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Strategies to Reduce Sodium Intake in the United States

Committee on Strategies to Reduce Sodium Intake

Food and Nutrition Board

Jane E. Henney, Christine L. Taylor, and Caitlin S. Boon, Editors



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Committee on Strategies to Reduce Sodium Intake Food and Nutrition Board Jane E. Henney, Christine L. Taylor, and Caitlin S. Boon, Editors

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract No. 200-2005-13434, Task Order No. 14, between the National Academy of Sciences and the Centers for Disease Control and Prevention; Contract No. N01-OD-4-2139, Task Order No. 219, between the National Academy of Sciences and the National Institutes of Health, National Heart, Lung, and Blood Institute; Contract No. HHSF223200811156P between the National Academy of Sciences and the Food and Drug Administration; and Contract No. HHSP233200800635P between the National Academy of Sciences and the Office of Disease Prevention and Health Promotion. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Strategies to Reduce Sodium Intake. Strategies to reduce sodium intake in the United States / Committee on Strategies to Reduce Sodium Intake, Food and Nutrition Board ; Jane E. Henney, Christine L. Taylor, and Caitlin S. Boon, editors. p. ; cm. Includes bibliographical references. ISBN 978-0-309-14805-4 (pbk.) — ISBN 978-0-309-14806-1 (pdf) 1. Nutrition policy— United States. 2. Sodium in the body—United States. 3. Salt-free diet—United States. 4. Food—Sodium content—United States. I. Henney, Jane E., 1947- II. Taylor, Christine Lewis. III. Boon, Caitlin S. IV. Title. [DNLM: 1. Sodium, Dietary—United States. 2. Diet—United States. 3. Health Policy— United States. 4. Health Promotion—United States. WB 424 I59s 2010] TX360.U6I57 2010 613.2'85—dc22 2010020736 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, For more information about the Institute of Medicine, visit the IOM home page at: www. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Strategies to Reduce Sodium Intake in the United States. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

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COMMITTEE ON STRATEGIES TO REDUCE SODIUM INTAKE JANE E. HENNEY (Chair), College of Medicine, University of Cincinnati, OH CHERYL A. M. ANDERSON, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD SONIA Y. ANGELL, New York City Department of Health and Mental Hygiene, New York, NY LAWRENCE J. APPEL, School of Medicine, Johns Hopkins University, Baltimore, MD GARY K. BEAUCHAMP, Monell Chemical Senses Center, Philadelphia, PA RONETTE R. BRIEFEL, Mathematica Policy Research, Washington, DC MARSHA N. COHEN, Hastings College of the Law, University of California, San Francisco CHRISTINA A. MIRELES DEWITT, Oklahoma State University, Stillwater GREG DRESCHER, The Culinary Institute of America, St. Helena, CA MARY K. MUTH, RTI International, Research Triangle Park, NC ROBERT J. RUBIN, School of Medicine, Georgetown University, Washington, DC JOHN RUFF, Winnetka, IL GLORIAN SORENSEN, School of Public Health, Harvard University, Boston, MA ELIZABETH A. YETLEY, Upper Marlboro, MD Study Staff CHRISTINE L. TAYLOR, Study Director CAITLIN S. BOON, Program Officer HEATHER B. DEL VALLE, Associate Program Officer EMILY ANN MILLER, Research Associate MARIANNE J. DATILES, Senior Program Assistant (from December 2007 to June 2009) SAUNDRA LEE, Senior Program Assistant (from June 2009) ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board 

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Armand V. Cardello, U.S. Army Natick Soldier Research, Development, and Engineering Center, Natick, MA Nancy M. Childs, St. Joseph’s University, Philadelphia, PA Robert Earl, Grocery Manufacturers Association, Washington, DC John D. Floros, The Pennsylvania State University, State College Karen Glanz, University of Pennsylvania, Philadelphia Deanna M. Hoelscher, University of Texas Health Science Center at Houston Daniel W. Jones, University of Mississippi, Oxford Eileen T. Kennedy, Tufts University, Boston, MA Barbara K. Rimer, The University of North Carolina at Chapel Hill Dwight Riskey, PepsiCo (retired), Plano, TX William B. Schultz, Zuckerman Spaeder, LLP, Washington, DC Frances H. Seligson, Nutrition Consultant, Hershey, PA Walter Willett, Harvard School of Public Health, Boston, MA ii

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iii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, Columbia University, and Johanna Dwyer, National Insti- tutes of Health. Appointed by the Institute of Medicine, they were respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.

