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1. Institute of Medicine, Strategies to Reduce Sodium Intake in the United States (Washington, DC: The National Academies Press, 2010).
2. Centers for Disease Control and Prevention, “Heart Attack,” August 18, 2017, https://www.cdc.gov/heartdisease/heart_attack.htm (accessed October 26, 2019); Centers for Disease Control and Prevention, “Heart Disease Fact Sheet,” August 23, 2017, https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm (accessed October 26, 2019).
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8. L. Ambard and E. Beaujard, “Causes de’l hypertension arterielle,” Archives générales de Médecine de Paris 1 (1904): 520–533.
9. “The Use of Salt,” JAMA 293 (2005): 100.
10. F. M. Allen and J. W. Sherrill, “The Treatment of Arterial Hypertension,” Journal of Metabolic Research 2 (1922): 429–545.
11. Sources for box 2.1: “Among adults, 54 percent of African Americans have hypertension”: Centers for Disease Control and Prevention, “High Blood Pressure, Facts about Hypertension,” January 28, 2020, https://www.cdc.gov/bloodpressure/facts.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdhdsp%2Fdata_statistics%2Ffact_sheets%2Ffs_bloodpressure.htm (accessed February 6, 2020). “80 to 90 percent of adults will develop hypertension”: P. Muntner, R. M. Carey, S. Gidding, et al., “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline,” Circulation 137 (2018): 109–118; R. S. Vasan, A. Beiser, S. Seshadri, et al., “Residual Lifetime Risk for Developing Hypertension in Middle-Aged Women and Men,” JAMA 287 (2002): 1003–1010. “Hypertension is responsible for over $131 billion in annual healthcare costs”: E. B. Kirkland, “Trends in Healthcare Expenditures among US Adults with Hypertension: National Estimates, 2003–2014,” Journal of the American Heart Association 7 (2018): e008731. “Together, coronary heart disease and stroke kill about 500,000 people annually”: E. J. Benjamin, M. J. Blaha, S. E. Chiuve, et al., “Heart Disease and Stroke Statistics—2017 Update: A Report from the American Heart Association,” Circulation 135 (2017): e146–e603. “High blood pressure is a primary or contributing cause of 472,000 deaths per year,” “About 7 of every 10 people suffering a first heart attack have high blood pressure”: Centers for Disease Control and Prevention, “High Blood Pressure, Facts about Hypertension,” January 28, 2020, https://www.cdc.gov/bloodpressure/facts.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdhdsp%2Fdata_statistics%2Ffact_sheets%2Ffs_bloodpressure.htm (accessed February 6, 2020). “The average adult should consume no more than 2,300 mg of sodium per day”: US Department of Health and Human Services and US Department of Agriculture, Dietary Guidelines for Americans 2015–2020, 8th Edition (December 2015), http://health.gov/dietaryguidelines/2015/guidelines/. “Average sodium intake of sodium for everyone 2 and older is 3,400 mg per day”: L. J. Harnack, M. E. Cogswell, J. M. Shikany, et al., “Sources of Sodium in US Adults from 3 Geographic Regions,” Circulation 135 (2017): 1775–1183. “For children, the recommended sodium limits are 1,200 mg for ages 1 to 3”: National Academies of Sciences, Engineering, and Medicine, Dietary Reference Intakes for Sodium and Potassium (Washington, DC: The National Academies Press, 2019), https://www.nap.edu/download/25353. “Children 6 to 10 years old actually consume 2,900 mg of sodium per day”: US Food and Drug Administration, “You May Be Surprised by How Much Salt You’re Eating,” January 23, 2018, https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm327369.htm (accessed March 11, 2018). “Worldwide, reducing sodium intakes to an average of 2,000 mg per day could prevent about 2.5 million deaths”: World Health Organization, “Salt Reduction,” June 30, 2016, http://www.who.int/mediacentre/factsheets/fs393/en/ (accessed October 20, 2019).
