Science Feature - October 2008
Tex Med . 2008;104(10):49-51.
By Ken Ortolon
The average American consumes nearly twice the recommended daily level of sodium and may not even know it. More than 75 percent of the sodium we eat is already in our foods when we buy them at the grocery store or in a restaurant.
The American Heart Association and other scientific and governmental organizations recommend that Americans consume no more than 2,300 milligrams of sodium daily. The recommendation for those with hypertension is even less, only 1,500 milligrams per day.
Vincent Fonseca, MD, MPH, a preventive medicine physician from Austin and a member of the Texas Medical Association Council on Scientific Affairs, says it's almost impossible for those with high blood pressure to limit their salt intake to recommended levels because of the way processed foods, which are easily accessible and affordable, are made in America.
"Even if a person never added salt at the stove while cooking and never added salt at the table, they can't get to that number - 1,500 milligrams of sodium a day - because of what's being delivered to them at a restaurant or what's being delivered at a store," said Dr. Fonseca.
Dr. Fonseca says the amount of food eaten in restaurants means it is important to provide information on labels on menus and menu boards. "In Texas we like personal responsibility, but we need information readily available so that a person has an opportunity to be responsible," he said.
With sodium intake solidly linked to high blood pressure and cardiovascular disease, a number of organizations, including the Center for Science in the Public Interest (CSPI) and the American Medical Association, and members the Texas Public Health Coalition are trying to tackle the salt issue head on.
Those groups are looking at state and local initiatives to require better labeling of processed foods and restaurant meals so that consumers can make better decisions about their sodium intake.
A Salty Diet
Dr. Fonseca says salt consumption is getting a lot of attention because of its direct link to hypertension and cardiovascular disease.
"Cardiovascular disease is the No. 1 killer in the United States and the No. 1 driver of health care costs," Dr. Fonseca said.
CSPI says 65 million Americans currently suffer from high blood pressure, contributing to some 650,000 deaths annually from heart disease and stroke. Experts at the National Heart, Lung, and Blood Institute have estimated that reducing sodium intake in processed and restaurant foods by 50 percent would save as many as 150,000 lives each year.
With that in mind, CSPI petitioned the Food and Drug Administration (FDA) last year to change the regulatory status of salt, including revoking its status as generally regarded as safe (GRAS).
At a public hearing on the petition in November 2007, Stephen Havas, MD, MPH, MS, AMA vice president for science, quality, and public health, supported revoking salt's GRAS status.
"Excess sodium consumption is one of the principal causes for the rise in blood pressure with age in the United States," Dr. Havas said. "This progressive rise leads to a lifetime probability of developing hypertension of approximately 90 percent."
In addition to revoking the GRAS status, Dr. Havas said AMA recommends that sodium be reduced in processed foods, fast-food products, and restaurant meals by 50 percent over the next decade and that FDA seek to improve labeling to help consumers understand the amount of sodium in processed food products. He also suggested FDA develop label markings and warnings for foods high in sodium.
Dr. Fonseca says food manufacturers in America have resisted previous efforts to get them to cut the salt in their products, saying that using other flavorings to replace the salt would drive up of the cost of their products.
But Dr. Fonseca says some Europeans countries have reduced sodium in food for years. Menu items at European McDonald's restaurants have lower sodium than in America, but they're still selling Big Macs, he says. "They're still making money. The manufacturers already know how to reduce sodium."
He says labeling also is an important step because "we know that merely labeling changes behavior."
A 1996 study by the FDA's Center for Food Safety and Applied Nutrition found that 48 percent of American adults say reading nutrition information on food labels made them change their purchasing habits. And, when given nutrition information on food served in restaurants, diners are 24 to 37 percent less likely to choose high-calorie menu items, according to a 2006 study published in the American Journal of Public Health.
The European Experience
Dr. Havas told FDA last year that the Europeans have achieved tremendous success in reducing high blood pressure by cutting salt intake.
Finland launched a major campaign aimed at the food industry and the public to reduce sodium consumption more than 30 years ago. Through use of front-of-package warning labels for foods high in salt and a heart-healthy symbol for foods low in salt, that country has reduced sodium consumption by 40 percent. Simultaneously, average blood pressure decreased by more than 8 millimeters of mercury and age-adjusted cardiovascular disease mortality rates declined by more than 80 percent, Dr. Havas said.
In the United Kingdom, food manufacturers have voluntarily adopted front-of-package labeling, and the amount of sodium in fresh and frozen prepackaged foods has decreased by 45 percent over the past four years as a result of product reformulation, according to Dr. Havas.
"Unlike the situation in countries such as Finland and the United Kingdom, the food-processing industry in the United States has been slow to respond to the medical and public health imperative to substantially reduce the sodium content of processed foods and restaurant foods," Dr. Havas said. "The voluntary approach to this problem has not worked in this country."
He recommended that FDA consider three alternate steps to require salt reduction in processed foods. The first step calls for FDA to divide processed foods into 30 major categories and to limit sodium levels to the median level currently found in such products. The second step would be to designate any product containing more than 50 milligrams of sodium per ounce as high in sodium and require a front-of-package warning label. The third alternative is to require a 5-percent per year reduction for all products designated as high in sodium.
"Each of these three approaches would lead to major reductions in sodium content by food manufacturers," he said.
While FDA has yet to act on the CSPI petition, public health advocates in Texas and elsewhere are addressing high sodium consumption at local and state levels.
Cities such as New York and Seattle already have enacted local labeling laws that require fast-food franchises and restaurant chains to post nutrition information on their menus or menu boards that give consumers the calorie content, as well as sodium, saturated fat, trans fat, carbohydrate, and other content information.
Meanwhile, the Texas Public Health Coalition is looking at labeling as part of a package of public health recommendations it is preparing in advance of the 2009 session of the Texas Legislature. While that group's recommendations are not yet final, preliminary recommendations called for a reduction of sodium during preparation of food sold through retail food outlets and requiring labeling to provide information on sodium, fat, and other content at the point of sale.
The TMA Council on Scientific Affairs was expected to consider supporting similar recommendations at its meeting at TMA's Fall Conference in September.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon .