Strategies to Reduce Sodium Intake in the United States (2010) / Chapter Skim
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2 Sodium Intake Reduction: An Important But Elusive Public Health Goal
2 Sodium Intake Reduction: An Important But Elusive Public Health Goal
Pages 29-66
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From page 29... ...
Efforts to provide such point-of-purchase information relate to both the consumer-oriented strategies and the supporting strategies associated with voluntary changes in the food supply. That is, nutrition labeling -- which includes information about sodium -- is intended to assist consumers at the point of purchase; the ability to make claims on food labels about the sodium content of the product was historically viewed as providing an incentive to the processed food industry to voluntarily reformulate its food products, while at the same time informing consumers at the point of purchase.
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From page 30... ...
. These initiatives have ranged in scope from sweeping national dietary recommendations and goalsetting activities to fact sheets for consumers and health professionals, to calls for food industry and government actions to create or alter policies that might help to reduce sodium intake.
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From page 31... ...
More recently, scientific reviews, recommendations about sodium reduction, and auxiliary outreach activities have been part of the 1997 and 2003 activities of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Partnerships with state, local, and community-based organizations formed the basis for the recent development and dissemination of educational materials and the production of broadcast-ready public service announcements about fighting high blood pressure through dietary changes.
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From page 32... ...
A = action; ADA = American Dietetic Association; AHA = American Heart Association; AICR/WCRF = American Institute for Cancer Research/World Cancer Research Fund; AMA = American Medical Association; APHA = American Public Health Association; CDC = Centers for Disease Control and Prevention; FDA = Food and Drug Administration; Gov't = Government; HHS = U.S. Department of Health and Human Services; I = initiative; (m)
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From page 33... ...
included language compelling CDC to work with food manufacturers and chain restaurants to reduce sodium content; CDC is in the process of responding to this charge. c World Salt Awareness Week occurs annually.
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From page 34... ...
. Other groups such as the American Public Health Association and the American Dietetic Association have also been active in promoting sodium reduction messages.
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From page 35... ...
Over the years, the message content also changed from advice for consumers to reduce the addition of salt added to foods at the table or in home food preparation to choosing high-sodium foods in moderation and using the nutrition label when purchasing foods to enable selection of foods with lower sodium content (Loria et al., 2001)
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From page 36... ...
, average daily sodium intake remained > 3,000 mg/d -- a level in excess of the Dietary Guidelines for Americans goal of < 2,300 mg/d. As mentioned previously, these data put in motion a change in the emphasis of recommendations from encouraging consumers to reduce or avoid salt use at the table and in home food preparation to an emphasis on encouraging food processors to reduce the sodium content of their products.
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From page 37... ...
. Later, in implementing the 1993 nutrition labeling regulations, FDA and others anticipated that the regulations relating to mandatory declaration of the sodium content of foods and sodium-related criteria for voluntary food label claims (described in Chapter 7)
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From page 38... ...
The response for the total population in 2002 was calculated by multiplying the percentage of respondents reporting they had heard of dietary factors being related to high blood pressure (75 percent) by 0.526, the proportion of those who had heard of dietary factors related to high blood pressure and who identified salt/salty foods/sodium as the dietary factor (FDA, 2007)
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From page 39... ...
While almost half of U.S. consumers were aware of the link between salt/sodium intake and high blood pressure during the decade from 1984 to 1994, fewer made the link between salt/sodium intake and heart disease and heart attacks.
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From page 40... ...
The results do indicate, however, that consumers are more aware of the relationship of sodium intake to high blood pressure/hypertension risk than to the associated risk of heart disease. Consumers' Belief About Importance of the Sodium-Disease Relationship to Self and Behaior Intentions Knowing that excess sodium intake can cause adverse health effects does not necessarily mean that an individual will recognize a personal need for concern or that an individual will take action to reduce intake.
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From page 41... ...
Thus, both the groups who thought their sodium intake was about right and the groups who thought their sodium intake was too high appeared to have similar sodium intake, as well as intake well in excess of the recommendations of the Dietary Guidelines for Americans. In an experimental study in which participants consumed fast food meals from several national chains, participants estimated that, on average, the 11 The population-based prevalence rates were obtained by multiplying the percentage of persons responding "yes" to the question of whether or not there were any foods or ingredients that they had avoided or eaten less of, by the proportion of this group indicating that they had avoided salt, sodium, or spices.
