Strategies to Reduce Sodium Intake in the United States (2010) / Chapter Skim
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8 Committee's Considerations and Basis for Recommendations
8 Committee's Considerations and Basis for Recommendations
Pages 235-284
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From page 235... ...
Next, the committee considered the array of factors outlined in Chapters 4 through 7 ranging from the functional effects of sodium in foods to the food environment to regulatory options. The goal was to examine the lessons learned from past and current efforts to reduce sodium intake within the context of the available information about important factors in considering strategies to reduce sodium intake.
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From page 236... ...
Efforts to put in place point-of-purchase information about the sodium content of foods and to encourage the food industry to voluntarily reduce the sodium content of foods were included as adjunct activities to assist consumers. Given that sodium intake estimates from national surveys beginning in 1971 have not shown a decline, and suggest that sodium intake has increased, the goal has not been achieved.
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From page 237... ...
Table 8-1 lists some examples of related comments from study authors. Despite long-standing efforts by government, public health groups, and food industry leaders to encourage reformulation of foods to lowersodium content and thus reduce sodium in the food supply, the U.S.
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From page 238... ...
, discussions among food industry panelists suggested that a 10–20 percent reduction in sodium for some products was a realistic estimate, but there are also reports that a few products may have achieved a 50 percent reduction in sodium while others achieved reductions smaller than 10 percent.1 While such information is generally encouraging, the overall picture for the United States reveals little success for the industry as a whole. Even though there is evidence of efforts to reduce sodium in some food products on the part of larger food processors and a few restaurant chains, meaningful overall reductions in the food supply have not been accomplished.
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From page 239... ...
An important consideration is that while the preference for salt taste, if not addressed, will be a barrier to success in lowering the sodium content of the food supply, salt taste preference is mutable and can be lowered. The preference for salt beyond physiological need may be due to evolutionary pressures to consume salt that have shaped an innate liking for its taste, or, alternatively and perhaps concomitantly, be due to learning, particularly early learning.
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From page 240... ...
High levels of salt in the food supply can reinforce the preference for salt taste. Finally, point-of-purchase information about the sodium content of foods has been the third prong of national public health initiatives.
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From page 241... ...
. At least one current voluntary initiative in the United States addresses the sodium content of the food supply.
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From page 242... ...
• Food industry efforts to voluntarily reduce the sodium content of the food sup ply face technological challenges, are not consistently undertaken by all, are difficult to sustain on a voluntary basis, and in the aggregate have not resulted in overall success. • Food manufacturers and restaurant/foodservice operators face challenges in marketing lower-sodium foods in the context of the current food supply because such foods may be considered less palatable than higher-sodium competitors; it is known that food taste is a major determinant of food choice.
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From page 243... ...
CONSIDERATIONS AND BASIS FOR RECOMMENDATIONS TABLE 8-2 Overview of Initiatives in Other Countries Requests to Industry Public for Sodium Food Country Education Reformulation Labeling Comments About Program Canada Yes Yes Voluntary • Early voluntary reductions by food industry combined with public education and labeling had no impact on sodium intake from processed foods • Too early to assess Finland Yes Yes Mandatory • Government regulation and implementation of food labeling with high-sodium-content warning • Strong media campaigns to increase public awareness • Much sodium intake under control of consumer (salt at table) • Replacement of usual salt with potassium-enriched Pansalt • Sodium intake decreased from 5,600 mg in 1972 to 3,200 mg in 2002 • Blood pressure and stroke mortality rates declined France Yes Yes Voluntary • Efforts initiated in 2004 • Optional sodium labeling being developed • Limited public education in which sodium reduction is the main message; done through the National Nutrition and Health Program • Not much change to date except in the bakery sector, where 33% of bakers claim to have reduced sodium Ireland Yes Yes Voluntary • Collaborative program between pending government and industry to heighten industry's awareness about salt and health • Government seeks salt reduction commitments from industry sectors; more than 70 have registered • Working on voluntary universal labeling of salt in packaged foods • No intake data available post-implementation continued
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From page 244... ...
. The UK effort at present is an entirely voluntary activity that relies on the impact of strong messaging from public health authorities, highly targeted and specific messages to the population, and highly visible efforts to enlist industry involvement and cooperation.
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From page 245... ...
In 2003, Ireland began its work with a program intended to raise the food industry's awareness about the relationship between salt and health, and to work with the industry to voluntarily reduce sodium levels in foods. The Irish government reports that 72 companies have registered with the program, and reductions of approximately 20 percent in the sodium content of key foods such as breads and sausages have been reported.
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From page 246... ...
These include agricultural subsidies for foods with lower sodium, tax incentives for production of lower-sodium foods, a salt tax on foods with higher sodium content, and a cap and trade system for salt or sodium. Although each of these possible approaches has the potential to reduce sodium intake, these may not be fine-tuned enough to reduce sodium intake or may be burdensome and costly relative to the potential reduction of sodium intake.
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From page 247... ...
. It has been suggested that income tax incentives could be provided to food manufacturers for producing lower-sodium processed foods and to restaurant/foodservice operators for providing lower-sodium menu items.
