9

Progress at Last!

Given the overwhelming scientific evidence, pursuing voluntary reductions of sodium in the food supply is warranted and overdue.

—Thomas R. Frieden, MPH, MD, Director of the Centers for Disease Control and Prevention, 20161

Little was happening on the salt front in somnolent Washington during the first decade of the twenty-first century, despite prodding from two of the largest health organizations. The American Medical Association (AMA) pointed out what health experts all knew:

Even motivated individuals find it difficult to moderately reduce sodium intake because most sodium consumption derives from salt added during food processing and by restaurants. Therefore, any meaningful strategy to reduce population sodium intake must rely on food manufacturers and preparers to reduce the amount added during preparation.2

The AMA called for at least a 50 percent reduction in sodium in processed foods and restaurant meals over the next decade in order to slash stroke and heart attack rates. A few years later, another major organization of health professionals, the American Public Health Association (APHA), called for a major decrease in sodium by 2021. Both recommendations were ignored in Washington.3

New York City and Allies Challenge Companies

Several local health officials, distressed by the high rates of cardiovascular disease in their communities, decided that it was time to take on salt and not wait for the federal government to act. In 2009, New York City’s Department of Health and Mental Hygiene, the most action-oriented health department in the country, spearheaded a new effort to cut sodium intakes. To pressure companies to use less salt, the health department created the National Salt Reduction Initiative (NSRI), which ultimately was supported by over one hundred nonprofit health organizations and local and state health authorities.4 The goal was to reduce sodium in packaged and restaurant foods by 25 percent over five years.5 The NSRI, analogous to the British plan, developed a set of voluntary sodium targets for 61 categories of packaged foods and 25 categories of restaurant foods. NSRI announced modest two-year and tougher four-year recommended reductions ranging from 15 to 40 percent, depending on the category. Those were not maximum amounts for any given product, but the sales-weighted average for a company’s products in each category. The goals were based on foods some companies were already marketing, so New York officials knew that the goals were achievable. Officials then met with company and trade association officials to encourage them to meet the targets.

The food industry did not exactly rally en masse in support of the NSRI. The Grocery Manufacturers Association (GMA), the packaged-food industry’s powerful lobbying arm, said it supported a voluntary, gradual approach to reducing sodium consumption to 2,300 mg per day, but carped that the “food industry continues to have a number of outstanding issues” with the initiative.6 In its 23-page letter, GMA complained about virtually every aspect of the program. It said, for starters, that New York should focus on the whole diet and lifestyle instead of just one ingredient. Its members “strongly” felt that New York should not even be mounting a “national” initiative, but should let the federal government do so—never mind that the federal government had done nothing for decades, and that dozens of other cities and states across the country and numerous national health organizations supported the NSRI.

Next, GMA criticized the specific goals for many food categories, such as charging that the 40 percent reduction goal for breakfast cereals was “too aggressive” and that a 25 percent reduction in cold cuts would impair the industry’s widespread practice of incorporating water into processed meats. Of course, if companies disagreed with the targets that affected some of their products, they could ask for changes or simply ignore the purely voluntary NSRI. (In January 2020, GMA changed its name to the Consumer Brands Association, representing a broader range of companies than makers of grocery goods, and stopped lobbying on food safety and nutrition.)

In the end, more than two dozen manufacturers and chain restaurants, both local and national, agreed to meet the NSRI targets for at least some of their foods. Kraft, Heinz, Mars, Starbucks, and Subway were some of the largest participants. Mondelēz International, a spinoff of Kraft Foods and maker of Oreo cookies and Triscuit crackers, reduced sodium in Nabisco’s Teddy Grahams Honey flavor crackers by one-third, from 150 mg to 100 mg per serving. Subway reduced the sodium in two of its most popular sandwiches, the Subway Club and Italian B.M.T., by about 30 percent.

The city saw progress in many food categories. In 2009, when the targets were established, no categories met the 2012 or 2014 targets. By 2014, 16 of 61 categories (26 percent) met the 2012 targets and 2 of those (3 percent) met the 2014 targets. The period between 2009 and 2014 found a “modest” 7 percent decrease in sodium in all packaged foods, but that was far short of the 25 percent goal.7 The pressure exerted by the NSRI dovetailed nicely with the pressure that other countries were putting on industry.

The key takeaway from the NSRI was that focused government attention could spur sodium reductions. But then a development occurred that moved the action from New York City to Washington, DC.

A Salutary Recommendation from the IOM

Long before the New York City–led program, CSPI had encouraged Congress to fund a report not on whether Americans were consuming too much sodium, but on how to lower sodium levels. Representative Rosa DeLauro (D-CT) and Senator Tom Harkin (D-IA), two of the most stalwart health advocates then in Congress, got Congress to fund the Centers for Disease Control and Prevention (CDC) to prepare a report on how sodium intakes could be lowered.

The CDC and other agencies within the US Department of Health and Human Services (HHS) called on the Institute of Medicine (IOM, now the National Academy of Medicine, or NAM) of the National Academy of Sciences in 2008 to undertake that study. In 2010, the NAM issued its landmark report, “Strategies to Reduce Sodium Intake in the United States,” that immediately energized the policy debates.8 The report pointed out the “staggering” health costs—$73.4 billion in 2009—related to hypertension. Jane E. Henney, a professor of medicine at the University of Cincinnati and former commissioner of the US Food and Drug Administration (FDA) who chaired the IOM committee, lamented, “For 40 years we have known about the relationship between sodium and the development of hypertension and other life-threatening diseases, but we have had virtually no success in cutting back the salt in our diets.”9 “The vast majority of the US population is consuming sodium at levels that are simply too high to be safe.”10

The top recommendation in the IOM report was that “the Food and Drug Administration should expeditiously initiate a process to set mandatory national standards for the sodium content of foods” [emphasis added]. The IOM also recommended that those limits should apply to both packaged and chain-restaurant foods and be decreased gradually every several years.

In defending the need for mandatory limits, the report said that voluntary initiatives “are challenged by the inability to ensure that there will be compliance and they do not guarantee a level playing field for food producers. Additionally, it is likely that volunteers will drop out as reductions become more challenging over time.” The IOM emphasized that “adopting an exclusively voluntary approach in the United States may have limited success and questionable potential for long-term sustainability based on past US experience.”11

That echoed what Richard Kahn, the chief scientific and medical officer of the American Diabetes Association, told the FDA several years earlier: “Voluntary action has clearly not worked to reduce the sodium content in processed foods. . . . So to continue along with another twist of some voluntary standards or voluntary mandate, so to speak, it’s not going to work at all.”12

Predictably, anti-regulatory forces attacked the IOM’s recommendations. Conservative talk show host Rush Limbaugh, sounding like a latter-day Paul Revere, decried (falsely), “they’re going to take away our salt shakers.”13 The Salt Institute, of course, weighed in. Morton Satin, the group’s vice president and science director, charged that the IOM report ignored research that questioned the health benefits of widespread salt reduction. “This whole thing doesn’t seem to have been well thought out,” he said of the 400-plus-page report. Satin argued that the government should promote a balanced diet rather than a lowered salt intake—a boring message that has never had any effect in either balancing diets or lowering salt.14 The next year, the Salt Institute was back at it with more rhetorical flair when the FDA and US Department of Agriculture (USDA), spurred in part by the IOM report, invited comments from the public on reducing sodium intakes: “Yet, at a time when the overwhelming evidence is against population-wide salt reduction, the same FDA is preparing to turn consumers into 300,000,000 guinea pigs with an untested, ideology-based, risk-prone dietary intervention.”15

Typical of industry’s comments was one from the National Frozen Pizza Institute. “NFPI supports the goal of achieving gradual but significant voluntary reductions in the sodium content of the US food supply under the leadership of the federal government. . . . It should take into account the potential impact of sodium reduction on food safety, functionality, cost, consumer acceptance, nutrition, and overall public health.”16 The pizza makers say, in effect, that sure, they want to lower sodium levels. But then they give every excuse as to why it shouldn’t and couldn’t be done.

Would consumers support mandatory limits on sodium, as the IOM recommended, or would they oppose “nanny state” health measures? The CDC sponsored a survey of almost 10,000 consumers to answer that question. It found that a remarkable 82 percent of consumers supported policies to limit sodium at fast-food restaurants.17 Close behind, 56 percent of people surveyed supported policies to limit sodium in packaged foods, with another 24 percent neutral.

The FDA Awakens

The day before the IOM report was released, the Washington Post stated that the FDA was developing voluntary guidelines for companies to reduce sodium that “would eventually lead to the first legal limits on the amount of salt allowed in food products.”18 The IOM’s recommendations and the Post story hit the food industry like a bombshell and certainly got the FDA’s attention, too. But instead of going down the IOM’s recommended mandatory route, FDA commissioner Margaret Hamburg immediately said that her agency would set voluntary targets. “We believe we can achieve some substantial voluntary reductions,” she said. (What was going on here? Let’s not forget, as I noted in chapter 8, that 30 years earlier FDA commissioner Arthur Hull Hayes said: “If sufficient positive action is not forthcoming, I would feel compelled to pursue a mandatory solution.”)19

So, the FDA pulled together a team of scientists, economists, lawyers, and policy experts to shape a voluntary sodium-reduction plan. Their challenge: the FDA had to figure out sensible targets for every segment of the food supply, which consists of well over 100,000 packaged products.20 The FDA said, though, that less than 10,000 packaged foods accounted for more than 80 percent of sales.21 Add to that mix many thousands of dishes offered by tens of thousands of restaurants.

The FDA’s staff proceeded with the task, but it was slow going, partly a consequence of its complexity, partly because of the inherent slowness of bureaucracies (more about that later in this chapter). Meanwhile, forces outside the agency sought to accelerate its work or stop it.

From inside the government, CDC director Tom Frieden weighed in with a series of memos and emails. According to someone familiar with their contents, the missives were extremely forceful, reflecting Frieden’s increasing frustration with the slowness.

Michael M. Landa—the director of the FDA’s Center for Food Safety and Applied Nutrition who had overseen the FDA’s sodium-reduction proposal—retired in January 2015. But by March he was expressing his dismay about the FDA’s slow pace. Landa wrote to the Secretary of the Department of Health and Human Services, Sylvia Mathews Burwell, and urged swift action: “There should be no further delay in issuing draft voluntary sodium reduction targets, whether to help set a ‘level playing field’ to facilitate industry reduction efforts or to lay the groundwork for mandatory limits, should the targets fail.”22 Seven months later Landa rebuked his former agency directly, telling it:

The Federal government’s failure to take any substantive action in response to the [2005] Citizen Petition [from CSPI] is incomprehensible, and it would be irresponsible to wait any longer. . . . What is the Federal government waiting for? Sodium reduction talk from the Federal government is cheap and has long been getting cheaper.23

At the same time, the threat of sodium guidelines did not go without notice in Congress. One of the key opponents of the FDA’s guidance was Representative Andy Harris (R-MD), an anesthesiologist turned legislator. Though he did not receive significant campaign contributions from the food industry, Harris was typical of the anti-regulatory, pro-corporate Tea Party legislators who poured into Congress in 2011.24 At a congressional hearing in 2015, Harris hauled out the much-criticized PURE study I discussed in chapter 3. He told FDA commissioner Hamburg:

That study actually indicates that if you are a healthy person you actually have an increased cardiovascular risk of salt restriction. . . . That’s not clear. I mean, I think you know that the party line is that salt is bad and decreasing salt is good, but it appears that’s not really true.25

That was representative of how flawed research can be used to muddy the waters, confuse consumers, and impede policy changes.

