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Strategies to Reduce Sodium Intake in the United States 6 The Food Environment: Key to Formulating Strategies for Change in Sodium Intake As often pointed out, the United States has one of the most diverse and plentiful food supplies in the world. On balance, food is relatively inexpensive and readily available. However, the food supply is also characterized by high levels of sodium. Very little of the sodium in foods is naturally occurring; most of it is added by the food industry in the form of sodium chloride, but other sodium-containing compounds make a contribution. Further, as described in Chapter 5, the amount of salt added to foods at the table and during cooking currently contributes only minor amounts to the overall diet of Americans. An important consideration for this report is not only that the food supply contains high levels of sodium, but also that increasing amounts of the food consumed by Americans are formulated by entities outside the home (see Chapter 5). These range from single items typically regarded as processed foods, such as canned soups and baked goods, to entire meals and sometimes entire diets. This is mirrored in the steady growth of the processed food industry, the high consumer demand for convenience and ready-to-serve products, and changes in the types of stores selling foods (Martinez, 2007). The food environment framework reflects an interaction of multiple components: manufacturers, retailers, restaurant/foodservice operations, consumers, regulation/policy, and communication/advertising (Glanz et al., 2005). This chapter outlines the nature of the first four components. It begins with an overview of U.S. food manufacturing and retailing industries, then continues with an overview of restaurant/foodservice operations. Large-scale government programs that provide foods to individuals and
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Strategies to Reduce Sodium Intake in the United States households are also discussed. The chapter concludes with a discussion of consumer interactions with the food environment, looking specifically at how the food environment influences consumer choice and at current understanding of consumer behavior change models. MANUFACTURING AND RETAILING OF PROCESSED FOODS WITHIN THE FOOD ENVIRONMENT Since the late 1800s, the U.S. food environment has experienced tremendous growth and changes in the food manufacturing and retailing sectors, which continue to evolve (Beckley et al., 2007). Today, the majority of food undergoes some type of processing before reaching consumers. Some processing is so extensive that little or no preparation of the food is needed before consumption. As discussed in Chapter 5, processed foods are major contributors to sodium intake, making the food manufacturing and retailing sectors of key interest to the committee. This section provides an overview of food manufacturing and retailing in the United States, information on how food products are developed, and examples of efforts taken by the food industry to reduce sodium intake and the levels of sodium in the foods it produces. Characteristics of the Processed Food Industry Processed food represents one of the largest sectors of the U.S. manufacturing industry, accounting for 10 percent of manufacturing shipments and valued at $538 billion in 2006. The U.S. Department of Commerce defines food manufacturing as an industry that “transforms livestock and agricultural products into products for intermediate or final consumption.”1 Although the definition of processing may include minimal manipulation, such as cutting meat or slicing fresh produce, the term “processed foods” is most closely associated with more complex products, such as baked goods, canned soups, and frozen meals. Restaurant foods and food served by commercial foodservice operations are considered in the following sections. Table 6-1 shows the wholesale value of shipments for various food categories. To produce these goods, the food manufacturing industry employed 1,476,300 people as of September 2009.2 There are approximately 31,000 food and beverage processing plants in the United States; however, most of the output of the processed food industry is derived from a relatively 1 Available online: http://www.trade.gov/td/ocg/report08_processedfoods.pdf (accessed July 20, 2009). 2 Available online: http://www.bls.gov/iag/tgs/iag311.htm#workforce (accessed October 12, 2009).