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Preface I n 1969, the White House Conference on Food, Nutrition, and Health is- sued recommendations that, among other important nutrition concerns, highlighted the role of sodium in hypertension and marked the start- ing point of public health initiatives to address the high levels of sodium intake among the U.S. population. Forty years later, in January 2009, the first meeting of the Institute of Medicine (IOM) Committee on Strategies to Reduce Sodium Intake convened. In the intervening years, much had changed—what we eat, where we eat, and who prepares our food. How- ever, in spite of the attempts of many in both the public health community and the food industry, what did not change is the amount of sodium we consume each day, largely in the form of salt. High sodium intake puts the whole population—young and old, male and female, all ethnic groups—at risk for hypertension and subsequent cardiovascular events such as heart failure and stroke. Hypertension is extraordinarily common: 32 percent of adult Ameri- cans have hypertension, and roughly another third have pre-hypertension. The costs of these health conditions are staggering. Estimates place the direct and indirect costs of hypertension at $73.4 billion in 2009. The committee’s charge was to recommend strategies to reduce Ameri- cans’ intake of sodium to levels consistent with the Dietary Guidelines for Americans. In the wake of the many unsuccessful and/or unsustain- able efforts, this was no small task, but—in light of the potential public health benefit that could be achieved if the goal was met—it was a worthy one. Simply put, the task of the committee was broad, far-reaching, and complex. I am delighted that the assembled committee had the individual ix

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x PREFACE expertise and experience as well as the collective will to serve the health of the public and the willingness to meet the significant challenge of our charge. It was a privilege to be a part of this effort. Over the course of the study, we met often and consulted many sources. Our first meeting set the tone as we heard from each of our study spon- sors. A subsequent public hearing elicited needed input and was extremely useful to the committee’s deliberations. Invited speakers and panelists in- cluded Paul Breslin, Cindy Beeren, Ed Roccella, Susan Borra, Michael R. Taylor, Fred Degnan, Philip Derfler, Cliff Johnson, Alanna Moshfegh, Eric Hentges, Corinne Vaughan, Vanessa Hattersley, Ed Fern, Chor San Khoo, Todd Abraham, Douglas Balentine, Deanne Brandstetter, Stephanie Rohm Quirantes, and Elizabeth Johnson. A host of persons chose to share their perspectives and experience with us on that day and afterward by input to the committee’s website. We sought specific advice and analysis regarding current dietary patterns, a better understanding of restaurants and others in the foodservice industry, and the range of options available for consider- ation from a regulatory perspective. Each request was met fully and greatly facilitated our work. On behalf of the committee, I extend our deepest thanks to the able project staff of the Institute of Medicine: Christine Taylor, study direc- tor; Caitlin Boon, program officer; Heather Del Valle, associate program officer; Emily Ann Miller, research associate; Marianne J. Datiles, senior program assistant; and Saundra Lee, senior program assistant. All gave generously of their talents and time. Our committee benefited greatly from their industry and guidance as we deliberated on our approach and chal- lenges. In addition, the committee would like to thank other members of the Food and Nutrition Board staff including Linda Meyers, director; Sheila Moats, associate program officer; Alice Vorosmarti, research associate; Julia Hogland, research associate; Heather Breiner, program associate; Anton Bandy, financial officer; and Geraldine Kennedo, administrative assistant, who assisted at critical times during the project. On behalf of the commit- tee, I would also like to thank David Vladeck for his service as a commit- tee member from October 2008 until May 2009. Further, the committee would like to thank Mathematica Policy Research, Inc. for providing data analyses. In the view of the committee, the recommendations in this report, when undertaken, will result in the desired decrease in sodium intake across the U.S. population. To this end, we are grateful to have been a voice for this important initiative that will now require the commitment of many. Jane E. Henney, Chair Committee on Strategies to Reduce Sodium Intake

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Contents SUMMARY 1 1 Introduction 17 2 Sodium Intake Reduction: An Important But Elusive Public Health Goal 29 3 Taste and Flavor Roles of Sodium in Foods: A Unique Challenge to Reducing Sodium Intake 67 4 Preservation and Physical Property Roles of Sodium in Foods 91 5 Sodium Intake Estimates for 2003–2006 and Description of Dietary Sources 119 6 The Food Environment: Key to Formulating Strategies for Change in Sodium Intake 153 7 The Regulatory Framework: A Powerful and Adaptable Tool for Sodium Intake Reduction 213 8 Committee’s Considerations and Basis for Recommendations 235 9 Recommended Strategies to Reduce Sodium Intake and Monitor Their Effectiveness 285 10 Next Steps 297 COMMITTEE MEMBER BIOGRAPHICAL SKETCHES 317 xi

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xii STRATEGIES TO REDUCE SODIUM INTAKE APPENDIXES* A Acronyms, Abbreviations, and Glossary 325 B Government Initiatives and Past Recommendations of the National Academies, the World Health Organization, and Other Health Professional Organizations 335 C International Efforts to Reduce Sodium Consumption 357 D Salt Substitutes and Enhancers 405 E Background on the National Health and Nutrition Examination Surveys and Data Analysis Methods 409 F Sodium Intake Tables 417 G National Salt Reduction Initiative Coordinated by the New York City Health Department 443 H Federal Rulemaking Process 453 I Nutrition Facts Panel 457 J State and Local Sodium Labeling Initiatives 459 K Approach to Linking Universal Product Code (UPC) Sales Data to the Nutrition Facts Panel 467 L Public Information-Gathering Workshop Agenda 469 INDEX 473 *Appendixes A through L are not printed in this book, but can be found on the CD at the back of the report.