Like Frieden and Landa, I, too, felt the public had waited long enough for the FDA to act. After all, the Obama administration’s last year was fast approaching, and there was no way to predict what the next administration would do. So on October 8, 2015, CSPI, represented by the Public Citizen Litigation Group, sued the FDA in federal court.26 We charged that the FDA unlawfully had not responded to CSPI’s 2005 petition calling for mandatory sodium reductions. That lawsuit led to a negotiated agreement between the government’s lawyers and our lawyers that set a deadline of June 1, 2016, for the FDA finally to respond to our petition.

Target Time at FDA

And exactly on schedule, on June 1, the FDA proposed voluntary targets. Progress at last! The FDA provided goals for more than 150 categories of foods—both packaged and restaurant. They ranged from flavored potato chips to semisoft blue-veined cheese to frozen pizza with meat, poultry, or seafood.27 In setting targets, the FDA made sure that the lower sodium levels were practical for each food category and would not compromise the safety of any food. While the targets would still have to be finalized after a period of public comment, the proposal was a giant step forward.

The official name of the FDA’s proposal is “Voluntary Sodium Reduction Goals: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods: Guidance for Industry—Draft Guidance.” I’ll refer it to as the FDA’s guidance, plan, or targets.

The FDA proposed easy targets for industry to meet two years after they were finalized. Many foods were already meeting those targets, and the FDA did not anticipate any food safety or taste problems. If the entire food industry adhered to the two-year targets (an unlikely occurrence), the FDA estimated that Americans’ average sodium consumption would drop from 3,400 mg to 3,000 mg, a moderate 12 percent reduction.

The FDA also proposed much more ambitious targets to be met in 10 years. Full adherence to those targets would reduce average consumption to 2,300 mg, about one-third less than people now consume and in line with the “Dietary Guidelines for Americans” recommendation. Reaching those goals would prevent tens of thousands of premature deaths each year. The FDA said, “A consensus exists that reducing sodium intake to 2,300 mg/day is a viable, achievable, and effective strategy to reduce the incidence of [cardiovascular disease].”28

To buttress its case in anticipation of opposition, the HHS and FDA had undertaken an economic analysis of potential savings that would result from lower sodium intakes. (To obtain the document I had to file a request under the Freedom of Information Act and then wait more than a year.) The numbers are staggering. Cutting about 1,300 mg (about one-third) of sodium out of the average diet and getting close to 2,300 mg, according to the report, would save $142 billion over 20 years in reduced or delayed medical costs.29 The healthier and longer lives that Americans would enjoy would be worth an additional—and astonishing—$3.6 trillion over 20 years. Even if the FDA overestimated the benefits by several-fold—because lowering sodium would not happen overnight, and the assumptions might have overstated sodium’s effect on blood pressure—I’m sure that the medical savings alone would dwarf the estimated cost to companies of reformulating some of their products.

FDA’s blueprint was a variation of the ones developed in the United Kingdom and by New York City. It includes two kinds of targets, with one specifying sales-weighted average levels of sodium for each food category. (“Sales-weighted” means that the sodium content of an individual product is weighted by the volume of it sales—popular products are given more weight than poor-selling ones.) Those targets establish a benchmark for a whole category (for example, breakfast cereals made by various companies), but not for individual products (Kellogg Corn Flakes). Note that some companies could do nothing, but instead rely on their competitors to lower sodium sufficiently for the category to meet the target. The second kind, to help ensure that no individual product had huge amounts of sodium, sets maximum (voluntary) sodium levels for all products in a category. Maximum levels are important because they encourage companies to reformulate their saltiest products—and enable health officials, journalists, consumer groups, and consumers to identify foods containing grossly excessive amounts of sodium.

To understand how the two kinds of targets would operate, consider white bread.30 The FDA found that in 2010 the average bread (weighted by sales) had 523 mg per 100 g (or 148 mg per 1-ounce slice). At least one brand had 700 mg per 100 g. The two-year targets seek to lower that average to 440 mg, with no bread containing more than 570 mg. FDA’s 10-year target aims to bring the industry-wide average down to 300 mg per 100 g, with no bread having more than 460 mg.

Similarly, the average sodium level for all canned, ready-to-eat (not condensed) soups, weighted by the volumes of each soup sold, would (assuming that all the major companies met the guidelines) drop from 265 mg per 100 g (equivalent to 636 mg per cup) to 230 mg in two years and 200 mg in 10 years. Also, no ready-to-eat soup would have more than 310 mg per 100 g after two years and no more than 260 mg after 10 years. For comparison, Campbell’s Chunky Beef with Country Vegetables soup now contains 360 mg per 100 g. If Campbell followed the FDA’s guidance, the soup would have no more than 260 mg per 100 g in 10 years.

The CDC’s Frieden was one of many who cheered FDA’s announcement. He wrote in the Journal of the American Medical Association “that a decrease in sodium intake by as little as 400 milligrams a day could prevent 32,000 heart attacks and 20,000 strokes annually.”31 The American Heart Association (AHA)’s CEO Nancy Brown applauded the FDA’s move and urged the agency to finalize the targets soon (see box 9.1 for a look at the valiant salt reductions efforts of the AHA).32 “These new targets will spark a vital, healthy change in our food supply, a change consumers say they want,” Brown said, adding that lowering sodium levels could eliminate 1.5 million cases of uncontrolled hypertension and save billions of dollars in healthcare costs over the next decade.33 CSPI, too, applauded, saying, the proposal “provides clear goals by which companies can be held accountable. And, it helps level the playing field for those companies that are already trying to use less salt in their foods.”34

As welcome as the FDA’s action was, comparing a few of the FDA’s targets to those of Britain indicates how far behind the United States has fallen. For instance, the FDA’s short-term, sales-weighted target for breakfast cereals is 550 mg per 100 grams,35 whereas the average sodium content for cereals in Britain is already 176 mg.36 Similarly, American breads have about 500 mg per 100 g, and the FDA’s proposed goal is 430 mg. British breads already average 380 mg per 100 g, with a 2023 goal of 340 mg.

Box 9.1

Salt hero—American Heart Association

The American Heart Association (AHA) has been the only major health charity or professional organization that has stayed on the sodium battlefield through the decades. Its credible spokespersons—under the leadership of CEO Nancy Brown and backed by the association’s stellar reputation—have testified at government hearings, pressed for strong government recommendations, and lobbied Congress to require healthier school meals. Its physician allies have regularly, publicly, and loudly rebutted flawed scientific reports. Its Heart-Check program, by licensing companies to use the familiar heart-shaped logo on labels of heart-healthy foods, encourages companies to improve their products and enables consumers to choose healthier foods. On the educational front, the AHA has done everything from publishing low-sodium cookbooks, to sponsoring clever online videos on reducing salt, to publicizing “The Salty Six” processed-food categories: bread and rolls, cold cuts and cured meats, pizza, poultry, soup, and sandwiches. In recent years, the group has consistently supported the sodium limit of 1,500 mg per day for most adults as stated in the 2010 “Dietary Guidelines for Americans.”

Industry, Trade, and Food Giants Respond to Targets

Industry did not exactly embrace the program like a long-lost friend come home. Even though industry got its prize of an entirely voluntary proposal, some companies still feared that it could lead to mandatory regulations and subject companies to lawsuits if they did not meet the targets. I believe those concerns are akin to Chicken Little’s worries, but they led some industry officials to consider the voluntary targets to be little better than mandatory limits.

The Salt Institute blasted its predictably hyperbolic salvo at the FDA: “The issuance today of new ‘voluntary’ sodium reduction mandates by the FDA is tantamount to malpractice and inexcusable in the face of years of scientific evidence showing that population-wide sodium reduction strategies are unnecessary and could be harmful.”37 (Several months earlier, the industry group predicted that the FDA was going to issue guidelines because of “long-term pressure from the Center for Science in the Public Interest,” not because of the massive amount of scientific evidence it disagrees with.)38 Of course, the FDA did not issue any “mandate” and its guidance was only a proposal. Its final guidance would be entirely voluntary and could be ignored by any or all companies (an obvious defect in the eyes of those who hope that sodium consumption would be reduced rapidly and substantially).

The snack-food industry’s trade association, SNAC International, also criticized the FDA for proposing a new policy before a “real scientific consensus is reached.”39 It said that the modest two-year goals for snack foods were far too ambitious (100–300 mg too low), and wanted the agency to eliminate the upper-bound targets entirely.40 It contended that the National Academy of Medicine should conduct a new review before the FDA did anything. In fact, in 2019 that organization published just such a report—a scientific consensus—that recommended that healthy adults consume less than 2,300 mg of sodium per day, exactly what it recommended more than a decade earlier. SNAC did not dispute (or applaud) the NAM’s conclusions, but said that it supported stepwise reductions provided that they were small and voluntary.41

The GMA was more measured, but also raised concerns about endangering people who might consume too little sodium. The group said, “Like others inside and outside of government, we believe additional work is needed to determine the acceptable range of sodium intake for optimal health. This evaluation should include research that indicates health risks for people who consume too much sodium as well as health risks from consuming too little sodium.”42 With almost all Americans consuming far more sodium than is recommended, being concerned about under-consumption is like being concerned that a roller coaster will crash into your home.

The GMA’s official responses to the FDA were 15-page and 74-page epistles reminiscent of its statement about New York City’s NSRI. The association complained that two years did not give companies enough time to revise their recipes and that many proposed reductions were too steep.43

Other trade associations and individual companies also put in their two cents.44 General Mills, Red Lobster, and the National Restaurant Association all asked the FDA to extend the two-year targets for another one to three years. As for the longer-term targets, the American Bakers Association said, “We believe that ten years, for certain products, is not a feasible timeframe for complying with the proposed targets.” It asked that that target date be extended. The American Butter Institute and American Cheese Society asked the FDA to drop their entire food categories from its program.

Refreshingly, several leading manufacturers welcomed the FDA’s plan. Mars, which makes some salty Uncle Ben’s rice products in addition to its non-salty candy bars, said, “Mars applauds FDA for releasing its draft voluntary guidelines on sodium and we look forward to providing additional comments on the recommendations. At Mars, we have been working on reducing sodium in our products since . . . 2010.”45 Two weeks earlier, Nestlé, PepsiCo, and Unilever had joined Mars in urging that the FDA propose sodium targets.46 Interestingly, those industry giants, except for PepsiCo, quit the GMA and created the Sustainable Food Policy Alliance to support more progressive food and environmental policies. In 2019, that alliance also applauded the NAM’s updated recommendation for lowering sodium to an average of 2,300 mg per day, saying, “Food companies can and should do more to reduce sodium in food products. Reducing sodium levels can be a powerful public health action to lower blood pressure, a leading risk for heart disease.”47

Flaws in the Ointment

I was delighted that the FDA had finally taken a big step forward on the sodium issue, even if its proposed guidance was voluntary. But one prominent flaw would limit the plan’s impact: the 8-year gap between the 2-year and the 10-year goals. That is different from the voluntary plans developed by the NSRI and the United Kingdom, which phased in gradually lower targets every two or three years. Similarly, Chile had two-year nutrient targets for its food-labeling standards and then tightened them after two years and again after one more year.