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Strategies to Reduce Sodium Intake in the United States TABLE 6-1 Value of Shipments by the U.S. Food Manufacturing Industry in 2006 Type of Shipment Value (billions of U.S. dollars) Meat 145 Dairy 69 Other food 71 Grain and oilseed milling 52 Fruit, vegetable, and specialty food 54 Bakeries and tortilla 49 Sugar and confectionery 28 Seafood 10 SOURCE: U.S. Department of Commerce Processed Food Outlook, 2008. Available online: http://www.trade.gov/td/ocg/report08_processedfoods.pdf (accessed July 20, 2009). small number of large manufacturing plants. Large plants (100 or more employees) comprised only 12 percent of all processing plants in 2005, yet produced 77 percent of products by value. Small plants (1–19 employees) comprised 69 percent of all plants in 2005, while producing only 4 percent of products by value.3 Further, the size of the domestic manufacturing system does not provide a complete picture because substantial amounts of the food sold for consumption in the United States are processed overseas. In 2007, more than $60 billion in consumer-ready processed foods were imported, an increase from approximately $30 billion in 1998. Canada, the European Union, Mexico, and China were the top four exporters of these products (Brooks et al., 2009). In addition, many ingredients for foods processed in the United States are imported.4 Table 6-2 lists the top 20 food processors in the United States and Canada on the basis of food sales in 2008. The top food manufacturers in the United States are multinationals that create and sell a variety of products under numerous national brand names. National brands are typically those that are well known and advertised, and most have strong customer loyalty.5 In addition to large multinationals, thousands of small- and medium-sized companies make products that are sold nationally or regionally. For example, it is estimated that the average supermarket stocks products from more than 16,000 food processing companies (Harris et al., 2002), many of which produce far fewer products than large multinationals. Both large 3 Available online: http://ers.usda.gov/Briefing/FoodMarketingSystem/processing.htm (accessed August 1, 2009). 4 Available online: http://www.foodprocessing.com/articles/2008/037.html (accessed November 11, 2009). 5 Available online: http://www.fmi.org/glossary/index.cfm (accessed October 12, 2009).
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Strategies to Reduce Sodium Intake in the United States TABLE 6-2 Top Food Processors in the United States and Canada Company Name 2008 Food Sales (millions of U.S. dollars) Nestlé 26,477 Tyson Foods Inc. 26,325 PepsiCo Inc. 25,346 Kraft Foods Inc. 23,956 Anheuser-Busch InBev 15,571 Dean Foods Co. 12,455 General Mills Inc. 12,100 Smithfield Foods Inc. 10,726 Kellogg Co. 8,457 Coca-Cola Co. 8,205 ConAgra Foods Inc. 8,031 Pilgrim’s Pride Corp. 8,025 JBS USA 8,000 Dole Food Co. Inc. 7,620 Mars Inc. 7,000 Sara Lee Corp. 6,828 Hormel Foods Corp. 6,755 Unilever North America 6,647 Saputo Inc. 5,793 Dr Pepper Snapple Group 5,710 SOURCE: Food Processing, 2009. and small manufacturers produce private label products for retailers and products for the restaurant/foodservice sector in addition to well-known brand name products. Private label products are those sold under retailer brands.6 On average, private label goods account for 16 percent of supermarket sales (Leader and Cuthill, 2008), but the dominance of such products varies greatly by food category. Although still less prevalent than brand name products, private label products are an important component of the processed food supply, especially given their current rate of growth, which is higher than that of national brand name products (Martinez, 2007). Overall, the U.S. food manufacturing sector can be characterized as having a multitude of players of varied sizes. The sector ranges from large multinationals selling brand name and private label products in a range of food categories to small processing plants with only a few employees to produce a single regional brand or product. As discussed later, this land- 6 Available online: http://www.plmainternational.com/en/private_label_en3.htm (accessed July 31, 2009).