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From page 42... ...
As shown in Figure 2-2, the advent of voluntary labeling in the 1970s resulted in about 40 percent of products carrying some form of permitted nutrition labeling as reported in 1978 -- increasing to about 63 percent in 1991, but these data do not distinguish between simple content declarations and the use of claims. With the initiation of mandatory nutrition labeling in 1993, virtually all processed food labels now contain nutrient content information, including sodium content (LeGault et al., 2004)
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From page 43... ...
As shown in Figure 2-3, compared to other nutrients, sodium does not appear to be the top concern in the minds of consumers (Food Marketing Institute, 2004)
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From page 44... ...
assumed that sodium content information from Nutrition Facts panels would be available for foods consumed at home but not for foods consumed away from home. Individuals were classified from USDA's 1994–1996 Diet and Health Knowledge Survey as label users or non-users based on their response to the question of whether they use the panel's information on nutrient content when buying foods.
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From page 45... ...
This section focuses on the sodium content of foods from various food channels -- that is, the various sources of foods available to consumers. The following section focuses on how changes in portion sizes and energy intake have affected the relative contribution of different food channels to total sodium intake.
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From page 46... ...
. Likewise, foods obtained from fast food restaurants and schools have sodium densities that were not too different from those of the at-home food category, as shown in Panel B
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From page 47... ...
According to their data for calories and sodium as the basis for calculating sodium intake density, school lunches served to students provided an average of 1,901 mg/1,000 calories. In addition, none of the schools offered lunches that met the benchmark for sodium content, which is set at one-third of the maximum daily intake recommended by the 2005 Dietary Guidelines for Americans.
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From page 48... ...
Clearly, larger portion sizes will deliver greater amounts of sodium if sodium densities are not reduced. With limited data on portion sizes across food channels, another way of estimating relative changes in sources of nutrients is to look at changing patterns in sources of energy intake.
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From page 49... ...
Overall, the above results underscore the potential benefit of a comprehensive approach to sodium reduction across all food channels. They also suggest that the effectiveness of sodium reduction programs will likely be enhanced if they are linked to other public health programs that focus on portion size and calorie control, as increased energy intake and portion
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From page 50... ...
While declarations of the sodium content per serving of all processed foods became mandatory with the implementation of nutrition labeling in 1993, a manufacturer's use of descriptive claims about the sodium content (i.e., nutrient content claims) and claims about the usefulness of low-sodium intake in reducing the risk of hypertension (i.e., health claims)
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From page 51... ...
TABLE 2-4 Sales-Based Percentages of Brands with Sodium Content Claims Percentage, 1997 Percentage, 2000–2001 Carbonated soft drinks and water 47.3 Beverages, water 83.7 Fluid milk 26.7 Beverages, carbonated soft drinks 62.0 Diet and health benefit foods 24.6 Sugars and sugar substitutes 44.9 Baby foods 15.0 Nuts and seeds 34.8 Soft drink and beverage mixes 11.1 Beverages, juices/drinks, refrigerated 32.8 SOURCES: Reprinted from Journal of the American Dietetic Association 100(9) , Brecher et al., Status of nutrition labeling, health claims, and nutrient content claims for processed foods: 1997 Food Label and Package Survey, pp.
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From page 52... ...
Sodium content claims were never as commonly used as fat and cholesterol claims, but they were used more often than saturated fat claims in magazine advertising. This same study also tracked the use of health claims (referred to as 40 35 30 Fat 25 Saturated Fat Percent 20 Cholesterol Sodium 15 Sugar 10 5 0 77 79 81 83 85 87 89 91 3 95 97 9 19 19 19 19 19 19 19 19 19 19 19 Year FIGURE 2-8 Percentage of magazine advertisements with "negative" nutrient content claims, 1977–1997.
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From page 53... ...