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From page 248... ...
Furthermore, food manufacturers and restaurant/foodservice operators that can most easily reduce the sodium content of their foods are likely to do so, with the result that this strategy might achieve reductions only in some foods offered in some locations. In other words, tax incentives may not result in broad sodium intake reduction across the population.
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From page 249... ...
Food manufacturers would have to determine how to produce foods given their allocation of sodium credits, or they would have to purchase sodium credits from those manufacturers that can more easily reduce the sodium content of their foods. Thus, a cap and trade system could lead to reformulation of existing food products; development of new, lower-sodium foods; or 5 Ibid.
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From page 250... ...
Setting a cap for sodium would also be difficult because the optimal quantity of sodium credits would vary over time depending on the size of the population and demographic shifts that may be difficult to predict. Thus, for all of the reasons stated above, the costs of developing, implementing, and monitoring a successful cap and trade system for sodium undercut the ability to justify uncertain reductions in the sodium content of the food supply.
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From page 251... ...
The possibility of modifying the size and structure of salt particles holds some promise. Use of sea salt to replace regular salt is an emerging interest in the food industry that could be of value to food formulators and chefs to assist in reducing the sodium content of some foods perhaps in part by enhancing overall flavor.
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From page 252... ...
Further, the differences in sodium content of similar foods, as outlined in Chapter 4, suggest that there is some flexibility for the food industry in meeting safety and functional needs for sodium, although this is likely to vary depending upon product type and conditions of food manufacture. As with salt substitutes, technological advances to reducing sodium while maintaining food safety and physical properties may have an associated cost and therefore may be more responsive to policy/regulatory changes or increased consumer demand.
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From page 253... ...
• A mechanism to reduce sodium in a gradual, consistent manner across the food supply to allow for changes in consumer taste preferences. • A sustainable approach that will maintain sodium reductions over time.
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From page 254... ...
While there is an inevitable tension between wanting to move quickly to protect public health and moving more gradually with informed decision making, it is evident that the only viable approach is a gradual, universal reduction if a sustained reduction consistent with achieving the goals of the Dietary Guidelines for Americans is to be accomplished. If initiated judiciously as part of an informed process, monitored extensively once implemented, and adjusted as needed, standards set for the levels of salt across the food supply should reduce sodium intake.
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From page 255... ...
To initiate it will require considerable information gathering, detailed input from stakeholders, in-depth analysis of the food supply, use of simulation modeling of the effect of different levels of sodium content on total intake, examination of consumer eating behaviors, adjustments for food safety concerns, and studies of economic impact and potential unintended consequences. To ensure its success and responsiveness to emerging realities, extensive ongoing monitoring will be needed.
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From page 256... ...
The acquired taste preferences for high-sodium diets would be gradually reduced in conjunction with decreases in the salt content of foods across the food supply. Additional support for a stepwise approach has been provided by several food manufacturers that reported successfully using this strategy in their products at the committee's public information-gathering workshop (March 30, 2009)
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From page 257... ...
Establishing Ongoing Ealuation to Further Inform the Stepwise Approach An identified plan for and rigorous use of ongoing monitoring and evaluation system are central to the success of using standards for the sodium content of foods to reduce the overall intake of sodium. They will be critical to the success of the initiative.
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From page 258... ...
Comment New technologies Rulemaking Monitoring of intake Monitoring of changes in salt taste preference Monitoring of sodium in food supply/food composition Monitoring of use and consequences of any labeling Step-down 1 Monitoring of industr y activities First Monitoring of related concerns; for example, iodine and Step-down potassium status Step-down 2 Evaluation* (Adjustment)
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From page 259... ...
Restaurants/Foodserice Operations The evidence that restaurant/foodservice operations contribute significant amounts of sodium to the American diet (see Chapter 5) means that efforts to reduce the overall sodium content of such foods should be consistent with activities pertaining to the rest of the food supply.
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From page 260... ...
However, strategies can be adopted to promote sodium reductions in the menus and menu items of small and non-standardized restaurant/ foodservice operations. Since many of these types of operations use preprocessed foods to reduce preparation time, standards for salt addition to these foods would have an impact on the final sodium content of menu items as served.
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From page 261... ...
On this basis and with recognition that many implementing issues would need to be addressed, there is considerable benefit to be gained by considering restaurant/foodservice menu items, particularly for heavily standardized operations, in the establishment of GRAS standards. While it must be recognized that such activities would be challenging and will undoubtedly require considerable analysis as part of a public process carried out by FDA, the facts regarding the contribution made by foods eaten away from home to total dietary intake are concerning and point to the clear need to extend efforts to reduce the sodium content of the food supply to restaurant/foodservice operations.
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From page 262... ...
While it is clear that much of the sodium added to foods comes from the addition of salt, it is not clear how much sodium is attributable to these other compounds and whether their contribution to total sodium intake has increased. Therefore, it would be important for FDA to closely examine these other sources of sodium, take into account their conditions of use and function in food, and in turn integrate their presence in the food supply into considerations for reducing the overall sodium content of the food supply and achieving sodium intake consistent with the Dietary Guidelines for Americans.
