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Thanks to Courtney Scott, a doctoral student at University of North Carolina, for sending me this account of the fate of Britain’s salt reduction strategies, published in the BMJ (British Medical Journal).

The lead author on the article is Dr. Graham MacGregor, Britain’s leading advocate for diets lower in salt.  It is about the derailing of Britain’s remarkable successful salt reduction strategy.

Under the auspices of Britain’s Food Standards Agency (FSA), the salt reduction program initiated in the early 2000s—getting companies to slowly but steadily reduce the salt in their products—was working well.

Most impressive: salt intake, blood pressure, heart disease, and stroke declined in parallel with the decline in salt in the food supply.

But in 2010, Britain elected a more conservative government.

Andrew Lansley was appointed secretary of state for health, and he moved the responsibility for nutrition from the FSA to the Department of Health. This disrupted the salt reduction programme, making it unclear who would be responsible for the policy. In 2011 Lansley launched the responsibility deal, whereby he made the alcohol and food industries responsible for reducing alcohol consumption and improving nutrition, respectively. As a result, salt reduction lost momentum.

The key points of the article:

• Most of the foods that industry currently provide are very high in salt, fat, and sugars and are therefore more likely to cause cardiovascular disease and predispose to cancer than healthier alternatives.

• The UK’s salt reduction programme…led to a significant reduction in population salt intake, accompanied by reductions in blood pressure and cardiovascular mortality.

• The programme has been set back by the coalition government’s decision to hand power back to the food industry as part of the responsibility deal.

• An independent agency for nutrition with a transparent monitoring programme is urgently needed to improve the food that we eat.

As I’ve explained previously, most salt—80% or more—in American diets is already in processed and prepared foods when they are presented to us.  That’s where the salt reduction has to come from.  As the authors explain,

Members of the food industry have said that they are keen to reformulate their foods to make them healthier. All they require is to be on a “level playing field” with the other major companies, so that they can make their foods healthier in a structured, incremental way. They need to be assured that there are proper reporting mechanisms in place and that all of the companies are being monitored equally. Enforcement is required, and if it doesn’t work, regulation or legislation must be enacted.

The debates over salt may be the most contentious in the field of nutrition (as the Washington Post puts it), but the parallels between the British decline in salt intake and in salt-related disease are impressive.

On a population basis, eating less salt is healthier.

This is something you can’t easily do on your own.  The food industry has to do it.  And food companies don’t want to, for obvious reasons.

Hence: the need for regulation.

Congress, in its infinite wisdom, is again using the appropriations process to micromanage nutrition standards for school meals and the WIC program, against the advice of the Institute of Medicine and other health experts.

The new appropriations bill includes several provisions relevant to issues I discuss frequently here.  By all reports, this is the best that can be expected, given the makeup of this Congress.

• Section 751 grants exemptions to states from the whole grain requirements for school meals “Provided, That school food authorities demonstrate hardship…in procuring specific whole grain products which are acceptable to the students and compliant with the whole grain-rich requirements (my translation: forget whole grains and recommendations by health experts.  They are way too much trouble).
• Section 752 says that no federal funds may be used to pay the salaries of people doing work “that would require a reduction in the quantity of sodium contained in federally reimbursed meals, foods, and snacks sold in schools…until the latest scientific research establishes the reduction is beneficial for children (We know more about the effects of salt on health than do health professionals and expert committees).
• Section 753 says Congress won’t pay the salaries of anybody who tries to “exclude or restrict, he eligibility of any variety of fresh, whole, or cut vegetables (except for vegetables with added sugars, fats, or oils) from being provided under the Special Supplemental Nutrition Program for Women, Infants, and Children (no, you can’t keep white potatoes out of the WIC program).

Chalk these up to effective lobbying by the School Nutrition Association, makers of salty snacks, and the potato lobby.

The good news, such as it is:

• Congress did not roll back most of the USDA’s food standards for school meals.
• It only cut SNAP by $400 million.
• It only cut WIC by $93 million.

These must be considered enormous victories, given the circumstances.

Addition, December 12:  The Hagstrom Report quotes USDA Secretary Tom Vilsack:

On the provision to require the availability of white potatoes in the Special Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC), Vilsack said, “With all due respect to the politicians who make the law, I have more confidence in pediatricians and more confidence in medical science than in political science.” 

 

 

I like the special editions of the business newsletter, FoodNavigator USA.  This especially big one collects its recent articles on sodium reduction—a big issue these days.   These give a good idea of how food companies are dealing with pressures to lower their salt content.