Mary R. L’Abbé, the former director of the Bureau of Nutritional Sciences at Health Canada and now a professor at the University of Toronto, says that the lack of interim targets means that sodium reduction would likely quietly slide off the agendas of both industry and government after the first flurry of activity. She worries that “10 years is really almost a way of burying something sometimes. There’s a lot of in-house corporate expertise that you lose if you just pick up and start and stop.”48 Government and industry experts likely would move on to pressing new issues. And journalists, legislators, and the public would probably forget about the whole thing.

The National Hispanic Medical Association said in 2016, “If anything, the FDA should set a more aggressive timetable; after all, this is only voluntary guidance.” As it pointed out, “Establishing the 10-year targets in 2017 would mean 17 years between the long-term sodium-reduction goals and the 2010 baseline.”49 Now, as I write in 2020, it is clear that industry would have had more than 20 years to reach the 10-year targets, assuming that those targets are finalized.

Separate from the long-drawn-out timetable, the National Medical Association (the organization of African American physicians) pointed out a serious weakness in how the targets applied to restaurants.50 It said, “many restaurant meals are enormous, with some providing one or more days’ worth of sodium, even though their sodium content per 100 grams may not be excessive.” It urged the FDA to set maximum sodium levels per serving, not just per 100 grams, for three key food categories: Sandwiches, Mixed Ingredient Dishes, and Other Combination Foods.

New White House, New Scrutiny

Unfortunately, because the Obama administration took so long to propose the sodium targets, it did not have enough time to obtain comments from industry and consumers and finalize the sodium targets before the president left office in January 2017. Once Donald Trump was elected president, I assumed that it would be a long, long time before the targets were finalized. President Trump was far more enthusiastic about repealing laws, regulations, and voluntary guidances than adopting new ones—no matter how many lives they might save. But, remarkably, the new commissioner of the FDA, Dr. Scott Gottlieb, was not a shrink-the-government crusader like many other high-level appointees. He was seriously interested in fulfilling his responsibilities as a health official.

In March 2018, Gottlieb expressed his concerns about diets high in sodium. He said that “researchers have estimated that reducing sodium intake by one-half teaspoon [about 1,200 mg] a day could prevent nearly 100,000 premature deaths a year and up to 120,000 new cases of coronary heart disease, 66,000 strokes, and 99,000 heart attacks.” He added, “There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet.” Gottlieb said that the FDA planned to finalize the two-year targets in 2019.51

But the salt wars took an unexpected turn when Gottlieb resigned from his position in March 2019 and was not replaced until December. Also in 2019, the snack-food industry, including PepsiCo (Frito-Lay), ConAgra (Slim Jims, Orville Redenbacher’s), Campbell (Pepperidge Farm cookies), and others, was hatching a plan to delay the finalization of the targets. The American Bakers Association, American Frozen Food Institute, International Dairy Foods Association, North American Meat Institute, and National Restaurant Association were also part of that effort, according to Politico, the news outlet focusing on politics.52

One knowledgeable person (who would discuss the issue only on an anonymous basis) said that much of the food industry “was terrified” that the Trump administration would finalize the sodium targets. So the trade associations, doing business as the Sodium Coalition, lobbied the FDA and the White House to keep the targets in abeyance until Trump administration economists conducted a new estimate of the costs and benefits of the FDA’s program. That could easily delay the final program for another year and give industry more time to kill it completely (such as by getting Congress to include a fatal sentence in an appropriations bill). As of spring 2020, the FDA’s four-year-old, life-saving plan was still not finalized.

But wait. Why is the White House involved—isn’t the FDA an independent agency? By law it is, but in reality its parent agency, the Department of Health and Human Services, and the White House scrutinize every major action the agency wants to undertake.

Meanwhile, that same insider told me that SNAC apparently was telling the White House and other parts of the government about its own assessment of the costs—but not the benefits—of complying with the sodium guidelines. That person understood that the costs were “grossly exaggerated.” The industry group told Politico that it was merely trying to be helpful: “We believe an OMB review will be a helpful part of the policymaking process.” Laura MacCleery, CSPI’s policy director, was more candid, telling Politico, “It’s unfortunate that there’s a last-ditch attempt to throw sand in the gears.”53 (SNAC did not respond to my emailed questions.)

Big Questions: Why the Voluntary Path and Long Gestation?

Considering the utter failure of voluntary action in the past, why did the FDA once again go the voluntary route? And—considering that CSPI petitioned the FDA in 1978 and 2005 to lower sodium levels in the food supply, that the agency’s SCOGS advisory committee concluded in 1979 that salt was not “generally recognized as safe,” and that the Institute of Medicine in 2010 recommended that the FDA set mandatory limits on sodium—why did the FDA take so many years to propose targets? The answers are complicated—and good examples of why it takes a lot longer to adopt new federal policies in real life than in a one-hour TV drama.

I was initially sorely disappointed that the FDA was not setting mandatory maximum sodium levels. Such limits for all foods in a category, even if they would affect only a minority of products, have at least three advantages over a voluntary approach. First, they would have teeth and ensure that all companies actually trimmed sodium in their saltiest products. Second, the FDA could easily enforce them. And third, they would provide a level playing field—companies that made the effort to lower sodium would not have to compete with companies that spared themselves the effort and expense. Kraft Food’s Senior Vice President of Research and Nutrition, Todd Abraham, said that Kraft lost sales when it reduced sodium but other companies did not.54

On the other hand, FDA officials recognized that just setting maximum limits on sodium would not spur companies to reduce levels in the great majority of foods already below those limits. In fact, companies that used less sodium might even feel they had permission to add more salt up to the maximum. The FDA wanted to accomplish more. Complementing maxima with targets for entire food categories would give companies a benchmark for cutting the sodium in large fractions of their portfolios.

I have since been persuaded that the voluntary approach was inevitable. Mike Taylor, who was the FDA’s Deputy Commissioner for Foods at the time and a strong public health advocate, defended the voluntary approach. FDA officials felt they lacked “the data to justify specific limits for each of the many categories of food products.” However, Taylor felt that even a voluntary program would represent major progress.55 He added, “Importantly, of course, FDA did do a lot of technical homework to produce the voluntary targets, and my hope was that there would be learning and additional data collection that could in the future support mandatory limits.”56 He might have added that most other nations’ salt-reduction initiatives are voluntary.

Landa, another dedicated health proponent, regarded even the voluntary guidance as “a fairly heavy lift” both scientifically and legally and believed that an actual regulation to limit sodium “would not have gotten off the ground” because of implacable industry opposition—but it would have been tough even without that opposition.57 For one thing, libertarians would have waved the “nanny state” flag.

Companies fearing that strict legal limits on sodium content would necessitate expensive reformulations of salty foods, impair their products’ taste, and reduce sales might well have gotten their friends in Congress to shut down the whole sodium-reduction initiative. In contrast, setting voluntary targets would shrink all the pitfalls and still impose pressure on industry to cut the salt.

But even the FDA’s voluntary scheme was temporarily handcuffed by Congress. Representative Harris sponsored a measure that prevented the FDA from working on its 10-year guidelines until the NAM had issued a report on the safety of cutting sodium to 2,300 mg per day. The appropriations legislation for 2017, 2018, and 2019 included a measure that

prohibits the FDA from using funds provided . . . to develop, issue, promote, or advance any regulations applicable to food manufacturers for population-wide sodium reduction actions or to develop, issue, promote or advance final guidance . . . for long term [10-year] population-wide sodium reduction actions until the dietary reference intake report with respect to sodium is completed.58

The administration’s slowness in proposing its guidance is another story. After all, the FDA scheme for targets was similar to what the United Kingdom and New York City had done, so the agency was not breaking any new conceptual ground. But what seemed all too slow from the outside was par for the course, or even rapid, for people whose watches worked on government timetables.

To help understand the administration’s concerns and emphasize the urgency of reducing sodium, in 2012 the AHA, APHA, and CSPI met with White House staffers. Across the table were several officials, including Sam Kass, a restaurant chef who had been the Obamas’ personal chef before he became the White House Senior Policy Advisor for Healthy Food Initiatives and a chef at 1600 Pennsylvania Avenue. In other words, he was the nutrition chief at the White House, the first such person to have that role. The officials explained that competing priorities inevitably slowed down the release of sodium guidelines. But at that time, the FDA’s proposal for voluntary guidelines was nowhere near completion or headed to the White House.59

I don’t know if we impressed them with the importance and practicality of lowering sodium across the entire food supply. But I do remember well one awkward moment when a member of our delegation stated with utmost confidence that manufacturers and restaurants could easily lower salt levels by simply omitting salt from all their recipes. That person—as I soon discovered—had no idea who Kass was or that Kass had more than a little experience cooking delicious meals in some very prestigious kitchens. I bet Kass got a good laugh out of that faux pas.

In February 2014, those same health groups, plus the AMA, met again with White House officials to press for action on salt. At that time, the FDA still had not sent a proposal to the White House. One official asked what we thought about setting targets for only key—not all—sources of sodium and also said that the administration was not likely to move ahead on salt before it acted on heart-disease-promoting trans fat (which the FDA banned a year later). Another official criticized the health groups for exaggerating the risks of high-sodium diets and warned that even a voluntary reduction program could trigger the ire of companies that suspected that voluntary recommendations could lead to mandatory requirements.

In doing research for this book, I asked former officials familiar with the “sausage-making process” inside the government why it took so long to propose the guidelines. Several talked to me on the condition of anonymity. At the FDA, Michael Landa and others emphasized the sheer enormity of the task. Staffers had to evaluate the range of sodium levels in products that spanned more than 150 categories, identify sensible and defensible average and maximum levels for each category, make sure that sodium’s preservative and other functions were not lost, and determine that the whole initiative jibed with the law. Another reason was bandwidth: the FDA’s staff had other major priorities competing for their time—implementing a complicated new food safety law, banning partially hydrogenated vegetable oil (the source of artificial trans fat), and making controversial revisions to the Nutrition Facts label. The sodium guidelines sometimes got pushed aside.60 From the White House’s perspective, Kass said, “it took [the FDA] years to get us a proposal.”61

Adding to the scientists’ challenge was the bureaucratic problem. The government’s process for issuing anything is complicated and slow. The FDA’s foods division first must develop a plan and get buy-in from the commissioner’s office. (The draft document was almost cleared to go upstairs in July 2013.)62 The agency then needs to circulate it to and get agreement from sister agencies, such as the CDC, USDA, and the National Heart, Lung, and Blood Institute (part of the National Institutes of Health). Next, its parent agency, the Department of Health and Human Services (HHS), has to approve the plan. HHS staffers told me they as well had too much work and too little time, but the department always supported, not nitpicked, the FDA’s draft plan.

