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tiatives were begun, trends have been evaluated in several relevant areas: consumer awareness, knowledge, and behavior; the food industry; sodium intake; and the prevalence of hypertension. To assess changes over time, available data from the National Nutrition Monitoring System and, in a few cases, the scientific or trade literature were used. Despite the fact that the publicly available data were somewhat spotty and incomplete in all of the areas examined, the totality of available evidence reveals a consistency of findings across those areas.

From the available data, it is clear that past initiatives and recommendations have not been successful in achieving the ultimate goal of reducing sodium intake and sodium-related health concerns. Initially, consumer messages most strongly encouraged higher-risk groups (e.g., African Americans and older adults) to reduce sodium intake, and use of salt at the table and during cooking was emphasized. As evidence became stronger that sodium should be a concern throughout the lifespan and as new data emerged on major sources of intake, messages were adjusted to include the entire population, and to encourage consumers to consume processed and restaurant/foodservice foods that were lower in sodium. The results from the three different types of exposure estimates (salt disappearance, dietary recall, and urinary excretion) all consistently show that, despite the broad-based and long-term efforts, neither the salt disappearance nor the sodium intake data show a sustainable trend in declining sodium intake over the 40 years of carrying out the past and existing initiatives. Today, sodium intake by Americans is well in excess of the Dietary Guidelines for Americans recommendation of < 2,300 mg/d sodium. Similarly, significant declines in the prevalence of high blood pressure and stroke mortality have not been seen in the United States.

While the ultimate goal of sodium reduction initiatives has not been met, intermediate goals have seen some success. Public education campaigns in the early 1980s created a dramatic rise (from 12 percent to 48 percent) in consumer awareness of the relationship between sodium and hypertension. Many consumers also believed that sodium reduction was an issue of personal importance, with 62 percent of main meal preparers saying they were personally concerned about sodium. Over a third of the population has been found to always or often use sodium information on the Nutrition Facts panel. 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.

As will be discussed elsewhere in this report, notably in Chapter 6, consumers live in a broad food environment in which social, organizational, and macro-level factors influence the types of foods consumed and, thus,



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