It’s expensive, risky, and difficult, but manufacturers have made huge progress on sodium reduction in recent years. But how much further can they go, and where is the return on investment if consumers are at best indifferent to their efforts, or at worst downright suspicious?

This special edition explores the challenges of sodium reduction, and asks whether it’s falling down the food policy agenda in the US, but also provides examples of creative solutions that can help manufacturers reduce it without compromising on taste or functionality.

Is sodium reduction falling down the food policy agenda?  Four years ago sodium was public enemy #1. The Institute of Medicine (IOM) was calling for the FDA to modify the GRAS status of salt and slash the daily value for sodium to 1,500mg, and the food industry was on high alert. Today, sugar is the new bogeyman, and while sodium intakes remain stubbornly high, the FDA has yet to issue voluntary guidelines. So is sodium reduction falling down the food policy agenda?

AHA education campaign pressures food manufacturers to reduce sodium: The American Heart Association says its recently launched consumer education campaign encouraging Americans to “break up with excess salt” seeks to “build an army of passionate and willing supporters” to pressure food manufacturers to reduce sodium in packaged foods.

Advanced technology eases sodium reduction efforts: Advances in technology can help firms more quickly and easily reduce sodium in breads and grain-based packaged foods – a previously repetitive and expensive trial and error process, according to Janice Johnson, food applications leader in salt at Cargill.

Will proposals to mandate potassium labeling on the Nutrition Facts panel give potassium-chloride based sodiumreplacers a shot in the arm?  Some food manufacturers still worry that using potassium chloride to replace salt in their recipes might compromise their clean label credentials. But the FDA’s recent proposal to include potassium as one of the nutrients that must be listed on the Nutrition Facts panel is helping to change that mindset, says NuTek Salt.

Sodium reduction: has all the low-hanging fruit been plucked?  Food manufacturers are under increasing pressure to reduce sodium, but surveys suggest many shoppers are, well, not that bothered. So where does this leave firms plugging sodium reduction solutions?

Reformulation by stealth: Just 2% of new launches in salty snacks make overt sodium reduction claims: The vast majority of sodium reduction activity in the US food industry is now being conducted by ‘stealth’ in order to avoid alienating shoppers, according to Tate & Lyle.

Industry to FDA: Think again before setting category-by-category sodium reduction targets.  Two leading food industry associations have urged the Food and Drug Administration (FDA) not to set category-by-category limits for sodium amid rumors that the agency is planning to outline a new sodium reduction strategy this year.

Can seaweed become the ultimate salt replacer – and why hasn’t it yet?  Seaweed is well-researched, sustainable and effective, according to an expert. So what is stopping it from really taking off as a salt replacer?

Mandatory salt reduction could save more in healthcare costs: Study.  Mandatory salt reduction may save more in healthcare costs than the current voluntary system, say the authors of a study published in Value in Health.

Myth busting? High salt intake may not increase thirst:  It is commonly believed that consumption of salty foods increases thirst, and could be a reason for increased consumption of sugary soft drinks and alcoholic beverages. But just how true is this notion?

Are salt reduction efforts reflected in heart health?  Salt reduction efforts around the world are making progress – but how has lower salt consumption affected health?

Salt substitutes help reduce blood pressure.  Efforts to reduce consumer blood pressure and risk of hypertension by replacing normal salt with blends of potassium chloride, magnesium sulfate and less sodium chloride are working, but may be more effective in countries where the majority of salt comes from home cooking, according to a meta-analysis in the December American Journal of Clinical Nutrition.

‘Quiet’ salt reduction is vital – but gourmet salt growth may stifle industry efforts.  Salt replacer use is growing but low salt claims are not, as food companies favour a ‘quiet’ approach – but growth in gourmet table salts may threaten salt reduction efforts.

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Here are the burning questions about sodium (which is 40% of salt) intake:

(a) Does too much dietary sodium cause high blood pressure?   Answer: an unambiguous yes (although not necessarily in everyone).

(b) Are public health recommendations to reduce salt intake warranted?  I think so, but others disagree.

(c) If so, to what level?  Although virtually all committees reviewing the evidence on salt and hypertension view public health recommendations as warranted, and advise an upper limit of about 2 grams of sodium (5 grams of salt, a bit more than a teaspoon (see table from the Wall Street Journal), these too are under debate.

These recommendations are strongly opposed by The Salt Institute, the trade association for the salt industry, its industry supporters, and some groups of investigators.