After going up and down the departmental ladder at HHS, a draft proposal has to pass muster at the White House, which typically asks for changes or an economic analysis that would show that the whole endeavor was worth the trouble. Competing priorities there may have played a role, too. First Lady Michelle Obama, the most ardent advocate for better nutrition ever to occupy the White House, was pressing especially hard for requiring calorie labeling at chain restaurants, updating the Nutrition Facts labels, and promoting children’s health through healthier school meals and the Let’s Move program, though she also championed sodium reductions. And the White House considered implementing the Affordable Care Act (Obamacare) its absolute top priority, with any other health issues being a distraction or obstruction, according to one former administration official. That person wished progress could have been faster, but did not question the strategic focus on Obamacare. Kass, however, disagreed with the “competing priorities” problem. He said, “I just think it’s inaccurate. . . . We can walk and chew gum at the same time.”63 From the FDA’s perspective, though, Commissioner Hamburg “felt like there were a million pushbacks and ‘slow walks’ of reviews.”64 (Several former White House officials who might have rounded out the picture did not respond to my interview requests.)

Kass told me that everyone in the White House was on board with the sodium plan. But, he added, “It just takes time to do a piece of policy that is that complicated. . . . At every turn it was a priority.” The GMA, ConAgra, and others were lobbying the White House to drop or water down the sodium-reduction plan, but that did not appear to have been a major impediment. For Kass, a bigger concern was the FDA’s estimate of the possible costs of the plan to industry. He was shocked by the magnitude of the costs—billions of dollars. “It was astronomical,” he said, a “f***ing disaster.” Kass feared that disclosure of those costs—even though the benefits might be hundreds of times greater—would trigger a firestorm of opposition from Republicans in Congress and the food industry. That “could potentially kill this project,” Kass said, adding that the FDA “did a great job on a very, very complicated piece of policy.” Then he suggested how the cost estimate and political risk could have been kept significantly smaller:

They treated [the guidance] as if this would be a law and that every company would have to change their products, which dramatically inflated the perceived costs of the effort and, in our opinion, left the policy really susceptible to attack, and made it quite vulnerable, both as a policy and also how Republicans could potentially use it to put forward laws that in the future could ban the FDA from taking this kind of action.65

I fervently wanted to obtain the FDA’s estimate of the potential costs to industry, but even a Freedom of Information Act request couldn’t pry the document out of the agency.

Kass was right that the voluntary nature of the sodium-reduction program means that some companies would do nothing or make smaller reductions than the guidelines call for—greatly shrinking industry’s actual costs. Consequently, the White House had the FDA rework its economic estimates, adding further delay.

Though all those explanations make sense, another official who is knowledgeable about the Obama administration’s regulatory practices thinks they downplay industry’s role. That official spoke of two factors he felt had a major impact on the sodium effort. First, industry was more opposed to sodium limits, even if voluntary, than to food safety, school meals, and other matters because those limits could ultimately lead to requirements that would force companies to reformulate large percentages of their products. Second, and more generally, this person told me, the administration was excessively risk-averse and could have made more and faster progress on many issues.

The process to propose sodium reductions was frustratingly slow, but there was no villain or cabal that sought to undermine the FDA’s effort to lower sodium consumption. Rather, it was a case of how the Washington policy-making apparatus works when it comes to anything that is complicated, controversial, and consequential. As Kass said, “It took longer than everybody wanted, but we got it done. And I think that’s what’s most important.”66 True, but the matter was not really “done.” It took the administration so long to propose the guidelines that there was no time to finalize them, and the matter has languished for four years.

School Cafeteria Fights

One of the important battlefields in the salt wars is schools. Health advocates have long focused on the nutritional quality of school meals, because some 30 million children eat low-cost or free lunches per day, and 15 million children eat breakfast at school.67 For decades, the meals needed improvement and updating to be consistent with the “Dietary Guidelines” as required by law. All too often they were brimming with excess calories, sodium, and saturated fat and deficient in vegetables and whole grains. Recall from chapter 2 the research indicating that higher-sodium diets in infancy and childhood lead to higher blood pressure as children grow older. Reformers hope that eating healthier meals in school would accustom children (along with their families) to eating healthier meals outside of schools, too.

Health advocates in government (especially First Lady Michelle Obama, Secretary of Agriculture Tom Vilsack, Senator Tom Harkin, and Representative Rosa DeLauro) and out (including Margo Wootan, my long-time colleague at CSPI, and the coalition of local and national nutrition organizations, National Alliance for Nutrition and Activity, that she created) waged long battles to improve school meals. Their efforts led to the passage in 2010 of the Healthy Hunger-Free Kids Act, which mandated more-nutritious school meals.68

In 2012, the USDA, which oversees school meals, adopted an ambitious schedule for improving them. New regulations required schools to serve more fruits, vegetables, and whole grains and to use less salt. The USDA told schools that they would have to reduce sodium levels in three stages over the next decade, with Target 1, 2, and 3 deadlines of July 1, 2014, 2017, and 2022—hardly a rushed schedule. Target 2 aimed to reduce sodium 24 percent below the 2014 level, and Target 3 aimed to cut sodium by an ambitious 48 percent below the 2014 level.69

Almost all schools met the relatively easy 2014 Target 1 goals, but then the school-food industry swung into action and lobbied Congress hard to block further improvements.70

Schwan’s Company supplies about 70 percent of the pizzas—notoriously salty foods—served in K–12 schools. The company’s social responsibility report states that Schwan’s Food Service “works . . . to continuously improve on our great-tasting, wholesome foods for students.”71 Sadly, Schwan’s was one of the companies that fought the hardest against lowering sodium levels. Considering its products, its opposition was not a great surprise.

But opposition to the cutbacks came not just from industry. The School Nutrition Association (SNA), which represents some 58,000 people who direct school-food programs and prepare those meals, took a surprising position. In keeping with its wholesome-sounding name, the group claims that its members “have been providing America’s students with healthy, balanced school meals that help them succeed in the classroom and beyond.”72 In fact, until recently the SNA campaigned for healthier meals, but then it joined the opponents.

So why, you might ask, would a “nutrition association” oppose improved nutrition? The group said that many students would have scraped their less-salty meals into the garbage bins and eaten fewer cafeteria meals, reducing revenues.73 I think, though, that it is more likely that this is an occasion to “follow the money.” Around 2012, the SNA got $6.7 million, or two-thirds of its total revenue,74 from companies that sell foods to schools: Campbell, Del Monte, Domino’s Pizza, General Mills, Kellogg, Kraft Heinz, Land O’ Lakes, PepsiCo, Perdue, Schwan’s, Tyson, Uncle Ben’s, and dozens of others.75 (That’s now down to about half its revenues.)76 In 2012 and 2013 those commercial interests flexed their muscles and got the SNA to change its tune.77 (One other money issue: the SNA pays its CEO, Patricia Montague, about $400,000 per year in salary and benefits.)78

The SNA fired its lobbyist of more than three decades, Marshall Matz of OFW Law and a long-standing and widely respected nutrition and anti-hunger advocate. In his stead, the SNA hired a major Washington lobbying firm, Barnes & Thornburg, which represents the pesticide industry, McDonald’s, and Kellogg. The SNA even filed an ethics complaint, which was ultimately dismissed, with the DC Bar that could have led to the disbarment of Matz and a law partner.79 The stunning reversal of the SNA’s stance on nutrition led to a mini-revolt, with 19 former presidents of the group urging Congress to stay the course and not interfere with the USDA’s plan.80 Stanley C. Garnett, who had run the USDA’s child nutrition division, said that the SNA “sold their souls to the devil.”81

The industry forces succeeded in delaying the 2017 and 2022 sodium reductions until the matter was studied further. Congress used the appropriations process to temporarily prohibit “funds from being used to implement regulations requiring a specified reduction in sodium in federally reimbursed meals, foods, and snacks sold in schools.”82 But the SNA continued to lobby for a permanent delay to allow “school nutrition professionals to continue serving healthy, nutritious meals that students will eat.”83 They contended that meeting the tougher sodium standards would not only be expensive, but would be impossible without some kind of technological breakthrough.

Major industry players supported SNA. In a letter to USDA, 14 trade associations—from the American Association of Meat Processors to the Wheat Foods Council to SNAC International—avowed, as somberly and sincerely as a funeral director, how “it is vitally important for scientific consensus to be the basis for our US policies.” They then called on USDA secretary Sonny Perdue not to require any further reductions in sodium until the NAM updated its sodium recommendations.84 The 2019 NAM report was exactly what they said they wanted—but it recommended almost exactly the same sodium intakes as before—except lower ones for children 4 to 13 years old. I have not seen any indication that industry, now that it got the report it had demanded, will support to new sodium limits in school meals.

The USDA did not wait for the new NAM report, but granted the industry’s wish in 2018 when it delayed the 2017 Target 2 requirements until 2024. It also eliminated the original 2022 Target 3 deadlines. The agriculture department, newly a subscriber to Orwellian phrasing, professed that it “remains committed to strong nutrition standards for school meals”85 and that its lengthy delays actually “empowered local schools with additional options to serve healthy and appealing meals.”86 The USDA earlier said it wanted to revise its nutrition standards so as to “make school meals great again,” playing off President Trump’s favorite slogan. That, officials said, would prevent greater food waste by children who balked at eating more whole grains and vegetables and less-salty foods.87 The SNA applauded the USDA for its revised rule.88 But CSPI’s Wootan said, “The Trump rollbacks are recklessly putting kids’ health in jeopardy.”89

The argument for rolling back the health-oriented rule was totally undercut by 2019 research—conducted by USDA itself.90 The department’s Food and Nutrition Service found that the initial 2014 changes led to much healthier school meals without increasing plate waste. But the study had no effect on the USDA’s policies.

The USDA’s actions appeared to be illegal and have been challenged in court. The law requires the nutritional quality of school meals to be based on the “Dietary Guidelines for Americans.” It also requires the USDA to provide cogent responses to comments that people submitted in response to the proposed rule changes (96 percent of the 85,000 comments favored sticking to the original sodium restrictions). To force the USDA to reinstate the original sodium limits, in April 2019 New York State, along with California, Illinois, Minnesota, New Mexico, Vermont, and the District of Columbia, sued the USDA in federal court for not giving a rationale for ignoring the law and the outpouring of public support.91 New York attorney general Letitia James, said, “The Trump Administration has undermined key health benefits for our children—standards for salt and whole grains in school meals—with deliberate disregard for science, expert opinion, and the law.”92

On the same day two consumer groups, Healthy School Food Maryland and CSPI, filed a similar lawsuit.93 One year later, in April 2020, a federal judge struck down USDA’s rule, declaring that the USDA failed to allow the public notice to comment on possibly gutting the standards.94 That decision mooted the states’ lawsuit still in court.95

Notwithstanding the USDA’s degradation of school meals, in 2020 Secretary Perdue had the chutzpah to say, “Food ought not be political. Goodness. If we can do anything in a bipartisan way it should be about feeding kids.”96

The Trump administration’s delays are one reason why many kids are still eating high-sodium Campbell soups marketed to schools.97 On a per-cup basis, Campbell’s Classic Minestrone provides 670 mg of sodium, Reserve Red Lentil Vegetable provides 890 mg, and Chunky Beef with Country Vegetables a whopping 1,520 mg. In supermarkets, Campbell’s kid-oriented soups—such as Marvel Avengers soups or Disney Princess Jasmine Soup—contain no more than 480 mg per cup. (The recommended daily limit for children 4 to 8 is 1,500 mg; for children 9 to 13 it is 1,800 mg.)

