sodium intake. The broad food environment can be linked to the reasons for the lack of effectiveness of 40 years of sodium reduction initiatives. The food supply itself is a key obstacle for consumers. The sodium densities of available foods—both in the marketplace and from restaurant/foodservice operations—make it difficult for consumers to meet dietary recommendations. Further, sustainability of consumer interest and concern is an obvious problem. This becomes intertwined with food producer interest in developing lower-sodium products and in using sodium-related claims and advertising. As a result of these developments, there is a manifest role for increased use of foods naturally low in sodium (e.g., fruits, vegetables) as well as linkages to other public health initiatives because of increasing portion size. Importantly, the number of food channels outside the home and the pervasiveness of salt use throughout the food supply—with average sodium intake density well in excess of that recommended by the Dietary Guidelines for Americans—make it very difficult for consumers and meal planners to achieve recommended sodium intake.

Overall, the outreach and educational efforts to date have failed to reduce the sodium intake of the American public; unfortunately, a lack of available data regarding the implementation and evaluation of these efforts prevents the drawing of firm conclusions about why they did not succeed. Currently, sodium intake remains well in excess of the goals in the Dietary Guidelines for Americans. It is now apparent that outreach and educational programs to consumers and food producers, although a necessary component of any strategy, are insufficient by themselves to achieve the public health goal of reducing sodium intake by Americans to < 2,300 mg/d. 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. Years of educational efforts failed to make a significant impact on the intake of folic acid by the at-risk population (women of childbearing age). However, once folic acid fortification was instituted, folic acid intake increased without behavior changes (Johnston and Staples, 1995; Pfeiffer et al., 2007). At the same time, consumers have a role to play: the impact of any food supply approach can be enhanced by informed consumer choices. Therefore, efforts to ensure this role is supported may benefit from activities that are now more fully researched, better designed, and effectively implemented than past efforts.

Alderman, M. H. 2010. Reducing dietary sodium: The case for caution. Journal of the American Medical Association 303(5):448-449.