Lots of controversy over salt.
See the following:
SALT:
Intake of potassium- and magnesium-enriched salt improves functional outcome after stroke: a randomized, multicenter, double-blind controlled trial January 2018
Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds. June 2011
The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease December 2014
Why Everything We Know About Salt May Be Wrong May 2017
The latest here:
Our Food Supply Is Drowning in Salt
FDA's new sodium reduction guidance is a step in the right direction
Since the first Dietary Guidelines for Americans (DGAs) were released in 1980, and for each updated version released every 5 years, there has been a consistent message: decrease dietary sodium. The 2020-2025 DGAs recommend 2,300 mg/day of sodium for men and women 14 years and older, and many esteemed scientific societies have issued similar guidance about the importance of decreasing dietary sodium.
Despite decades of guidance to decrease dietary sodium, intakes have remained relatively constant and markedly above recommendations. Based on NHANES 2013-2016 data, 97% of men and 84% of women ages 19-30 exceed dietary sodium recommendations; as do 97% and 82% of men and women ages 31-59, respectively; and 94% and 72% of those 60 years and older. This is of great concern to public health officials, including former FDA Commissioner Scott Gottlieb, MD, who commented in 2018, "There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet."
Sodium is present in almost all food categories. The major food sources of sodium in the U.S. diet include: mixed dishes such as sandwiches, burgers, and tacos; rice, pasta, and grain dishes; pizza; meat, poultry, and seafood dishes; and soups. The majority of sodium (71%) comes from salt added during commercial food processing and preparation, including foods prepared at restaurants. About 14% of sodium is a normal constituent of foods, while 6% is added in home food preparation and 5% comes from the salt shaker.
So, what do these sodium sources tell us? The problem is less about the salt individuals are adding to their food and more about the sodium added by the food industry. To achieve a significant reduction in dietary sodium, processed foods and foods eaten away from home need to contain less salt.
New Sodium Guidance for Industry
In response to little progress on reducing sodium intake on a population level despite years of advice, FDA is finally responding. In October, the FDA issued "Guidance for Industry" on voluntary sodium reduction goals with the purpose of reducing average sodium intake in the U.S. to 3,000 mg/day over 2.5 years -- approximately a 12% reduction from the current levels. The guidance offers target sodium concentration goals for a food category versus single products in that category. The goals were developed by evaluating the sodium concentrations in available food products, making achieving the goals feasible. The new guidance aims to balance the need for broad and gradual reductions in sodium with the technical constraints for the food industry associated with sodium reduction and product reformulation.
Widespread adoption of this voluntary program is intended to be sustainable, allowing for gradual reductions over time so consumer taste preference can acclimate. Adoption will be assessed and monitoring will be ongoing to evaluate its effectiveness and assure there are no unintended consequences (such as saturated fat or added sugars replacing sodium for flavor in foods). FDA also plans to continue the dialogue on sodium reduction to encourage adoption.
Other Efforts to Reduce Sodium Intake
This initiative in the U.S. isn't groundbreaking. The best example of a voluntary salt reduction program working on a populations basis is the U.K.'s salt-reduction program. Voluntary, incrementally lower salt-reduction targets were set for >85 food categories, which resulted in a 15% reduction in salt intake (from 3,800 to 3,240 mg/day) between 2003 and 2011. This led to a 2.7 mmHg decrease in population systolic blood pressure and, impressively, a significant reduction in mortality from stroke and ischemic heart disease. This a growing trend worldwide -- to date, at least 50 countries have launched initiatives to support sodium reduction in the food supply.
In the U.S., the National Salt Reduction Initiative (NSRI), a partnership of 70 local and state health departments and health organizations, had a goal to decrease population sodium intake by 20% over 5 years (2009-2014). At the end of 2014, NSRI reported that although the target goal for the 25 participating companies was not met, there was still a 6.8% reduction in sodium in the food products of the participating companies.
Does the New Guidance Go Far Enough?
The FDA Voluntary Sodium Reduction Goals program is long overdue and addresses a critical public problem in the U.S. There is a clear and urgent need to decrease population sodium intake, but over the past few decades, our nutrition education efforts have failed in this area. The challenge has been that our food supply is awash in sodium. It is now time for a new approach -- a partnership between FDA and the food industry -- to begin rectifying the problem.
What FDA has proposed is a good first step. It has been criticized as too little, too late, and over too long a period of time (2.5 years). However, the FDA's approach to slowly decrease sodium (a decrease of 12% initially) allows the population to adjust to new flavor profiles that are only subtly different from consumers' taste preferences. Indeed, this program should have been started years ago. But now is better than never. With respect to the 2.5 year timeline, it doesn't take this long to reformulate and repackage new food products if the food industry makes a concerted effort to prioritize improved public health. The government should consider incentives, such as a tax break, that might help speed up the timeline.
Future U.S. efforts at sodium reduction will need to focus on further lowering the target mean sodium concentration to more closely align with dietary recommendations. In the case that a majority of companies do make changes and this leads to shifts in consumer sensory preferences, then companies that haven't lowered their sodium content could lose market share as consumers stop buying their products. However, the current guidance is voluntary and industry adoption uncertain. In the future, FDA could mandate sodium reduction for food products.
The current public health system catastrophe of an uptick in cardiovascular morbidity and mortality has to be halted. The FDA Voluntary Sodium Reduction Goals program is a much-needed initiative, and efforts to encourage industry adoption of the guidance should be prioritized. We must take action now.
Penny M. Kris-Etherton, PhD, RD, is the Evan Pugh University Professor of Nutritional Sciences in the Department of Nutritional Sciences at Penn State University.
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