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Strategies to Reduce Sodium Intake in the United States scape creates both challenges and opportunities for reducing the sodium content of the U.S. food supply. Characteristics of the Food Retailing Industry Food retailers are increasingly important in the food environment, not only because of their longstanding role as key distributors for and promoters of processed foods, but also because their increasing concentration and data-gathering technologies have given them the ability to influence the types of products developed by manufacturers. Over the past decade, the food retail sector has seen dramatic changes driven by the growth of non-traditional food retailers such as big box supercenters (Martinez, 2007) and changes in technology that have revolutionized sales tracking (Leader and Cuthill, 2008). Supercenters (e.g., Wal-Mart, Super Target) and warehouse clubs (e.g., Costco, BJ’s) increased their shares of food-at-home expenditures from 4 percent in 1994 to 17 percent in 2005 at the expense of traditional food retailers (Martinez, 2007). Wal-Mart alone increased its number of supercenters from 672 U.S. stores in 1995 to 2,349 in 2005 (Martinez, 2007). Table 6-3 shows the share of food-at-home expenditures in 2005 by outlet type, and a list of the top 10 food retailers in the United States and Canada and their 2008 sales is provided in Table 6-4.7 Supermarkets commonly carry 30,000 to 40,000 stock keeping units (or distinguishable products) (Leader and Cuthill, 2008) but space remains limited, even in the largest of retailers. Convenience stores, drugstores, and dollar stores are also important parts of the food retailing industry. These retailers have more limited offerings than supermarkets, but have expanded their food offerings in recent years (Martinez, 2007). Because of their purchasing power, large retailers gained the ability to influence the types of products produced by food manufacturers by determining which products will reach the limited space on retail shelves (Martinez, 2007). The introduction of checkout scanners and automated inventory control has given retailers powerful tools for determining which items sell best and, in turn, helped retailers determine which products they are willing to sell. With thousands of food products introduced to the market each year, products must compete for limited space on retail shelves, and manufacturers must develop products that will generate high profits for retailers in order to stay in the marketplace (Leader and Cuthill, 2008). To convince retailers that a new product should be carried, manufacturers often give them detailed sales pitches, including information on expected 7 Available online: http://supermarketnews.com/profiles/top75/2009-top-75/ (accessed July 31, 2009).
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Strategies to Reduce Sodium Intake in the United States TABLE 6-3 Share of Food-at-Home Expenditures by Type of Outlet, 2005 Type of Outlet Percentage Traditional Grocery Retailers Supermarkets 58.2 Convenience stores 2.9 Other grocery stores 3.6 Specialty food stores 2.7 Nontraditional Grocery Retailers Supercenters (e.g., Wal-Mart, Super Target, Super Kmart, Meijer, Fred Meyer) and warehouse clubs (e.g., Costco, Sam’s Club, BJ’s) 17.1 Mass merchandisers (e.g., traditional Wal-Mart, Target, and Kmart stores) 1.8 Other stores (e.g., Walgreens, Dollar General) 8.7 Home-delivered and mail order 4.0 SOURCE: Martinez, 2007. TABLE 6-4 Top 10 Retailers in the United States and Canada Company Name 2008 Sales (billions of U.S. dollars) Wal-Mart Stores 258.5 Kroger Co. 77.2 Costco Wholesale Corp. 72.5 Supervalu 45.0 Safeway 44.8 Loblaw Cos. 31.5 Publix Super Markets 24.0 Ahold USA 21.8 Delhaize America 19.2 C&S Wholesale Grocers 19.0 NOTE: Sales volume includes revenues from both food and non-food merchandise in North America. SOURCE: Supermarket News, 2009. Available online: http://supermarketnews.com/profiles/top75/2009-top-75/ (accessed July 31, 2009). sales, marketing plans, and consumer research on the product category (FTC, 2003). Retailers also often control what products are sold and where they are placed on retail shelves by creating slotting fees. Slotting fees are one-time payments made by food processors to retailers in exchange for placement of new products on store shelves (FTC, 2003). Some manufacturers are charged as much as $40,000 per store to stock a new food item (Desiraju, 2001).