Fortunately, many school districts are reducing sodium regardless of what industry’s friends in Washington do. A few are meeting the Target 2 levels, but the Target 3 goals are more aspirational than realistic for now.

Tamara Yarmon is the nutrition director of Omaha Public Schools, which has more than 50,000 students. To achieve Target 2, she says that several changes have been key: cooking more foods from scratch, such as gravies, dressings, chili, and sloppy joes; buying lower-sodium breads, chicken nuggets, and other foods from local or national suppliers; offering more fresh vegetables; and having a low-sodium seasonings bar.98

Stephen O’Brien, Director of Strategic Partnerships and Policy for New York City’s Department of Education, says that meeting the Target 2 levels is challenging because chefs and manufacturers must adjust ingredients in numerous dishes while still delivering meals that are tasty and accepted by students. But, he says, schools need to make the effort, and New York’s school meals largely meet Target 2 numbers. If New York City’s schools, with more than a million ethnically diverse students who have equally diverse taste preferences, can serve tasty, moderate-sodium meals, then presumably other school districts could.

The Dallas school district’s executive director of food service, Michael Rosenberger, says that Dallas’s meals also are close to meeting Target 2 levels. He uses as much fresh and locally grown foods as possible. But many of the foods he buys from processors or obtains through the USDA’s commodities program, such as breaded chicken tenders or pizza, he says, are too high in salt.

Cities Pass Laws

Federal and state governments certainly have public support for setting nutrition requirements for schools. But getting restaurants to offer nutritious dishes is a much greater challenge. Part of the problem is that many people throw their health concerns to the wind when they eat out. That might have been okay when eating at restaurants was a special event, but now Americans get one-third of their calories at restaurants, cafeterias, and other places outside the home. The calorie labeling now required on menus and menu boards at chains with 20 or more outlets nationwide should encourage diners to think before they order. That might encourage some establishments to shrink their often humongous, high-calorie servings, simultaneously shrinking the amount of sodium, saturated fat, and sugar they contain. While sodium is not listed on menus, chain restaurants are required to provide, upon request, brochures that list all the same nutrients that are on food labels.

Many large American cities have high percentages of African Americans, and African American adults have among the highest rates of hypertension in the world—40 percent.99 That is one of the reasons why a few cities are trying to reduce sodium consumption. First New York City in 2015 and then Philadelphia in 2018 demonstrated one way that local or state governments could educate consumers and chain restaurants, decrease sodium intakes, and fight hypertension. Both cities require a saltshaker icon to be depicted on menus and menu boards next to any food or meal that has more than a whole day’s worth of sodium—2,300 mg (see figure 9.1). Philadelphia’s version also requires the words “SODIUM WARNING,” printed in red or black, to the right of the icon.100 “Heart disease and stroke are robbing too many Philadelphians of their lives and their ability to work and support their families,” said Mayor Jim Kenney. “A sodium warning label gives people information they need to help keep themselves healthy.”101

Figure 9.1

Saltshaker warning icons: Sodium warnings required next to high-sodium items on menus at chain restaurants in (a) New York City and (b) Philadelphia.

A whole day’s worth of sodium is, if anything, an enormously generous threshold for triggering a warning notice. But even so, the litigious National Restaurant Association sued New York to kill the Board of Health’s mandate, charging that it was “arbitrary and capricious” and “filled with irrational exclusions and nonsensical loopholes.”102 To the association’s dismay, the justice presiding over the case, Eileen Rakower, upheld the saltshaker warning, saying: “Information is power.” The association’s lawyer, Angelo Amador, was quick to announce not only the NRA’s plan to appeal but also its intention to “seek interim emergency relief” given the emergency as he saw it: “Today’s decision by the court to uphold this arbitrary, onerous, and costly mandate is a blow to small business owners.”103 Now, four years after the court loss and the subsequent lost appeal,104 I haven’t heard a single word about small restaurants experiencing any harm. And that makes total sense, because only large restaurants, with at least 15 stores nationwide, are covered by the two cities’ ordinances.

At least one major chain, Panera, supported New York City’s warning notice. Ronald Schaich, the CEO of Panera, said, “There are a number of items on [our] menu, not a lot, that have high salt levels or that are indulgences and . . . that is OK as long as you are clear, you’re making that choice, you’re aware of it and you have the ability to make it on your own.”105 If only more industry officials felt that way! In response to the menu notices, Panera lowered the sodium in three items at its locations nationwide—the soup bread bowl (by 290 mg), the Bacon Turkey Bravo Sandwich (by 740 mg), and the Italian Combo Sandwich (by 630 mg).106 But several other items, including a large Baja Mac & Cheese (2,330 mg) and Chicken Noodle Soup Bread Bowl (2,150 mg), remain sodium shockers.

A gentler approach to inform consumers and, ideally, change their behavior is a public education campaign. Policy makers often propose such campaigns because they rarely offend companies (and corporate campaign contributors). But in the face of massive advertising and tempting unhealthy foods, health education campaigns are generally expensive and ineffective. One scientific review concluded that an education campaign that included intensive counseling might have a small effect on people with hypertension, but was “unsuited” for population-wide efforts.107

Philadelphia’s health department decided to take a different approach to education. In 2013 it started a campaign aimed not at consumers but at Chinese restaurants, which serve six million meals a year. The campaign focused on salt because Philadelphia is saddled with a higher rate of hypertension than other big cities. Its goal was to get the restaurants—where foods are generally absurdly salty—to cut the salt and monosodium glutamate (MSG), the flavor enhancer.108 Philadelphia has over 400 independently owned Chinese restaurants, and half of them participated in the program. Temple University researchers found that after three years, 206 take-out restaurants reduced sodium by an average of 36 percent in Shrimp and Broccoli, 28 percent in Chicken Lo Mein, and 19 percent in General Tso’s Chicken.109 Overall, the participating restaurants reduced sodium by almost one-third. Restaurateurs, take notice: Grace Ma, director of the Center for Asian Health at Temple University’s Lewis Katz School of Medicine, said that a taste test showed that customers could not even detect the lower sodium content.

Industry Begins to Awaken

For decades, most food manufacturers and restaurants never paid attention to the amount of salt and other sodium-containing additives they used. But especially after the United Kingdom’s Food Standards Agency in the mid-2000s began pressuring companies to use less salt, many multinational companies began to realize that they needed to put that issue on their agendas. And if they were going to use less salt in the UK, some felt they should do it elsewhere. Adding to the pressure in the United States were New York City’s 2009 National Salt Reduction Initiative and, especially, the call by the IOM in 2010 for mandatory limits on sodium.

ConAgra, General Mills, Kellogg, Kraft, Nestlé, and other major manufacturers began lowering sodium levels in some of their products, as did some large chain restaurants, including Arby’s, Boston Market, Denny’s, and McDonald’s. (No data are available for independent restaurants, but I doubt that many have lowered sodium levels.) Table 9.1 shows some of the promised or actual reductions. Notwithstanding the reductions, though, many of these companies’ products are still loaded with sodium.

Some of the sodium reductions have been dramatic. For instance, digging through my old files, I found that since 1978 the sodium content of Wishbone Italian Salad Dressing was reduced from 362 to 170 mg per tablespoon. Nabisco cut the sodium in Wheat Thins from 370 to 180 mg per ounce and in Cheese Nips crackers from 480 (in 1972) to 150 mg. General Mills cut the sodium in Cheerios from 330 (in 1984) to 140 mg and in Wheaties from 370 (1984) to 185 mg per ounce. Sodium in Campbell’s Tomato Soup was reduced from 760 to 480 mg per cup. Since the early 1980s, Frito-Lay reduced sodium from 260 to 170 mg (35 percent) per ounce in its Lay’s Classic Potato Chips. And three Hungry Jack Complete 4-inch pancakes used to have 1,150 mg, but now have only 480 mg (thanks, in part, to several potassium- and calcium-containing ingredients used in place of sodium-containing counterparts, a substitution I discuss later in this chapter). Admittedly, those are cherry-picked examples—many products had the same sodium levels over the decades, and a few even had more sodium—but it is nice to see some major reductions.

