The best way to proceed is to start with a voluntary salt reduction policy with the threat of regulation/legislation.
—Feng J. He and colleagues, Journal of Human Hypertension, 20141
The scientific evidence is crystal clear that lowering sodium consumption greatly improves health. That is something that almost all experts agree on—indeed, have agreed on for many years. And there is widespread recognition that lowering sodium would save tens of thousands of lives, along with many billions of healthcare dollars, per year.
Health officials traditionally placed their sodium-lowering bets on conducting weak, brief education campaigns to encourage consumers to choose less-salty foods. Such efforts convey an impression of promoting health, but at the same time do not offend industry. But that approach proved a dismal failure in reducing average sodium intakes, even after Nutrition Facts labels provided information on all packaged (though not restaurant) foods. More effective measures were needed, namely sodium reductions by food manufacturers and restaurants to make “the healthy way the easy way” for consumers.
The World Health Organization (WHO) and the governments of the United Kingdom, Chile, Canada, Turkey, South Africa, and elsewhere are increasingly placing their bets on pressing the food industry to cut the salt. Some companies have responded positively by using less salt and more vegetables, fragrant spices, or potassium-containing salt substitutes, as I explained in chapter 9. Progress can be accelerated by setting mandatory, not voluntary, limits on sodium in major sources of sodium or requiring warning notices on high-sodium foods.
Progress has been slow in the United States, but the US Food and Drug Administration (FDA) has laid the groundwork for significant progress by proposing voluntary sodium targets for companies to reach within 2 years and 10 years. If and when those targets are finalized, the FDA should not expect that all companies would quickly lower sodium levels. Based on his experience in the United Kingdom, professor and advocate Graham A. MacGregor emphasizes the importance of having health officials maintain strong pressure on industry to reformulate their foods, including the use of the bully pulpit.2 And simultaneously, he says, the agencies also should be open to valid industry arguments that certain goals are impractical or might introduce food-safety risks.
Because the FDA commissioner is too busy to focus full-time on this one issue, the FDA should appoint a “Salt Czar” who would use the agency’s bully pulpit to exhort companies to decrease sodium levels in their products. That person, along with other FDA staff, would have to have many meetings with companies and trade associations over a long period of time to emphasize the huge health benefits that would be obtained by reducing sodium and to persuade them to cooperate. The Salt Czar should publicly applaud companies both big and small that reached or did better than the targets—and do some public naming and shaming to let the laggards, and the public, know how serious the agency was about sodium reduction. With the support of staff members the Salt Czar could provide technical assistance to companies (especially smaller ones) having a hard time lowering sodium, and could revise targets that were unrealistically ambitious.
The FDA should have a robust program for periodically monitoring sodium levels in the overall food supply and in the categories of foods subject to its targets. It would have to determine the sales-weighted average sodium content in each of the 150+ food categories. It also would need to identify how many (and which) individual foods exceeded the “upper-bound” (maximum) sodium targets for each category. Journalists and health groups should do the same to keep companies’ feet to the fire.
Meanwhile, the Centers for Disease Control and Prevention will be conducting its ongoing National Health and Nutrition Examination Surveys (NHANES), which would provide the data to determine whether the sodium targets actually led to lower consumption. Though analyzing those surveys takes a year or more, they are essential to evaluating the effort and suggesting possible improvements.
But what if companies don’t even achieve the eminently achievable two-year targets? In that case, the FDA, or Congress, could impose incentives that would encourage compliance. The Institute of Medicine (IOM), now the National Academy of Medicine, suggested in 2010 that special “informational label” notices could be used to encourage companies to lower sodium.3 One approach would be to require products that exceeded the upper-bound targets to bear a label notice stating, “FDA Notice: The sodium content of this food exceeds the FDA’s recommended limit.”
The FDA—and, for meat and poultry products, the US Department of Agriculture—could adopt a broader labeling program that would require bold front-of-package warning notices on foods high in sodium, as well as on foods high in calories, added sugars, and saturated fat. Such labels are being used and appear to be effective in Chile, with several other countries requiring similar labels.
Labeling could be extended to restaurants by requiring saltshaker icons on menus of chain restaurants for items that contain more than a certain amount of sodium, as New York City and Philadelphia require. Instead of waiting for federal action, local and state agencies could require such notices.
The 2010 IOM committee recommended mandatory national standards for the sodium content of foods. If industry was clearly not meeting the FDA’s sodium targets, the FDA could make the upper-bound targets mandatory instead of voluntary. Such a requirement, which would affect only the saltiest foods, could be for all food categories or only certain major sources of sodium, such as bread, pizza, processed meats, sandwiches, and soups. Industry would fiercely oppose that measure and warning labels.
A major defect in the FDA’s plan is that the timeframe is far too protracted and does not include enough periodic step-downs in sodium. The plan would leave 8 years between the deadlines for the 2-year and 10-year targets. Without the pressure of targets that became progressively more stringent every one to four years (as in the United Kingdom, South Africa, Chile, and National Salt Reduction Initiative), sodium reduction almost certainly would drop off the FDA’s and industry’s agendas.4 The IOM suggested tightening the targets every three years. Hence, the FDA should issue an intermediate set of targets set halfway between the 2- and 10-year levels; such 6-year targets would keep the pressure on companies to reformulate their products (or drop some of their saltiest products), while still providing time for the FDA to evaluate the progress in reducing sodium intakes and make necessary adjustments for the next deadline.
Potassium chloride could replace about one-fourth of salt in many foods, but some companies fear that consumers perceive that ingredient as a “chemical” to avoid. To facilitate the use of that ingredient, the FDA should allow potassium chloride to be listed as “potassium salt” on food labels, as numerous companies and health organizations have encouraged it to do.
The USDA should help lower children’s sodium intake and accustom their taste buds to enjoying less-salty foods by setting a 2022 deadline for the Target 2 limits on sodium (which had been delayed from 2017 to 2024) and reinstating its cancelled Target 3 limits for 2025.
Federal, state, and local agencies should use their purchasing power to encourage companies to market lower-sodium foods. For example, giant purchasers, such as the Department of Defense and Department of Veterans Affairs, should choose only those products that met the FDA’s targets.
One reason that progress on salt came earlier in the United Kingdom than almost anywhere else is that a prominent academic, MacGregor, has devoted a substantial portion of his time to criticizing companies marketing excessively salty foods, waging successful media campaigns to inform consumers, debunking misleading studies, and spurring improved government policies. We need one or more American medical experts to make the same kind of commitment to public campaigning.
Finally, consumer education. Local, state, and federal health agencies should sponsor hard-hitting media campaigns emphasizing the risks of salty diets and encouraging people to read labels and choose lower-sodium foods. Primary care physicians should advise patients, especially those suffering hypertension and heart disease, how to lower sodium consumption (or refer patients to registered dietitians). And, of course, consumers should be encouraged to adopt an overall healthier diet immediately based primarily on fruits, vegetables, nuts, beans, whole grains, seafood, low-fat and fat-free dairy foods, and unsalted meat and poultry. I’ll now put on my chef’s toque and give you a few tips on how to do so, without sacrificing taste.