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27. N. T. Mueller, O. Noya-Alarcon, M. Contreras, et al., “Association of Age with Blood Pressure across the Lifespan in Isolated Yanomami and Yekwana Villages,” JAMA Cardiology 3 (2018): 1247–1249; S. A. E. Peters, P. Muntner, and M. Woodward, “Sex Differences in the Prevalence of, and Trends in, Cardiovascular Risk Factors, Treatment, and Control in the United States, 2001 to 2016,” Circulation 139 (2019): 1025–1035; supplemental data, https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.118.035550 (accessed February 27, 2020).
28. Sources for box 2.2: “Prehistoric animals developed powerful physiological processes”; G. MacGregor, “Dietary Sodium and Potassium Intake and Blood Pressure,” Lancet 321, no. 8327 (April 2, 1983): 750–753. • “Almost everyone consumes less potassium than they should”: “Salt and Your Health, Part I: The Sodium Connection,” Harvard Men’s Health Watch, October 2010, https://www.health.harvard.edu/newsletter_article/salt-and-your-health (accessed August 18, 2019). • “When compared with the BP of wild animals or of primitive man, BP levels considered to be ‘normal’ in civilized countries may actually be hypertensive”: H. Nakagawa and K. Miura, “Salt Reduction in a Population for the Prevention of Hypertension,” Environmental Health and Preventive Medicine 9 (2004): 123–129. Figure 2.1: American Heart Association. • “What Is High Blood Pressure?” 2017, https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings (accessed October 13, 2019). • “President FDR long had a blood pressure problem”: T. Bishop and V. M. Figueredo, “Hypertensive Therapy: Attacking the Renin-Angiotensin System,” Western Journal of Medicine 175, no. 2 (August 2001): 119–124; A. B. Sobocinski, “The President’s Vital Signs: A Look Back at FDR’s Heart Health,” Navy Medicine Live, Official blog of the US Navy Bureau of Medicine and Surgery, http://navymedicine.navylive.dodlive.mil/archives/8066 (accessed July 8, 2018). • “Sadly, few physicians knew at the time”: R. A. Pizzi, “Developing Diuretics,” Modern Drug Discovery 6 (February 2003): 19–20. • “The relationship between blood pressure level and risk of developing cardiovascular disease is strong, continuous, graded, consistent, independent, and etiologically significant”: S. Havas, E. J.Roccella, and C. Lenfant, “Reducing the Public Health Burden from Elevated Blood Pressure Levels in the United States by Lowering Intake of Dietary Sodium, American Journal of Public Health 94 (2004): 19–22. • “in 2017 the threshold for stage 1 hypertension was lowered again”: P. K. Whelton, R. M. Carey, W. S. Aronow, et al., “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines,” Journal of the American College of Cardiology 71, no. 19 (May 15, 2018): e127–e248. Correction: Journal of the American College of Cardiology 71, no. 19 (2018): 2275–2279. • “That lower threshold for concern”: P. Muntner, R. M. Carey, S. Gidding, et al., “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline,” Circulation 137, no. 2 (January 9, 2018): 109–118. • “Rises in blood pressure strike blacks earlier, hypertension is often more severe”: American Heart Association, “African Americans and Heart Disease, Stroke,” July 31, 2015, https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/african-americans-and-heart-disease-stroke (accessed October 16, 2019). • “And some medications are less effective”: American Heart Association, “What about African Americans and High Blood Pressure?” 2017, https://www.heart.org/-/media/data-import/downloadables/2/8/a/pe-abh-what-about-african-americans-and-high-blood-pressure-ucm_300463 (accessed October 16, 2019). • “African Americans may carry a gene that makes them more salt sensitive”: American Heart Association. “High Blood Pressure and African Americans,” October 31, 2016. https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/high-blood-pressure-and-african-americans (accessed October 16, 2019). • “Blacks consume slightly less sodium than whites”: National Academies of Sciences, Engineering, and Medicine, Dietary Reference Intakes for Sodium and Potassium (Washington, DC: The National Academies Press, 2019), table 11-2 https://doi.org/10.17226/25353. • “That’s roughly the same benefit”: P. K. Whelton, R. M. Carey, W. S. Aronow, et al., “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline”; “Correction.”