Table 9.1

Company commitments to lowering sodium*

Food Manufacturers
Company	Year	Commitments or Achievements
Barilla	2013	The company reduced salt by 11% across its portfolio.
Campbell	2010	By 2011, 71 Pepperidge Farm breads will have 25% less sodium than regular breads, rolls, bagels.
	2016	Sodium in more than 792 products has been reduced by 5–33%. Sodium in SpaghettiOs canned pastas was cut by up to 35%.
ConAgra	2013	Before 2006, sodium was cut by 20–30% in Kid Cuisine foods, 19% in the Chef Boyardee line, and up to 40% in Marie Callender’s foods. Sodium was reduced in 80% of its products by 20% since 2010.
	2016	By 2016, sodium in Orville Redenbacher’s Microwave Popcorn–Butter was reduced by 33%, Chef Boyardee Beef Ravioli by 34%, and Hunt’s Original Diced Tomatoes by 49%.
General Mills	2016	By 2020, General Mills met its goal of 20% reductions in all of its key product categories, including breakfast cereals, frozen pizza, and baking mixes.
Heinz	2016	Between 2010 and 2014, Heinz decreased sodium 10–40% in key retail products, including a 15% reduction in ketchup.
Kellogg	2017	By 2016, sodium in breakfast cereals was reduced by an average of 33%; 84% of cereals had 150 mg or less per serving.
Kraft	2012	Sodium was reduced by an average of 10% across its portfolio by 2013.
	2014	Reductions included Kraft Original BBQ Sauce (40%), Lunchables (average of 25%), Teddy Grahams Honey Graham Snacks (25%), Oscar Mayer Beef Bologna (25%), Kraft Singles American Slices (18%).
Mars	2015	Reduced sodium by 25% globally.
Nestlé	2014	Sodium was lowered in Stouffer’s Mac & Cheese by almost 15%, 12–31% in California Pizza Kitchen pizzas, in Lean Cuisine from an average of 1,000 mg (10 products in 1981) to less than 600 mg per package.
	2015	Reduce sodium by 10% across DiGiorno, Tombstone, California Pizza Kitchen, Jack’s, Hot Pockets, and Lean Pockets by 2016.
	2018	Reduce sodium by an average of at least 10% over 2017–2020 in foods that are not aligned with the WHO recommended limit of 2,000 mg per day. That is in addition to the more than 20% reductions since 2005.
Nissin	2016	Nissin reduced sodium 25% by reducing salt and eliminating MSG in Cup Noodles’ most popular flavor, chicken, from 1,430 to 1,070 mg.
PepsiCo	2013	Reduced sodium in flavored potato chips by an average of about 25%.
	2016	The 2025 goal is that at least 75% of its global-foods volume will not exceed 1.3 milligrams of sodium per calorie (in 2018 58% of foods met that level). Between 2006 and 2020 the average sodium per serving in key global food brands will have been reduced by 25%.
Sara Lee	2010	Reducing sodium by an average of 20% over five years in Ball Park franks, Jimmy Dean frozen breakfast meals, Hillshire Farms lunchmeat, Sara Lee breads.
Unilever	2013	In 2013 it gradually cut sodium in some soups and other products by up to 40%.
	2018	In 2018 sodium levels in 66% of its foods (by volume) were consistent with WHO recommended intakes of 2,000 mg per day.
Walmart	2011–2016	From 2011 to 2015 Walmart cut sodium in its private-label foods by 18% (shy of its 25% goal). A new goal set in 2016 was to reduce sodium by another 20%.
Restaurants
Company	Year	Commitments or Achievements
Boston Market	2010	Sodium in poultry gravy cut by 50%; reduced sodium in “fresh, all-natural chicken” and stuffing by 20% and mashed potatoes by 26%. Customers did not notice any difference.
	2012	Will reduce sodium by 15% menu-wide by the end of 2014.
Burger King	2008	Limited sodium in kids meals to 600 mg.
	2010	Reduced sodium in ketchup (25%), ham (40%), Chicken Tenders (30%).
Darden (Olive Garden, LongHorn Steakhouse, other restaurants)	2016	A 2011 commitment to reduce sodium company-wide by 10% over 10 years blossomed into a 19% reduction by 2016.
McDonald’s	2012	Reduced sodium in Grilled Chicken patty by 45%, Crispy Chicken patty by 50%, across product line by 11%. Its 2012 goal was to reduce sodium by an average of 15% across nationally available foods by 2015.
Sodexo (food service management)	2011	Reduce average sodium content in top 100 recipes by 25% over the next two years and by 50% over the next five years. Company has nutrition standards intended to lower sodium.
Subway	2013	Eight Fresh Fit 6-inch sandwiches that had more than 1,000 mg of sodium were reduced by an average of 32%.
Taco Bell	2017	An overall 15% sodium reduction since 2008, including 32% less in chicken, 6% less in ground beef, 12% less in steak, and 50% in sauces. Taco Bell is aiming for a 25% reduction across its menu by 2025.

*Information gathered from company reports and news articles without third-party verification.

Restaurants

Walmart, the supermarket behemoth, might have made a bigger dent in the salt problem than any other company—or than all other companies. In 2011, as part of a broader nutrition program, Walmart said it would reduce sodium in its house brand by 25 percent by 2015110 and press national brands to do the same. It did not quite reach that goal, but the 18 percent reduction in four years was still impressive.111 Sam Kass, who negotiated with Walmart for months to get strong commitments, told me in 2019, “in terms of what’s actually so far taken out, more sodium, there’s no question that the Walmart agreement did more for that than the FDA has at this point.”112

Looking more broadly at the food supply, several studies have measured changes in sodium levels. In one, researchers did not find any change in sodium consumption, be it from foods prepared at home or outside the home, between 1999 and 2012.113 More recently, the USDA and CDC started a Sentinel Foods Surveillance Program, which examined a large and diverse group of processed and restaurant foods.114 They reviewed labels and conducted laboratory tests to identify changes over roughly a four-year period. Based on the labels, sodium changed in one-third of the products, with about twice as many decreases as increases. The researchers said that some of the decreases were likely due to the use of potassium salts, such as in refrigerated biscuit dough. I have more to say about potassium later in this chapter.

The biggest study, and the one with the most optimistic results, looked at the sodium content of packaged (but not restaurant) foods between 2000 and 2014. Based on the purchases by 172,000 households at grocery stores, the sodium “density”—the amount of sodium per 100 grams (3.5 ounces) of food—declined by 12 percent over those 15 years.115 That decline has not yet been reflected in the National Health and Nutrition Examination Survey (NHANES). Despite their welcome finding, the researchers cautioned: “The slow rate of decline in sodium from store-bought foods suggests that more concerted sodium reduction efforts are necessary.” With sodium declining at the glacial pace of less than 1 percent per year, it would take several decades to reach the goal of 2,300 mg per person per day.

Progress has been even slower—or nonexistent—in restaurants. Researchers at Boston University and Tufts University found that fast-food meals have become less healthful over the years. Over a 30-year period, between 1986 and 2016, the sodium content of entrées and desserts at 10 major fast-food chains increased by almost one-third and of side dishes by an astonishing 82 percent.116 (Portion sizes and calorie counts generally increased, too.) Another study reported that the average sodium content of menu items at large chain restaurants did not change at all between 2012 and 2016.117 The one glimmer of hope was that items newly introduced in 2016—except for entrées at fast-food restaurants—were slightly lower in sodium than items that had been eliminated after 2012. A huge limitation of those two studies is that sodium levels were not sales weighted. That is, it would make a big difference if a new, lower-sodium (or higher-sodium) item were a huge sales success at a large chain or a poor-selling item at a smaller chain.

Clearly, the restaurant industry and foodservice operators more generally need a good kick in the pants. One group that is trying to make a difference is the Culinary Institute of America (CIA), one of the nation’s leading culinary schools. It has co-sponsored annual Menus of Change conferences with the Harvard T.H. Chan School of Public Health.118 Their goal is to encourage individual chefs, large restaurant companies, hotels, airlines, and other institutions to provide healthier meals and options that are plant based. The CIA and Harvard speakers give great health and culinary advice to companies whose meals reach millions of mouths.

The CIA recognizes that adding a little bit of salt can intensify the flavors of many meals, but decries “that the foodservice and food manufacturing sectors have long been too reliant on salt to do the heavy lifting to create high flavor impact and customer satisfaction.” Its informative (and beautifully designed) Menus of Change annual reports note that a single sandwich or entrée might contain more than a whole day’s worth of sodium. But occasionally even the CIA drops the ball. The same website that says “it’s possible to create flavorful dishes without adding a lot of salt or using high-sodium ingredients” also has recipes for several foods, such as Vietnamese Summer Rolls and Moroccan Chicken Pita Sandwiches, that are loaded with salt.119

Supermarkets could play a more significant role in helping their customers improve their diets. For one thing, most supermarkets carry house brand packaged foods. Those foods usually mimic the national brands as closely as possible in terms of taste and nutrition, but the stores could tell their house-brand suppliers to nudge sodium levels downward. They also should sell lower-sodium products at the same price as the standard ones. I discovered that a large Midwestern supermarket chain was selling lower-sodium condensed Tomato and Cream of Mushroom soups for $1.19 per can compared to $0.79 for the regular soups—a 50 percent premium.120

Corporate Salt-Cutting Techniques

Cutting salt is not brain surgery. The simplest way to lower sodium levels is to simply use less salt. In one experiment, researchers lowered the salt content of bread by 5 percent each week for a 25 percent total reduction without any decrease in participant acceptance.121 In another taste test, the salt content of chili was lowered by 40 percent without a reduction in acceptance.122 Cutting substantial percentages of sodium in processed meats and certain soups had no effect on acceptability either.123 It is simply a myth that cutting salt would inevitably cut taste.

Outside the academic testing lab, some manufacturers and restaurants have realized they were using unnecessarily large amounts of salt and that reducing salt modestly had no effect on taste or acceptance. Consumers often don’t notice modest reductions of 10 to 25 percent even if they result in a slightly less-salty taste.

Makers of crackers have found a nice trick for lowering sodium while maintaining acceptance. They simply salt just one side of the crackers. Obviously, that tactic won’t work in soups or stews.

An easy way for restaurants to reduce sodium (and help our waistlines), without affecting taste one whit, would be to reduce their humongous serving sizes. At a restaurant like Denny’s or IHOP, a single meal could involve chewing through two pounds of food. Executives at one large chain, though, told me that some long-time customers rebel when served meals that are just 5 or 10 percent smaller.

Another low-tech way to reduce sodium is to use salt crystals with a modified shape or size. One such salt is Cargill’s Diamond Crystal Kosher Salt. It is made by a method called the Alberger process, which results in pyramid-shaped hollow crystals. Salt processed that way provides the usual salty taste, but it lacks some of the “useless” salt in the middle of the crystals that may never touch the tongue when used on potato chips, French fries, nuts, pretzels, and other foods where much of the salt sits on the surface. A given volume of Diamond Crystal Kosher Salt has half as much sodium as regular table salt and 40 percent less than Morton’s Kosher Salt.

Martin Breslin directs the culinary services at Harvard University, which serves 25,000 meals a day. He swears by Diamond Crystal Kosher Salt as a great way to cut sodium. He was able to cut the sodium in many of his 7,000 recipes simply by switching from regular salt or regular kosher salt to Diamond Crystal’s salt and using the same number of teaspoons or tablespoons. Despite the lower sodium levels and less-salty taste, Breslin did not receive any complaints from students and other diners. He estimates that that one simple step cut sodium levels almost across the board by about 30 percent.124 (Changing the ingredient was easier than rewriting the recipes with half as much regular salt.) He also worked with local bakers and suppliers of deli meats, Indian dishes, and sauces to reduce sodium levels in their products.125 In some cases, those companies switched to the lower-sodium recipes not only for Harvard, but for all their customers.

Another special kind of salt consists of microscopic crystals that are up to one one-hundredth the size of regular crystals. They deliver an intense burst of saltiness to taste buds. Manufacturers claim that their “micro” salt (such as SodaLo) can cut sodium by 25 to 50 percent in bread, cheese, sausage, potato chips, and other foods.126 One thing I’ve found, though, is that while makers of salt substitutes ballyhoo their products, food manufacturers sometimes discover that they simply don’t work as promised.

Compass Group, which serves nine million meals a day at university, corporate, and other cafeterias throughout much of the world, has been at the forefront of providing healthier meals that also protect the environment. Deanne Brandstetter, the company’s vice-president of nutrition and wellness, described her company’s starting point: “Our first strategy for reducing sodium in our menu offerings should be reducing some of our portion size[s]. Research shows the more calories you consume, the more sodium you consume. Many of our portions offer too many calories as well as too much sodium.”127

Morrison Healthcare, a division of Compass Group, operates the foodservices in more than 650 hospitals and healthcare systems. It has worked with suppliers to obtain sodium reductions ranging from 10 percent in dressings to 49 percent in roast turkey. It has used thinner sandwich buns, cutting the calories and sodium in half. Morrison also has a “Great Living” menu for patients that cuts sodium almost in half—from 4,500 to 2,300 mg per day.128 Reducing sodium requires careful work by chefs, but there’s no reason that every cafeteria and restaurant could not make similar reductions.