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Strategies to Reduce Sodium Intake in the United States Some retailers have also created programs to pressure manufacturers into making changes in the product characteristics of the items they sell. A recent example is Wal-Mart’s work to encourage suppliers to improve the sustainability of product packaging.8 Although not from the United States, another example is the requirement that ASDA supermarkets (which are owned by Wal-Mart) in the United Kingdom placed on their private label manufacturers to meet certain standards for fat, saturated fat, sugar, and salt in their products and to remove artificial colors and flavors (Hattersley, 2009). Because a relatively small number of retailers are responsible for a large volume of processed foods sales, they can be the gatekeeper to new product success. If manufacturers are unable to convince major retailers that a new or reformulated product will appeal to consumers or if the company cannot safely take the risk of paying high slotting fees, its product has little chance of succeeding in the marketplace. These factors have become a major consideration in the development and reformulation of processed foods. Product Development Process In 2005, 18,722 new food and beverage products were introduced by food manufacturers (Martinez, 2007). The breakdown of these products by type is provided in Table 6-5. To create new products, the largest processed food manufacturers have TABLE 6-5 New Product Introductions in 2005 Type of Product Percentage of Total Candy, gum, snacks 27.7 Beverages 25.1 Condiments 10.2 Dairy 7.2 Baking ingredients 6.0 Processed meat 5.0 Meals and entrées 4.7 Bakery foods 4.1 Fruit and vegetables 3.4 Pasta and rice 2.2 Soups 1.6 Cereals 1.4 Desserts 0.8 SOURCE: Martinez, 2007. 8 Available online: http://walmartstores.com/Sustainability/9125.aspx (accessed October 12, 2009).
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Strategies to Reduce Sodium Intake in the United States FIGURE 6-1 Business groups involved with product development. SOURCE: Adapted from Beck, 2002. In Organizing human resources: By project? By discipline? As a matrix? Copyright © 2002 Iowa State Press. Reproduced with permission of John Wiley & Sons, Inc. large groups of employees with a range of skills. As shown in Figure 6-1, these groups include employees with operations, customer, technical, and administrative expertise, including market researchers, food scientists, nutritionists, engineers, chemists, and microbiologists. Research and development teams within these companies are involved in both developing new products and reformulating existing products. Multinational manufacturers may conduct some of their research and development activities at international research centers (Nestle, 2007). In smaller companies, research and development staff may be limited (Beck, 2002). For these manufacturers, a single scientist may be responsible for multiple functions. All sizes of food manufacturers are relying more on ingredient suppliers, external contract developers, and consultants to be part of the product development process (Beckley et al., 2007; Thomas, 2007). These groups are useful in providing expertise that may otherwise be lacking in the company or conducting research at a lower cost than the company could do in-house (Beckley et al., 2007; Fuller, 2005). Consultants may be from private companies or from universities that see consulting as a useful way to apply their research and to generate revenues (Fuller, 2005). State Coop-
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Strategies to Reduce Sodium Intake in the United States erative Extension Services also provide expertise, particularly to small food processors and entrepreneurs.9 The reasons companies undergo the costly and time-consuming process of new product development include the following (Fuller, 2005):10 New or reformulated products are needed for manufacturers to maintain and expand their business as products end their life cycle and suffer from reduced sales; New market demands arise (e.g., more demand for healthful products); New technologies may make possible the creation of new products that were not feasible in the past; Changes in government regulations and policies may make it necessary to reformulate existing products or create incentives for new product development and reformulation (e.g., to meet requirements for health or content claims); and New or reformulated products are needed to respond to new or improved competitive products. Steps to Develop New Products and Reformulate Existing Products The product development process generally involves a series of steps that are depicted in Figure 6-2, although the ordering of initial steps may vary from project to project. Valdovinos (2009) more simply categorized this process into four steps: (1) idea generation; (2) concept development; (3) plan and design; and (4) launch and produce. A more detailed description of these steps is provided below. Idea generation Ideas for new products come from a variety of internal and external sources. Examples of these sources are provided in Box 6-1. Large companies have marketing teams devoted to searching consumer data and gathering information on the existing food market. This work is intended to produce insights into how to fill consumer needs and, in the process, generate successful products (Straus, 2009). Marketing, business, and research and development personnel work to brainstorm ideas and determine which ideas are promising (Straus, 2009; Thomas, 2007; Topp, 2007). Several considerations are needed in screening ideas. Questions asked 9 Available online: http://www.uga.edu/nchfp/business/starting_business.html#ceslinks and http://www.ces.ncsu.edu/index.php?page=foodsafetyprocessing (accessed October 15, 2009). 10 Personal communication, J. Ruff, Kraft Foods (retired), October 2009.
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Strategies to Reduce Sodium Intake in the United States FIGURE 6-2 Phases of new product development. SOURCE: Fuller, 2005. Reproduced with permission of Taylor and Francis Group LLC from “New food product development: From concept to marketplace,” 2nd edition; permission conveyed through Copyright Clearance Center, Inc.
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Strategies to Reduce Sodium Intake in the United States BOX 6-1 Sources of Product Ideas Internal Sources Business and marketing teams Research and development teams Sales personnel Packaging teams Regulatory affairs departments External Sources Competitors Suppliers Consumers Retailers SOURCES: Straus, 2009; Topp, 2007. include the following (Heyhoe, 2002; Moskowitz et al., 2009; Straus, 2009): How closely does the new product idea fit with the corporation’s strength in the market (i.e., does the company have closely related products that are successful)? How technically feasible is the project? How well can the product idea be protected from competition (i.e., can patents or commercial secrets ensure that competitors will be unable to easily copy the product)? What capital expenditures will be needed? What is the expected life of the product (1 year, 3–5 years, etc.)? What is the spinoff potential of the product for line extensions and related products? How well do consumers rate the product compared to products with known success? Another consideration that has emerged with greater importance in recent years is determining what will influence a retailer to stock the product. Retailers are the first customers and their acceptance is needed (Topp, 2007) because their willingness to stock a new product will be a major factor in its success (van Boekel, 2009). With the above questions in mind, business teams can estimate the costs of production and the potential profit the product might generate and then
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Strategies to Reduce Sodium Intake in the United States rather than expert opinion or judgment. The available literature suggests that risk in the context of consumer products is difficult to communicate and comprehend, for both consumers and experts. There are many ways to conceptualize risk, and while many are considered appropriate and defensible, it is established that they can lead to very different behavioral outcomes (Stewart and Martin, 1994). Available research in this area has tended to focus on surveys designed to measure attention to a warning, perceived credibility of the messages, or awareness of warning information (Kimmerling, 1985; Lehto and Miller, 1986). Such measures, although useful, are incomplete because exposure and attention do not ensure that the warnings are perceived as credible, nor do they provide insight about whether and under what circumstances consumers will alter their attitudes, decision making, or behavior in response to warnings (Stewart and Martin, 1994). Putting It All Together: Embedding Health Behavior for Sodium Intake Reduction Within the Broader Food Environment In the case of sodium, removal of the environmental constraints to health behavior change is a critical first step. As stated above, with their growing reliance on processed and prepared foods, consumers have diminishing control over the amount of salt they consume. The need for a population-wide reduction strategy rests on the massive scope of the high blood pressure epidemic, documented in prior chapters, and the limited success of individual-based sodium reduction interventions. Such interventions have been notoriously difficult to implement, especially in the setting of the current food supply, which is replete with “hidden” salt. In clinical trials, intensive interventions that focused only on salt reduction were able to shift mean intake to approximately 100 mmol/d (2,300 mg/d) (see left panel of Figure 6-5). When efforts to reduce sodium intake were combined with weight loss or part of a comprehensive lifestyle intervention program, sodium reduction was more modest (see right panel of Figure 6-5), likely because of the complexity of making multiple lifestyle changes and potential trade-offs when there are multiple goals (Appel, 2008). Thus, it is unlikely that the average consumer will be able to successfully reduce sodium intake without changes to other components of the food environment. Changes at the policy level diminish the need for individual action to reduce sodium in the diet, which is of particular importance because, as documented in Chapter 2, the benefits of sodium reduction can accrue regardless of age or risk level. This approach to reducing risk at the source of exposure has been a long-standing cornerstone of public health practice (Winslow, 1984). In the case of sodium reduction, changes in the food supply could be aimed at reducing risk at the source of possible expo-