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From page 263... ...
State and local governments, health professionals, educators, the media, private foundations, corporations, and the food industry all have a role to play. Important goals include building on existing knowledge, obtaining new information through research, and seeking input from other fields of study in order to build a basis upon which to design effective programs to assist consumers in better navigating and supporting changes in the food environment to reduce sodium intake.
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From page 264... ...
Behaior Change Consumer-based initiatives to reduce sodium intake could benefit from the incorporation of behavior change models. The socioecological model provides a useful framework exploring the interacting multiple levels of influence and underscores the need to coordinate changes in the food environment, including changes in the food supply, with health communications aimed at individuals.
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From page 265... ...
While messages should be consistent, tailoring messages to the behaviors and interests of specific cultural groups and dispersing these messages through communication channels that are known to reach specific groups may also be beneficial. It is likely that the focus of coordinated messaging should extend beyond developing specific messages for sodium by integrating the issues important for sodium intake reduction into existing, broad messages about diet and
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From page 266... ...
The National Heart, Lung, and Blood Institute (NHLBI) is probably the agency most readily recognized as a federal leader in the area of dietary sodium reduction.
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From page 267... ...
recommended that CDC's Division of Heart Disease and Stroke Prevention take active leadership in convening other partners in the federal, state, and local government, and industry, to advocate for and implement strategies to reduce sodium in the American diet. That committee also recommended that all state and local public health jurisdictions immediately begin to consider developing a portfolio of dietary sodium reduction strategies that make the most sense for early action in their jurisdictions.
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From page 268... ...
that past attempts to promote low-sodium food lines have been less than successful, leading some companies to refocus their efforts on "silent" (unadvertised) sodium reduction.
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From page 269... ...
. • Use of the AI could better inform consumers of the actual contribu tion of sodium content to total sodium needs as an essential nutri ent and avoid misleading consumers into thinking that the sodium content of foods is more favorable than is actually the case.
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From page 270... ...
Producers, wanting to appeal to concerned consumers, would have incentive to lower sodium in their products so that the Nutrition Facts panel would show the product to have a lower contribution to daily intake. Overall, such changes could have a dramatic impact on the food supply even if it would raise challenges for making "low" sodium claims on a certain number of products.
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From page 271... ...
One potential obstacle to making nutrition labeling, and specifically sodium labeling, possible for all restaurant/foodservice establishments is a nutrition labeling exemption for products distributed only to restaurant/ foodservice operations. Requiring nutrition information on foodservice products would both help all restaurants in providing sodium information to consumers and help establishments monitor and lower the sodium content of their menu offerings.
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From page 272... ...
In turn, it was anticipated that manufacturers would be incentivized to reformulate foods to meet the standards for the claims. Failure to Use Claims It would appear that neither the call for the food industry to voluntarily reduce sodium intake nor the ability to make claims about the reduced levels of sodium in food products has seriously impacted the overall content of sodium in the food supply or the consumer's intake of sodium.
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From page 273... ...
Nonetheless, claims about the sodium content of food products implemented under the NLEA provisions in principle remain a helpful signal to consumers and should be a useful adjunct to stimulate food manufacturers to reformulate their products. The Grocery Manufacturers Association (GMA, 2008)
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From page 274... ...
. Food Safety Because salt and other sodium-containing compounds function as food preservatives, efforts to reduce their presence have the potential to impact the safety of the food supply.
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From page 275... ...
. Such testing is time consuming, requiring that adequate phase-in periods be provided to ensure that the push for a lowersodium food supply does not result in unintended food safety problems.
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From page 276... ...
population is challenging. Intake data are generally unreliable because they cannot accurately estimate the amount of table salt used by consumers, and information about whether iodized or non-iodized salt is used in food preparation at home or away from home is rarely captured in food composition databases or in dietary interviews.
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From page 277... ...
Therefore, if 5 percent of sodium in today's diet is assumed to be associated with iodized salt and the major sodium reduction strategies in this report are addressed to the sodium content of processed and restaurant/foodservice foods, it would appear that the recommended sodium reduction strategies would have minimal impact on iodine intake of the U.S. population.
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From page 278... ...
population, advocating for the greater use of potassium/sodium chloride combinations as a means of simultaneously reducing sodium intake and increasing potassium intake (IOM, 2010)
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From page 279... ...
Systematic monitoring of the food supply is essential for tracking the use of potassium chloride in foods and to monitor, and in turn mitigate, its ability to cause adverse health effects in those at risk. MONITORING The need for monitoring and surveillance is critical to establishing baseline data for and tracking the progress of strategies to reduce sodium intake.
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From page 280... ...
. It is desirable to explore new approaches for monitoring the sodium content of the food supply.
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From page 281... ...
2008. Salt taste.
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From page 282... ...
2008. Innovative regulatory approaches to reduce sodium consumption: Could a cap-and-trade system work?
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From page 283... ...
2009. Effective population-wide public health in terventions to promote sodium reduction.
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From page 284... ...
2007. Reducing salt intake in populations: Report of a WHO forum and technical meeting.
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