Norbert Bomm, Corporate Executive Chef for R&D at Morrison Healthcare, has his own palette of approaches for reducing sodium.129 He says the biggest impact came from using no-salt-added canned tomatoes and flavoring them with McCormick’s salt-free seasonings, which he called “absolutely mind-blowing.” He uses pureed black beans and white beans in soups. More generally, he uses local, seasonal, fresh fruits and vegetables wherever possible and prepares more foods in-house instead of relying on outside suppliers.

Food marketers typically like to reduce sodium quietly instead of bragging about it on the fronts of labels or restaurant menus, because they think consumers believe that “less salt” means “less taste.” As former Unilever scientist Doug Balentine (now Senior Science Advisor for Global Nutrition Policy at the FDA) told the Wall Street Journal, “Once you start saying you’ve taken salt down, it’s basically equal to, ‘it’s not going to taste good.’”130 Hence, companies prefer to make “stealth” reductions in salt. I’m hopeful that the public’s attitude will change to “that’s terrific” as people recognize the harmfulness of high-sodium foods and the tastiness of lower-sodium foods.

In most cases, how companies adjust their recipes to lower sodium are usually deep, dark secrets. But Heinz’s British division lifted the veil of secrecy regarding some of its recipe changes. Tristan Robinson, then the company’s nutritionist, said that Heinz worked hard to meet the UK government’s expectations for lower-sodium products.131 For example, the company markets Pasta Shapes in Tomato Sauce for young children. Because those children’s taste buds had been shaped by no-salt-added toddler foods, Heinz simply eliminated about 60 percent of the salt. No other changes were necessary, and kids apparently were no less happy with the less-salty product.

In other cases, Heinz had to reformulate in ways that compensated for the reduced salt. To offset the elimination of MSG and one-fourth of the salt in its traditional Cream of Chicken Soup, the corporate chefs needed to add 40 percent more chicken. They were able to chop the sodium content of its Cream of Tomato Soup in half and use less oil and sugar by adding at least 12 percent more tomatoes. And to cut almost half the sodium from its Big Soup Chicken & Vegetables, the chefs used less salt, dropped the MSG, and added 28 percent more chicken and 5 percent more vegetables. Such changes might increase costs and the prices consumers pay a bit, but few consumers would complain about getting more chicken and vegetables and less salt and MSG.

In the mid-2000s the food conglomerate ConAgra Foods made serious efforts to lower sodium levels. Pat Verduin, who led Product Quality & Development for the company, told me recently, “For a product line like Marie Callender’s, we were able to reduce salt levels with little impact on the flavor. In other product lines, we had to make more significant formula adjustments to reduce salt and match the flavor expectations of our consumers.”132 The company also made major reductions in Kid Cuisine, Chef Boyardee, and other lines. Besides just using less salt, ConAgra adjusted spice levels, added potassium salt, and employed natural sodium enhancers.

Revolution Foods, the school-cafeteria operator, has huge experience in satisfying some of the most vocal critics—kids. Unlike food manufacturers and restaurants, companies that provide school meals are required to meet the USDA’s nutrition standards. Cliff Lyles, Revolution’s executive chef, starts modifying recipes simply by reducing the salt content until a taste panel of kids says that a food tastes bland. To further cut the sodium he will add ingredients that provide a “sense of salt without having salt.” Those may include vegetable concentrates, onions, carrots and other root vegetables, herbs, spices, and sharp cheeses—ingredients that give meals a “heartier, richer, full-flavor profile that helps eliminate the need for salt.” Lemon and lime juices (and citric acid) work well for spicy, lower-salt dishes such as Cilantro Lime Rice, Orange Chicken, and Chile Verde. Revolution has not yet used potassium salt to cut the salt.133 (In my conversations with chefs, few were even aware they could use potassium salt to reduce sodium.)

Researchers have long maintained that children who get accustomed to a modest reduction of saltiness are more willing to accept another reduction. But Lyles says that taste buds have strong expectations when it comes to such familiar foods as hot dogs, hamburgers, and chicken noodle soup. Those are the toughest foods in which to reduce salt. As Campbell has done, foodservice chefs overcome the problem by creating whole new lower-sodium recipes.

Even a prison system is using some of the same culinary devices. Deserae, the lead cook and an inmate at the Coffee Creek Correctional Facility in Wilsonville, Oregon, says that using flavorful fresh vegetables is one of her major ways of reducing sodium and creating appealing meals.134 Oregon prisons have also switched to beef and chicken soup bases that are 89 percent lower in sodium.135 The Oregon Department of Corrections says that such measures led to a 17 percent reduction in sodium consumption.

Those of us looking to rely less on processed foods can use many of the same salt-reducing tricks in our homes that companies, and an occasional prison, use. I’ll expand on that in chapter 11.

Taste and Taste Perception: Lessons from Campbell Soup

In some cases, reducing sodium may require some sophisticated culinary substitutions, and major companies need to move cautiously. Campbell Soup Company’s former director of research and development, Lisa Thorsten, notes that salt affects all five dimensions of taste—salty, sweet, bitter, sour, and umami (savory or meaty tasting). Removing too much salt can result in unpleasant-tasting or bland foods unless other ingredients can be adjusted to compensate, whether by boosting the perception of saltiness or enhancing other taste perceptions that depend on an interaction with salt. Company chefs then need to experiment, such as by adding herbs and spices, natural or artificial flavorings, or roasted instead of boiled ingredients—all of which may increase costs. At home, it’s easy for a disappointed cook to suffer through, or toss, a lousy-tasting meal. The stakes are far higher for companies churning out millions of packages of food a year.

In the 1980s and 1990s, Campbell was one of the only companies that invested in research to lower sodium levels. Thorsten told me that lowering sodium is “in the DNA” of Campbell’s R&D and marketing departments.136 Sodium was probably so much on Campbell’s mind because so many of its soups were so high in salt and used as “don’t eat” examples by nutritionists. A typical cup of soup contains about five times as much sodium as an ounce of potato chips. One obvious reason for that difference relates to portion size: it takes a lot more salt to season an eight-ounce serving of soup than a one-ounce serving of chips.

Over the years, Campbell lowered sodium in products ranging from “red-label” condensed soups to V8 juice to SpaghettiOs. When Bonnie Liebman, Greg Moyer, and I wrote Salt: The Brand Name Guide to Sodium Content in 1983, Campbell soups typically contained around 1,000 mg of sodium per cup.137 In 2008, with much fanfare, Campbell announced it was reducing the sodium in 36 Select Harvest soups and a dozen “kid favorites” from an average of 700 to 800 mg per cup to 480 mg. Douglas R. Conant, Campbell’s President and Chief Executive Officer, said,

This is another significant step in our leadership in sodium reduction. Our lower sodium products continue to outperform expectations . . . but we will not rest here. Our journey to lower sodium across Campbell’s portfolio will continue with the goal of making soup the ultimate healthy simple meal.138

But then the roof caved in. Thorsten said, “Almost the moment the Select Harvest products hit store shelves, the phone started ringing.” The consumers were “crazy angry and disappointed,” describing the new taste as “bland” and “like dishwater.” Sales sunk, and so did the company’s commitment. The cause of the debacle, according to Thorsten, was that in its rush to lower sodium levels Campbell failed to do taste testing with existing consumers of the soups.

Unfortunately, Campbell didn’t just “rest here,” but reversed course. In 2011, the company boosted the sodium in Select Harvest soups back up to about 650 mg per cup.139 The CEO-elect (and now the former CEO) Denise Morrison, who had made the original call to cut sodium to 480 mg, explained that Campbell wanted to give consumers more choice by increasing the sodium content. In reality, that gave consumers less choice because people can add salt to their foods, but they cannot take it out. Instead of continuing to focus on “sodium innovation,” Campbell said it would shift to taste-oriented innovation.” A few years later it threw in the towel on the Select Harvest line, though some lower-sodium flavors were reincarnated as Homestyle or Healthy Request soups.140

It is possible that taste was not the only problem with Campbell’s soups, but also consumers’ perception of taste. In one investigation, which supported Balentine’s observation, declaring “Now Reduced Salt” on the front label led a taste panel of consumers to believe that the soups would not taste as good as soups without the label.141 If Campbell had alerted consumers to the change so that they would expect a different flavor from the one they had before, Thorsten said, perhaps consumers would have been more accepting of the change in order to obtain the benefits of the lower sodium content.

Fortunately, the Campbell story did not end with Select Harvest. In 2018 the company’s vice president for research and development, nutritionist Joshua Anthony, emphasized that Campbell recognized the importance of lowering sodium, but also that “taste is still king.” The company could not force people to consume healthier products that did not taste good. Still, he reported that between 2009 and 2017 the percentage of Campbell’s products with 480 mg or less of sodium per serving jumped from 45 percent to 71 percent.142 He explained that reducing sodium was hardest in the traditional red-label condensed soups, because consumers have such strong taste expectations based on years or decades of experience. Chicken Noodle soup, in particular, which has few ingredients and is watery, is an especially tough case. It was easier to develop new products, including ready-to-eat soups (such as Lightly Salted Santa Fe Vegetable Soup), so the company could gradually create new, less-salty norms.

To help Campbell and other food manufacturers use less salt and avoid sales debacles, and to help home cooks too, it would be great to have safe and tasty salt substitutes that performed some or all of the technical functions of salt, such as preservation and texture. Sprinkling such substitutes into our food, analogous to using non-caloric sweeteners like aspartame and stevia, could be a big help in lowering sodium consumption. To understand why ideal salt substitutes have never been found, let’s visit our taste buds.

The largely plant-based diet our ancestors consumed tens of thousands of years ago was extremely low in sodium. But sodium is absolutely essential for life. So evolution probably favored the development of a pleasant sensation when animals ingested salty foods, as well as a hormonal means of retaining the necessary amount of sodium in the body. Babies begin to develop a taste for salt at around three months.143 We may be hard-wired from a very young age to crave salt, but that doesn’t mean that we are condemned to eat dangerously salty diets. In fact, people can easily adjust to foods containing moderately less sodium over two or three months.144 After that, conventionally salted foods often taste too salty.

Surprisingly, given our vast scientific knowledge about the workings of the human body, just how our tongues perceive salt is complicated and still poorly understood. Taste buds scattered around our tongue and on our palate contain taste cells that detect substances that convey the five basic tastes. The primary way we detect salt involves a sodium receptor located on the surface of taste cells. That receptor is known as ENaC, which stands for epithelial sodium channel (Na is the symbol for sodium). When those taste cells are stimulated by sodium ions in foods and beverages, nerve cells at the base of the cells are activated and carry a signal to larger nerves and then to the brain, which registers the salty taste.

But the sense of taste is more complicated than just stimulation of ENaC. In animal studies, researchers blocked the ENaC taste cells, but the animals still detected salt.145 That indicated that animals have other means of tasting sodium chloride, as well as potassium chloride and other salts. Some researchers hypothesize that low levels of sodium (and potassium) activate other taste cells and trigger a pleasant taste sensation—but high concentrations of sodium (and moderate and high levels of potassium) are perceived as tasting unpleasant or even repulsive. Some research suggests that that mechanism involves taste cells that also detect sour and bitter foods. But Gary Beauchamp, Emeritus Director and President of the Monell Chemical Senses Center, warns that human taste buds may be very different from those in animals—for instance, cats do not even have any functional taste receptors for sweetness—and that a lot more research needs to be done to truly understand how we detect a salty taste.