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Strategies to Reduce Sodium Intake in the United States FIGURE 6-5 Mean pre- and post-levels of urinary sodium excretion in three trials (Trials of Hypertension Prevention Phase 1 and 2 [TOHP1 and TOHP2] and Trials of Nonpharmacologic Interventions in the Elderly [TONE]) that tested interventions focused only on salt reduction (left panel) and two trials (TOHP2 and PREMIER) that combined sodium reduction with other lifestyle interventions (right panel). NOTE: d = day; mmol = millimole. SOURCE: Appel, 2008. Copyright © 2008 Journal of Clinical Hypertension. Reproduced with permission from John Wiley & Sons, Inc. sure. Policy changes to increase the content of nutrients such as folic acid and niacin have been highly effective in improving the nutritional status of the U.S. population with respect to these nutrients (Park et al., 2000; Pfeiffer et al., 2007). Monitoring and surveillance activities were critical to documenting folate’s effectiveness and potential safety concerns (Lucock and Yates, 2009). However, sodium presents some unique challenges that were not encountered in these earlier policy issues, making effective monitoring and surveillance systems even more critical for implementing sodium reduction strategies. For example, sodium has taste and functional effects in foods, whereas earlier fortification policies were flavorless and had poten-
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Strategies to Reduce Sodium Intake in the United States tially less serious functional effects. Nevertheless, there is limited evidence that sodium intake reductions achieved by changes in the food supply can create meaningful changes in health status. Two decades ago, a small but significant study illustrated the potential impact on blood pressure of passive reductions of sodium in available foods. The Exeter-Andover study, conducted by Ellison and colleagues (1989), was designed to examine the extent to which reductions in the sodium content of dining hall foods would result in blood pressure reductions among students in the intervention versus control schools. Students were not instructed to change their dietary patterns or to avoid salty foods, and salt shakers were left on the tables. Sodium intake was reduced by 15–20 percent through modifications in food purchasing and preparation, and resulted in significant reductions in systolic and diastolic blood pressure over the academic year. These findings further illustrate the potential value of passive changes in the food supply, in line with changes in the macro-level environment. Policy changes have been highly effective in influencing the intake of other nutrients. For example, food fortification was likely an important tool in eliminating pellagra in the United States (Park et al., 2000). These findings further illustrate the potential value of passive changes in the food supply, in line with changes in the macro-level environment. By emphasizing changes in the food supply, individual consumer efforts to reduce salt intake are embedded in these broader changes. Consumers’ roles in reducing salt intake will change in response to the new environment. With a broader range of food choices, consumers’ control over the level of sodium in their diets is likely to increase. Additional changes of other factors in the behavior change process are supplemental. REFERENCES Ajzen, I., and M. Fishbein. 1980. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall. Appel, L. J. 2008. At the tipping point: Accomplishing population-wide sodium reduction in the United States. Journal of Clinical Hypertension 10(1):7-11. Balentine, D. 2009. Salt reduction: Making the healthy choice the tasty choice. Presented at the Institute of Medicine Committee on Strategies to Reduce Sodium Intake’s Public Information-Gathering Workshop, March 30, Washington, DC. Ball, P., D. Woodward, T. Beard, A. Shoobridge, and M. Ferrier. 2002. Calcium diglutamate improves taste characteristics of lower-salt soup. European Journal of Clinical Nutrition 56(6):519-523. Bandura, A. 1994. Social cognitive theory and exercise of control over HIV infection. In Preventing AIDS: Theories and methods of behavioral interventions, edited by R. J. DiClemente and J. L. Peterson. New York: Plenum Press. Bassett, M. T., T. Dumanovsky, C. Huang, L. D. Silver, C. Young, C. Nonas, T. D. Matte, S. Chideya, and T. R. Frieden. 2008. Purchasing behavior and calorie information at fast-food chains in New York City, 2007. American Journal of Public Health 98(8): 1457-1459.
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