Now the New England Journal of Medicine weighs in with three new studies, an editorial, and a cartoon video.  The papers:

• Association of Urinary Sodium and Potassium Excretion with Blood Pressure: A. Mente and Others | N Engl J Med 2014;371:601-611
• Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events: M. O’Donnell and Others | N Engl J Med 2014;371:612-623
• Global Sodium Consumption and Death from Cardiovascular Causes: D. Mozaffarian and Others | N Engl J Med 2014;371:624-634

Start with the video,  narrated by the editor, Dr. Jeffrey Drazen (click on video link on the right side).  It gives an excellent summary of the three papers.  Despite their methodological differences, all confirm (a).  They disagree on (c) and, therefore, (b).

Are public health recommendations warranted?

But note Dr. Drazen’s suggestion: “throw away the salt shaker.”

He is in favor of reducing salt intake.  But the salt shaker is not where most dietary salt comes from.  At least 75% of salt in American diets comes from restaurant and processed foods.   As Dr. Yoni Freedhoff explains:

If you’d like to reduce the sodium in your diet, rather than keep a running tally of how much you’re actually consuming, why not try instead to determine what percentage of your diet comes from restaurants and boxes? Sure, there’s data to suggest you might simply find other ways to add salt to your diet. But visit restaurants and consume processed foods less frequently, and I’d be willing to wager that you’ll be far more likely to see health benefits than were you to simply fill your grocery cart with low-sodium versions of highly processed foods.

Individuals cannot cut down on salt on their own.  That’s one reason why public health policies are needed—to get restaurants and processed food manufacturers to reduce salt content.

Two of the papers say that the only people who need to cut down on salt are those with hypertension and older people (one of the studies says that means people over age 55).

• How many Americans have hypertension?  67 million (1 out of every 3 adults) according to the CDC.
• How many Americans are over age 55?  More than 80 million, and rising.

You can’t expect 70 or 80 million people to reduce salt intake on their own.  Hence: public health recommendations.

Conflict of interest alert

Some of the investigators report receiving grants or fees from companies that make anti-hypertensive drugs but the editorial accompanying the papers is of special concern.   Written by Dr. Suzanne Oparil, it says about one of the studies:

These provocative findings beg for a randomized, controlled outcome trial to compare reduced sodium intake with usual diet. In the absence of such a trial, the results argue against reduction of dietary sodium as an isolated public health recommendation.

These conclusions sent me right to her conflict-of-interest disclosure statement.  Although Dr. Oparil reports receiving grants or fees from companies making anti-hypertensive drugs—-and, even more remarkable, from The Salt Institute—she states that she has no conflicts of interest.

I think she does.

Implications

Her editorial is especially unfortunate because it influences the way reporters write about the studies.

The Associated Press account, for example, begins:

A large international study questions the conventional wisdom that most people should cut back on salt, suggesting that the amount most folks consume is OK for heart health — and too little may be as bad as too much. The findings came under immediate attack by other scientists.

As well they should.  Blood pressure rises with age and huge swaths of the population would be healthier eating less salt.   The AP reporter quoted me saying so:

“People don’t eat salt, they eat food,” she said. “Lots of people have high blood pressure and lots of people are getting older,” making salt a growing concern, she said. “That’s the context in which this is taking place.”

The three studies are complicated to interpret because of differences in methods and discrepancies in outcomes.  They agree that if you already have hypertension or are “elderly,” or eat a lot of salt, you should cut down.

This seems like a good idea for just about anyone.   People don’t eat salt; they eat foods containing salt, and foods high in salt tend to be high in other things best consumed in small amounts.

The studies also talk about the protective effects of potassium, best obtained from vegetables.

Eat a lot of vegetables and not too much junk food, and you don’t have to worry about any of this.

I’m in Washington, DC this week on a bit of book tour for Eat, Drink, Vote (see Appearances for schedule).

At my Politics & Prose bookstore event last night, I got asked why I think the food environment matters so much in dietary choice.  Isn’t food choice a matter of personal responsibility?

It is, of course, but the food environment greatly influences personal choice.

Two examples:

Large portions: just about anyone presented with a large portion of food with eat more from it, take in more calories (larger portions have more calories!), and underestimate the calories consumed by a much greater proportion than from a smaller amount.

Salt intake: Because 80% or so of salt in the American diet comes from processed and restaurant foods, people eating in restaurants have no control over the amount of salt they take in.

To make it easier for people to take in fewer calories and less salt requires changes in the food environment: serve smaller portions and reduce the salt in restaurant foods.