Because the ENaC channel is highly specific to tiny sodium ions, researchers doubt that they will find any other safe atom, ion, or molecule that would taste just like salt. Lithium, which has been used at low levels for more than half a century to treat bipolar disorders, was a possibility because it is even smaller than sodium. It tastes perfectly salty—but is toxic at levels only slightly higher than the therapeutic doses.146 Potassium ions are a little larger than sodium ions, have a somewhat salty taste, and may be the closest we get to a versatile, inexpensive salt substitute.

Potassium Salt and Other Tricks of the Lower-Sodium Trade

If you remember the periodic table from Chemistry 101, you might recall that potassium falls right under sodium. The similarities between the two atoms indicate why potassium and sodium share some of the same qualities. As I have suggested earlier, potassium chloride, or potassium salt, as it is increasingly called, is the best partial substitute for sodium chloride.

Potassium-rich substances have a long, if accidental, history of use as a seasoning. Some hunter-gatherer tribes around the world have used the ashes from burnt plants as a condiment.147 The ashes contain several hundred times more potassium than they do sodium, and the urine of members of the tribes that use “culinary ashes” contains far more potassium than sodium. Our Paleolithic ancestors probably consumed around 10,000 mg of potassium per day, several times as much as Americans consume, indicating that it is safe to eat.

A physician with the World Health Organization (WHO) studied two tribes that lived in the Amazon basin of Brazil. The Mundurucú were the more acculturated of the two and their blood pressure rose with age, similar to most people in modern cultures. That may have been, in part, because they used salt as a condiment, whereas the other tribe, the Carajá, whose blood pressure did not rise with age, used potassium-rich plant ashes.148

Far from the Brazilian rainforests, some food manufacturers use potassium chloride (also called potassium salt) to replace one-fourth to one-half of regular salt, depending on the food. Not only does that cut the sodium, but it adds potassium, an essential nutrient that counteracts the effects of excess sodium in the body. Manufacturers buy the potassium salt and mix it in whatever proportion they want with regular salt and other ingredients.

NuTek Food Science, a small company based in Omaha, Nebraska, is the only marketer of potassium salt I know of that is a real crusader for reducing sodium consumption. It markets potassium salt, its sole product, mostly to manufacturers (Salt for Life is its consumer version). NuTek told the FDA in 2016 that its potassium salt helped companies lower sodium by an average of 34 percent in 19 different foods, from American cheese to hot dogs to white bread.149 All those foods were either being marketed or ready to launch. Significantly, 17 of those 19 foods met the FDA’s 2-year sodium targets, and 12 of the 19 even met the FDA’s 10-year targets. Clearly, potassium salt could play an important role in reducing sodium consumption.

One prominent example of the nutritional benefits of using potassium salt is obvious in the marketplace. Tomato soup, Campbell’s second most popular soup—with sales of 85 million cans each year150—is one of the company’s lowest-sodium condensed soups, with 480 mg per cup. Other condensed soups average around 800 mg. Tomato soup’s ingredients include both potassium salt and regular salt.

If potassium salt is such a great substitute for some of the table salt in foods, one might ask why it is not more widely used. The ingredient has two noteworthy limitations: The first is taste—it is somewhat less salty than regular salt, and it has a strong, unpleasant metallic taste when too much is used. But companies are discovering that they can use an amount that contributes to a salty taste and doesn’t impair a food’s flavor. Second, potassium chloride costs at least five times as much as table salt. That sounds like a lot, but on a per-serving or per-package basis, the extra cost is trivial. NuTek says that it would cost less than one extra penny to season a large, 13-ounce bag of potato chips that costs around three or four dollars. There’s another reason that limits the use of potassium salt, though, and that is inertia: it is both a nuisance and an expense for companies to test different amounts of potassium salt in various products and perhaps adjust the amounts of other ingredients.

But Brian Boor, NuTek’s chief strategy officer, offers a different explanation for many companies’ disinterest in using potassium salt. Boor, who travels the world talking to large manufacturers and chain restaurants, believes that the greatest impediment to wider use of potassium chloride is the “clean label” movement.151 Under pressure from consumers wanting foods made without additives, companies have been replacing ingredients that have chemical-sounding names and shortening their ingredient lists. Adding something that smacks of being a “chemical”—which potassium chloride is, of course—is the last thing most companies want to do. Also, some people might associate potassium chloride with chlorine bleach, or even with chlorine gas, which was used as a chemical weapon in World War I. Campbell Soup’s Joshua Anthony has echoed Boor’s concern, saying that the public’s chemophobia was one of the things that made it difficult to replace some of the sodium chloride, which, of course, is also a chemical. (Chemophobia can’t be too powerful a deterrent, though, because Campbell is using potassium chloride in a variety of soups, presumably without affecting sales, and a growing number of companies are doing the same.)

To reduce the clean-label problem, in 2016 NuTek petitioned the FDA (and foreign governments) to allow potassium chloride to be listed on food labels as “potassium salt.” Mars, Nestlé, Unilever, Campbell, Walmart, GMA, the city of Philadelphia, the Academy of Nutrition and Dietetics, CSPI, and many others supported that petition.152 Not surprisingly, the since-shuttered Salt Institute came out squarely against it, charging that allowing potassium chloride to be labeled as potassium salt would lead to “consumer confusion” and was illegal.153 That opposition was a bit ironic, because the major salt manufacturers, all members of the Salt Institute, also market potassium salt.

In 2019 the FDA responded to NuTek’s petition by proposing a synonym for potassium chloride—not “potassium salt” but “potassium chloride salt.” That was bureaucracy in action.154 Never mind that no one has heard of the term—it does not address the “clean label” problem. The food industry, CSPI, and others argued that allowing “potassium chloride salt” would not encourage companies to use potassium chloride. As of spring 2020, the FDA had not decided what to call it.

To see the potential impact of salt substitutes on nutritional values, I reviewed the sodium and potassium levels in three categories of food in which some brands contained, and others did not contain, potassium chloride.155 This is what I found:

• • Ready-to-serve soups: 154 soups containing potassium chloride averaged 18 percent less sodium and 92 percent more potassium than 229 soups without it.
• • Condensed soups: 129 varieties made with potassium chloride had 34 percent less sodium and 240 percent more potassium than 190 varieties without it.
• • Microwave popcorns: the 63 products with potassium chloride averaged 23 percent less sodium and 139 percent more potassium than 94 varieties without it.

Some of the manufacturers undoubtedly made other changes in their recipes when they added potassium chloride and subtracted regular salt, such as adding more vegetables, sugar, or flavorings. But the use of potassium chloride probably deserves much of the credit for the lower sodium levels and certainly for the higher potassium levels. In some food categories, companies might be replacing not salt, but ingredients like sodium bicarbonate or monosodium glutamate with their potassium counterparts.

Increasing potassium consumption is an unadulterated benefit for healthy adults. The FDA considers potassium chloride “generally recognized as safe” and permits it to be used without limit in any food.156 At least in people with hypertension, higher potassium intakes reduce blood pressure, as I discussed in chapter 2.157 Numerous studies also found an association between increased potassium and fewer strokes,158 although the NAM’s 2019 recommendations on sodium and potassium intakes did not consider them to be of high enough quality to say definitively that their findings were correct.159

While potassium is beneficial or innocuous to the great majority of people, too much of that nutrient—from salt substitutes or from bananas, beans, potatoes, and other foods naturally rich in potassium—can endanger certain people. Most prominently, that includes people with advanced chronic kidney disease (CKD), who are not able to excrete excess potassium. That leads to increased potassium in blood, or hyperkalemia, which can cause an irregular heartbeat or a heart attack. Patients with CKD represent under 0.5 percent of adults.160 In addition, people taking certain antihypertensive drugs, including potassium-sparing diuretics, ACE inhibitors, and ARBs, need to guard against excess potassium. Those people need to talk with their physician or other healthcare provider about their diets.

A recent computer-modeling study of the health impact if the entire Chinese population used potassium-enriched salt at home provided reassuring news.161 An international team of cardiovascular disease experts estimated that replacing 20–30 percent of salt with potassium salt would yield huge benefits: 460,000 fewer deaths each year, or one in nine deaths from cardiovascular disease. Even among CKD patients, three lives would be saved due to lower blood pressure for every life lost due to higher potassium intake and hyperkalemia.

In any case, sticking to a safe diet in the United States just became easier for CKD patients now that potassium is listed on Nutrition Facts labels. (The new labels also may encourage some companies to use potassium salt because they could tout the higher potassium content.)

If potassium salt became widely used as a salt substitute, health officials definitely would have to monitor for any harm to consumers.162 If problems were discovered, the FDA might have to set limits on the substance’s use or require a warning notice. But even if potassium salt replaced as much as one-fourth of the regular salt added to processed and restaurant foods, an unrealistic assumption at least in the short run, that would boost average potassium intake only from 2,800 mg to 3,500 mg per day. That is just a bit over the 3,400 mg that the NAM committee said in 2019 is an Adequate Intake for healthy men and somewhat over the 2,600-mg Adequate Intake set for women. The potassium statement on Nutrition Facts labels is currently based on a Daily Value of 4,700 mg per day, the NAM’s previous recommended daily intake. Healthy people do not have to worry about consuming too much potassium.

Besides potassium salt, several substances that do not contain potassium also may serve as salt enhancers and allow companies to use less salt.163 They include such flavor enhancers as MSG (the infamous but poorly substantiated cause of headaches or skin flushing that some people complain about after eating at a Chinese restaurant), hydrolyzed vegetable protein, yeast extracts, the nucleotides 5-IMP and 5-GMP, and the amino acid arginine. Those ingredients do not necessarily taste salty but can bring out some of the tastes that salt brings out, including umami. All those substances are much more expensive than regular salt and potassium salt.

A very different approach for reducing salt would be to find substances that make salt taste saltier. A company in California, Senomyx, is trying to do just that. Senomyx, now part of a larger Swiss firm, develops substances that increase the sensitivity of taste buds or that provide a strong flavor punch of their own. It already markets ingredients that make sweetness-detecting taste buds more sensitive to sugar, thereby allowing manufacturers to use less of it. It also found two substances that it says can reduce or eliminate MSG.164 But so far, despite years of trying, Senomyx has not found substances that sensitize the taste buds that trigger the “salty” sensation in our brains and would enable companies to use less salt.165 A safe and effective product could be the holy grail of sodium reduction, but don’t expect such ingredients to be discovered for many years, if ever.

Instead of counting on an unlikely technological or culinary breakthrough—or a sudden, increased consumer responsiveness to “cut the salt” campaigns—to bring about population-wide reductions in sodium consumption, in the next chapter I will offer some recommendations for national policies that could reduce sodium right now.