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Yam. “The Healthy Eating Agenda in Australia: Is Salt a Priority for Manufacturers?” Nutrients 9, no. 8 (2017): 881, doi:10.3390/nu9080881; Austria: Bundesministerium Für Gesundheit, Austrian Salt Initiative, 2014, http://www.bmgf.gv.at/cms/site2/attachments/7/1/0/CH1396/CMS1385031886552/who_conference_factsheet_oesi_final.pdf; Bahrain: G. Y. Lim, “Slashing Salt: Bahrain Follows Kuwait and Qatar in Move to Reduce Levels in Baked Goods,” FoodNavigator-Asia.com, September 11, 2019, https://www.foodnavigator-asia.com/Article/2019/09/11/Slashing-salt-Bahrain-follows-Kuwait-and-Qatar-in-move-to-reduce-levels-in-baked-goods#; Belgium: European Commission, “National Salt Initiatives: Implementing the EU Framework for Salt Reduction Initiatives,” 2009, http://bit.ly/1FTKE4A; Health, Food Chain Safety and Environment, 2013, Moins de sel dans l’alimentation des Belges, http://www.health.belgium.be/eportal/19088825_FR?backNode=9735#.U5s6j_ldWIM; Brazil: M. Brown, World Action on Salt and Health, “Brazil’s Salt Reduction Program,” October 4, 2017, http://www.worldactiononsalt.com/blog/2017/brazils-salt-reduction-program.html (accessed February 17, 2020); Bulgaria: European Commission, Survey on Members States’ Implementation of the Salt Reduction Framework, 2012, http://ec.europa.eu/health/nutrition_physical_activity/docs/salt_report1_en.pdf; Canada: Government of Canada, “Toward Front-of-Package Nutrition Labels for Canadians,” https://www.canada.ca/en/health-canada/programs/front-of-package-nutrition-labelling/consultation-document.html; Chile: C. Corvalán, M. Reyes, M. L. Garmendia, et al., “Structural Responses to the Obesity and Non-communicable Diseases Epidemic: Update on the Chilean Law of food Labelling and Advertising,” Obesity Reviews 20, no. 3 (2018): doi:10.1111/obr.12802. Ecuador: A. A. Díaz, P. M. Veliz, G. Rivas-Mariño, “Food Labeling in Ecuador: Implementation, Results, and Pending Actions,” Pan American Journal of Public Health 41 (2017): 41, e54, https://translate.google.com/translate?hl=en&sl=es&u=https://www.researchgate.net/publication/325226975_Food_labeling_in_Ecuador_implementation_results_and_pending_actions&prev=search (accessed February 18, 2020); Finland: H. Karppanen and E. Mervaala, “Sodium Intake and Hypertension,” Progress in Cardiovascular Diseases 49, no. 2 (2006): 59–75; Greece: European Commission, Survey on Members States’ Implementation of the Salt Reduction Framework, 2012, http://ec.europa.eu/health/nutrition_physical_activity/docs/salt_report1_en.pdf; Hungary: “Assessment of the Impact of a Public Health Product Tax,” http://www.euro.who.int/data/assets/pdf_file/0008/332882/assessment-impact-PH-tax-report.pdf; Israel: State of Israel, Ministry of Health, “Food Label and Nutrition Label,” 2018, https://www.health.gov.il/English/Topics/FoodAndNutrition/Nutrition/Adequate_nutrition/Pages/labeling.aspx and other sources; Kuwait: World Health Organization, “Kuwaitis Lower Blood Pressure by Reducing Salt in Bread,” September 2014, https://www.who.int/features/2014/kuwait-blood-pressure/en/; Mexico: F. Cortez, “Mexico Front of Pack Labeling Warning Signs,” USDA Foreign Agricultural Service, August 23, 2019, https://apps.fas.usda.gov/newgainapi/api/report/downloadreportbyfilename?filename=Mexico%20Front%20of%20Pack%20Labeling%20Warning%20Signs_Mexico%20ATO_Mexico_8-23-2019.pdf; Netherlands: E. H. M. Temme, M. A. H. Hendriksen, I. E. J. Milder, et al., “Salt Reductions in Some Foods in the Netherlands: Monitoring of Food Composition and Salt Intake,” Nutrients 9 (2017): 791; Paraguay: Consensus Action on Salt & Health, 2013 annual report, http://apps.charitycommission.gov.uk/Accounts/Ends18/0001098818_ AC_20130430_E_C.pdf; Peru: N. Michail, “Peru: Nutrition Warning Labels Become Mandatory,” FoodNavigator-latam, https://www.foodnavigator-latam.com/Article/2019/06/17/Peru-Nutrition-warning-labels-become-mandatory#; South Africa: S. A. E. Peters, E. Dunford, L. J. Ware et al., “The Sodium Content of Processed Foods in South Africa during the Introduction of Mandatory Sodium Limits,” Nutrients 9, no. 4 (2017): 404–419; South Africa Department of Health, Government notice no. R. 214, “Regulations Relating to the Reduction of Sodium in Certain Foodstuffs and Related Matters, March 20, 2013, and May 31, 2019, https://www.foodfocus.co.za/assets/documents/UPDATED_Notice%20214%20-Regulations%20relating%20reduction%20of%20sodium.pdf; Turkey: World Health Organization, “Progress in Reducing Salt Consumption in Turkey,” August 4, 2013, http://www.euro.who.int/en/countries/turkey/news/news/2013/04/progress-in-reducing-salt-consumption-in-turkey (accessed February 17, 2020); Y. Erdem, T. Akpolat, Ü. Derici, et al., “Dietary Sources of High Sodium intake in Turkey: SALTURK II,” Nutrients 9, no. 9 (2017): 933, doi:10.3390/nu9090933; United States: see details of US efforts in chapter 9; United Kingdom: Public Health England, “Salt Targets 2017: Progress Report—A Report on the Food Industry’s Progress towards Meeting the 2017 Salt Targets,” December 2018, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/765571/Salt_targets_2017_progress_report.pdf; Uruguay: Global Advertising Lawyers Association, “New Front- of-Package Labeling Regulation in Uruguay,” Gala Gazette 13, no. 4.
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28. Individual sources for figure 7.2: (top) L. Rodriguez, Chilean Ministry of Health, “The Implementation of New Regulations on Nutritional Labelling in Chile,” https://www.wto.org/english/tratop_e/tbt_e/8_Chile_e.pdf (accessed August 1, 2018); (middle) Courtesy of Israel Ministry of Health; (bottom) © All Rights Reserved. Health Canada, Consultation on Proposed Front-of-Package Labelling (adapted and reproduced with permission from the Minister of Health, 2019).
29. M. Shoup, “Brazil: Front of Package Warning Labels Found to Be an ‘Important Addition’ to Nutrition Facts,” FoodNavigator–latam.com, July 15, 2019, https://www.foodnavigator-latam.com/Article/2019/07/15/Brazil-Front-of-package-warning-labels-found-to-be-an-important-addition-to-nutrition-facts (accessed September 12, 2019); Vital Strategies, “Brazilians Call for New Food Warning Label System,” news release, November 13, 2018, http://www.vitalstrategies.org/press/brazilians-call-for-new-food-warning-label-system/ (accessed April 4, 2019).
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28. US Food and Drug Administration, “Draft Guidance for Industry: Voluntary Sodium Reduction Goals: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods,” June 2016, https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/ucm494732.htm (accessed October 7, 2019).
29. A. Jessup and D. Wilmoth, US Department of Health and Human Services, “The Value of a National Reduction in Dietary Sodium from Processed and Restaurant Foods,” preliminary draft, October 22, 2013 (in the authors’ files).
30. US Food and Drug Administration, “FDA Food Categories and Voluntary Targets,” https://www.fda.gov/downloads/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/UCM504014.pdf (accessed March 17, 2020).
31. T. R. Frieden, “Sodium Reduction—Saving Lives by Putting Choice into Consumers’ Hands,” JAMA 316, no. 6 (2016): 579–580.
