playing field. The IOM does recognize the value of the food industry voluntarily acting in meaningful ways to reduce the sodium content of foods in advance of implementing mandatory standards. One program intending to stir voluntary action is the NSRI.

Also at the Nutrition Summit, Thomas Farley, MD, MPH, commissioner of the New York City Department of Health and Mental Hygiene, presented an overview of the NSRI. The initiative is modeled after a successful program in the United Kingdom, where they’ve seen more than 40% sodium reductions in some categories and daily salt intake has fallen from 9.5 g in 2000 and 2001 to 8.6 g in 2008.1

The NSRI’s goal is to lower salt intake by 20% over five years from 2009 to 2014. Members of the NSRI partnership include 18 national health organizations (eg, the American Heart Association) and 30 cities, states, and related entities that are working with food manufacturers and the restaurant industry to lower the salt levels in commonly consumed products.

“The National Salt Reduction Initiative has worked with a wide range of manufacturers, restaurants, and foodservice companies to develop targets based on industry feedback,” explained Christine Johnson, nutrition policy manager in the Bureau of Chronic Disease Prevention and Control at the New York City Health Department. “At many of the companies, a registered dietitian has been our key contact, providing information on the company’s overall nutrition efforts and specifically its work on salt reduction.”

The reason to target categories rather than individual products is that product offerings change; setting targets for categories means that food manufacturers will be motivated to improve their overall category of products (and be held accountable on the category level as well, whether individual products come or go). Further, targets are sales weighted, which means reducing sodium in more popular products will have a proportionate impact.

One reason the NSRI gives for targeting the entire food supply is that “excess sodium in our diets is not the result of a few extra-salty products, such as pickles or cured meat. A muffin can pack as much salt as a whole bag of potato chips. Cutting the sodium gradually in all of the foods we eat every day is the best way to get us all to more healthful levels.”  

Like the IOM committee, the NSRI members considered the important ways in which salt contributes to a food’s flavor, texture, consistency, and safety. The good news is that their research found that there’s a spectrum of sodium levels across successful products in a category, which shows plenty of foods sell at lower sodium levels.

Since the IOM recommendations are not yet regulations, the NSRI responds to the part of the IOM report that notes that public-private partnerships can “achieve meaningful reductions of sodium intake prior to the implementation of mandatory standards.” The FDA has also said voluntary programs are “very important to making progress on this public health issue.” Federal agencies are aware of and supportive of the NSRI.

NSRI members have set targets in 62 packaged foods categories and 25 restaurant foods categories, and they will measure these targets at 2012 and 2014 benchmarks through a public and transparent process. They’ll collect baseline data from companies in 2010 as well as baseline evaluations of sodium status through 24-hour urine collection of 1,856 people who previously participated in a New York City telephone survey and for whom other health information is on file.

Improve Awareness
Considering the trans fat/saturated fat issue, some may wonder whether a salt-reduction initiative will push manufacturers to replace salt with other less-than-desirable ingredients (eg, added sugars). The NSRI discourages replacing salt with other unhealthful ingredients and will monitor salt levels in addition to sugar, fat, and total calories in the food supply.

“Registered dietitians can continue to work closely with their patients and colleagues to improve awareness of the high sodium in packaged and restaurant foods and can instruct consumers to compare nutrition labels and choose lower-sodium items,” said Johnson.

Final Thoughts
One fundamental tenet of the NSRI is that “reducing the salt levels in packaged and restaurant foods will increase consumer choice. Anyone can add more salt at the table, but no one can remove what was added during production.”

Back in 1939, researcher Clara M. Davis, MD, taught those in the nutrition field that young children, left to their own dietary devices and given a nutritionally varied and generally wholesome array of choices, would thrive and be healthy. On a broader scale, a systems approach to improving the American food supply aims to generate the same end result. As RDs, our passion for helping people eat well and be healthy means we have a role to play in improving the food supply. When Americans have more healthful choices, they’ll find it that much easier to eat right.

— Maggie Moon, MS, RD, is a supermarket dietitian for FreshDirect in New York City, one of the companies that has joined the National Salt Reduction Initiative.

1. New York City Department of Health and Mental Hygiene. Cut the salt. Get the facts. The National Salt Reduction Initiative. April 2010. Available at: http://www.nyc.gov/html/doh/downloads/pdf/cardio/cardio-salt-nsri-faq.pdf. Accessed May 3, 2010.

Resources for Healthcare Professionals
• Institute of Medicine’s Strategies to Reduce Sodium Intake in the United States: http://books.nap.edu/openbook.php?record_id=12818   

• National Salt Reduction Initiative: www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml

• Health and Human Services Communities Putting Prevention to Work: www.hhs.gov/recovery/programs/cppw/factsheet.html