The use of heart disease claims peaked in 1989 at 2.9 percent of ads, cancer peaked in 1997 at 2.2 percent, blood pressure peaked in 1995 at 1.2 percent, and osteoporosis peaked in 1997 at 0.5 percent. Thus, nutrient content claims are far more commonly used in magazine ads than are claims linking food products to reduction of disease risk, and sodium-related and/or hypertension claims are less commonly used in advertising than are claims for other nutrients and/or other diseases.
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From page 54... ...
. The interest in using sodium content claims compared to other types when introducing new food products that bear nutrient content claims is shown in Figure 2-11.
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From page 55... ...
Current estimates of sodium intake developed for this study are described in more detail in Chapter 5. Salt Disappearance Data The advantage of monitoring intake from disappearance data is that it allows for a reasonably accurate estimate of time trend patterns because
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From page 56... ...
Although the pattern of use over time suggests that early educational and program initiatives carried out in the 1980s were associated with a reduction in salt use, subsequent programs -- including the implementation in 1993 of mandatory declaration of sodium content on all food labels and multiple calls since 1969 for food processors to reduce the sodium content of foods -- appear to have had little or no impact on salt availability for human use. Intake by Indiiduals Since 1971, NHANES has provided estimates of individuals' nutrient intakes from a nationally representative sample of the U.S.
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From page 57... ...
. However, even with the caveat that intake by individuals tends to be underestimated and caution as to possible methodological sources of underestimation in the early surveys, the mean intakes, except for adult women in the first two survey periods, are all in excess of Dietary Guidelines for Americans recommendations.
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From page 58... ...
/1,0 00 kcal 1,600 1971–1974 1,400 1,200 1976 –1980 1,00 0 1988 –1994 80 0 1999 –200 0 600 400 2003 –2006 200 0 Children Men Women 6–11 20 –74 20 –74 Gender /Age Groups FIGURE 2-14 Trends in mean sodium intake densities from food for three gender/ Figure S–3.eps and 2–14 age groups, 1971–1974 to 2003–2006. NOTES: Analyzed using 1-day mean intake data for NHANES 2003–2006 to be consistent with earlier analyses and age-adjusted to the 2000 Census; includes salt used in cooking and food preparation, but not salt added at the table; 1-day mean intake calculated using the population proportion method.
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From page 59... ...
Changes in intake over time must be cautiously interpreted because of limitations in these data, particularly older data based on different methodologies. However, compared to a sodium intake density of < 1,150 mg/1,000 calories per day to be consistent with a Dietary Guidelines for Americans daily intake of < 2,300 mg sodium and assuming a 2,000-calorie reference diet, most groups had intakes that exceeded guideline levels, even during the earlier periods when sodium densities appeared lower than in more recent years.
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From page 60... ...
Furthermore, trials in children, non-hypertensive adults, and hypertensive adults have documented that sodium reduction lowers blood pressure. Although elevated blood pressure and hypertension are also related to other risk factors, reducing daily sodium intake is associated with significant reductions in population-based blood pressure values and prevalence of stroke mortality (DGAC, 2005)
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From page 61... ...
FINDINGS From the descriptions in this chapter, it is clear that a myriad of sodium reduction strategies, programs, and initiatives have been implemented by numerous government agencies, health professional organizations, and the food industry -- starting in 1969 and continuing to the present. These programs had common themes and a consistent message on the relationship between sodium intake and hypertension, with special emphasis on consumer education, sodium labeling of food products at point of purchase, and encouragement of reformulation by food processors and more recently by restaurant/foodservice operators.
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From page 62... ...
Past initiatives also saw some success in motivating the food industry to reduce sodium in some of its products, and make sodium content claims to indicate lower sodium options to consumers. Given these changes, the question becomes, what has kept the population from achieving actual reductions in intake.
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From page 63... ...
A new focus on changing the food supply to better enable consumers to reduce sodium intake may result in better outcomes in the future. While not completely analogous to sodium reduction, experiences with folic acid suggest a role for food supply changes in achieving public health goals.
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From page 64... ...
2000. Status of nutrition labeling, health claims, and nutrient content claims for processed foods: 1997 Food Label and Package Survey.
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From page 65... ...
2004. 2000– 2001 Food Label and Package Survey: An update on prevalence of nutrition labeling and claims on processed, packaged foods.
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From page 66... ...
2003. Patterns and trends in food portion sizes, 1977–1998.
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