32. Source for box 9.1: American Heart Association, “Heart-Check Food Certification Program Nutrition Requirements,” https://www.heart.org/en/healthy-living/company-collaboration/heart-check-certification/heart-check-in-the-grocery-store/heart-check-food-certification-program-nutrition-requirements (accessed August 26, 2019).
33. American Heart Association, “FDA Proposes Voluntary Targets for Food Producers to Lower Sodium,” June 1, 2016, https://newsarchive.heart.org/fda-proposes-voluntary-targets-for-food-producers-to-lower-sodium/ (accessed February 25, 2020).
34. Center for Science in the Public Interest, “FDA Issues Voluntary Sodium Reduction Targets,” June 1, 2016, https://cspinet.org/news/fda-issues-voluntary-sodium-reduction-targets-20160601 (accessed February 25, 2020).
35. U.S. Food and Drug Administration, “FDA Food Categories and Voluntary Targets,” https://www.fda.gov/downloads/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/UCM504014.pdf (accessed March 17, 2020).
36. Public Health England, “Salt Targets 2017: Progress Report—A Report on the Food Industry’s Progress towards Meeting the 2017 Salt Targets,” December 2018, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/765571/Salt_targets_2017_progress_report.pdf (accessed October 11, 2019).
37. Salt Institute, “Government’s War on Salt Is Malpractice,” June 1, 2016, http://www.saltinstitute.org/press_releases/governments-war-on-salt-is-malpractice/ (accessed August 16, 2018).
38. L. Roman, letter to the Secretaries of Agriculture and Health and Human Services, April 11, 2016.
39. SNAC International, “Statement from SNAC International CEO Regarding FDA Release of Sodium Targets per Food Category,” June 1, 2016, http://web.archive.org/web/20160611165335/http://snacintl.org/news/latest-headlines/story/statement-from-snac-international-ceo-regarding-fda-release-of-sodium-targets-per-food-category (accessed February 25, 2020).
40. SNAC International, Comment to FDA, October 17, 2016, https://www.regulations.gov/document?D=FDA-2014-D-0055-0429 (accessed January 19, 2020).
41. SNAC International, January 14, 2020, Statement from SNAC (in the author’s files).
42. L. Bruner, Grocery Manufacturers Association, “GMA Statement on Sodium Reduction Guidelines,” June 1, 2016, https://www.gmaonline.org/news-events/newsroom/gma-statement-on-sodium-reduction-guidelines/. Link no longer active.
43. Grocery Manufacturers Association, October 17, 2016, Docket No. FDA-2014-D-0055; Grocery Manufacturers Association, December 2, 2016, Docket No. FDA-2014-D-0055.
44. FDA Docket No. FDA-2014-D-0055.
45. Mars, “Mars’ Position on the Release of the FDA’s Draft Voluntary Guidance on Sodium,” June 9, 2016, https://www.mars.com/global/our-news/our-stories/press-release/mars-position-release-fda-draft-voluntary-guidelines-sodium (accessed August 19, 2018).
46. “Letter from Food Manufacturers and Health Groups to the Senate Agriculture Appropriations Subcommittee,” May 16, 2016, https://foodpolitics.com/wp-content/uploads/senate-ag-approps-sodium-letter-final-5.16.16.pdf (accessed November 13, 2018); E. Crawford, “Stakeholders Laud FDA’s Potentially Life-Saving Draft Voluntary Sodium Reduction Guidance,” FoodNavigator, June 1, 2016, https://www.foodnavigator-usa.com/Article/2016/06/01/Stakeholders-laud-FDA-s-draft-voluntary-sodium-reduction-guidance.
47. Sustainable Food Policy Alliance, “SFPA Supports the National Academies’ Findings on the Need to Reduce Dietary Sodium,” March 6, 2019, https://foodpolicyalliance.org/news/sfpa-supports-the-national-academies-findings-on-the-need-to-reduce-dietary-sodium/ (accessed April 7, 2019).
48. M. R. L’Abbé, interview with the author, October 11, 2018.