FDA: Get to work!

The American Journal of Hypertension has published a series of point-counterpoint articles on the salt debate: are public health campaigns to reduce sodium intake warranted by the data?  Public health agencies argue yes.Others argue to the contrary.

This debate is not easily resolved, mainly because everyone eats a high-salt diet; most salt is already in processed and restaurant foods and eaters have no choice.

So the issue really becomes one of whether it makes any difference to high blood pressure to reduce high salt intakes and, if so, to what level—questions difficult to answer with current methods.

Introduction

The Salt Discourse in 2013
Theodore A. Kotchen

CDC Response

Sodium Reduction Is a Public Health Priority: Reflections on the Institute of Medicine’s Report,Sodium Intake in Populations: Assessment of Evidence
Janelle P. Gunn, Jessica L. Barron, Barbara A. Bowman, Robert K. Merritt, Mary E. Cogswell, Sonia Y. Angell, Ursula E. Bauer, and Thomas R. Frieden

NYC DOHMH Response

Getting the Message Right: Reducing Sodium Intake Saves Lives
Jenifer E. Clapp, Christine J. Curtis, Susan M. Kansagra, and Thomas A. Farley

Editorial

The IOM Report Fails To Detect Evidence to Support Dietary Sodium Guidelines
Michael H. Alderman and Hillel W. Cohen

Researcher Responses

Physiology, Not Policy, Drives Sodium Intake 
David A. McCarron

Extreme Sodium Reductions for the Entire Population: Zealotry or Evidence Based?
Andrew Mente, Martin J. O’Donnell, and Salim Yusuf

Flawed Evidence Should Not Derail Sound Policy: The Case Remains Strong for Population-Wide Sodium Reduction
Lawrence J. Appel and Paul K. Whelton

Sodium: How and How Not to Set a Nutrient Intake Recommendation
Robert P. Heaney

Since 1980, U.S. dietary guidelines have advised eating less sodium (salt is 40% sodium, 60% chloride).  Although sodium is an essential nutrient, most Americans consume way more than they need or is good for them—around 3,400 milligrams a day.

The 2010 guidelines advised healthy people to consume no more than 2,300 mg per day (~6 grams, or 1.5 teaspoons).  They advised even less, 1,500 mg, for people with or at high risk for high blood pressure.  Since blood pressure increases with age in countries with high salt intake, this applies or will apply to just about everyone.  

In 2011, the Institute of Medicine said it was imperative to find effective strategies to lower salt intake.  This means dealing with processed and restaurant foods, because that’s where most of the salt comes from, as can be seen from this list of major food sources. 

Because consumers have no choice about the amount of salt in processed and restaurant foods, education cannot be enough to achieve salt reduction.  Scientists in Australia have just proved this point.

As I explained to a reporter,

Why anyone would think that nutrition education alone would change behavior is beyond me. By this time everyone should know that to change behavior requires not only education, but a food environment—social, political, economic—that supports and promotes the behavior change.

Most dietary sodium comes from processed foods, restaurant foods, and other pre-prepared foods.  All the label can do is say ‘don’t eat me’ It can’t help with what people can eat.

The easiest and most effective way to help people reduce sodium intake is to require food producers and food preparers to use less of it. Good luck with that. I’m not optimistic, particularly given the conflicting and confusing science. 

Ah yes.  The conflicting science.  The IOM now says that there’s no evidence one way or the other that reducing sodium below 2,300 mg per day, or even to 1,500 per day, does much good, and that low sodium intakes could be harmful (but this too is controversial).

Yes, they could, but as Mark Bittman blogs,    

It may be true that there are no benefits in an ultra-low-salt diet, but almost no one is eating an ultra-low-salt diet. It’s not quite like worrying about whether we get “enough” sugar, but it’s nearly as ridiculous.

And now, as Food Navigator explains, the IOM committee is complaining that its report has been badly misinterpreted.  All they said was:

As to whether we should cut back to 1,500 mg or to 2,300 mg sodium a day, meanwhile, the jury is out, says the IOM, not because consuming 1500 mg/day is dangerous, but because there is just not enough data on the benefits of consuming such low levels to support a firm conclusion.

IOM committee members were so bothered by misleading press accounts that they wrote an op-ed to JAMA to clarify:

Rather than focusing on disagreements about specific targets that currently affect less than 10% of the US population (ie, sodium intake of <2300 mg/d vs <1500 mg/d),  the IOM, AHA, WHO, and DGA are congruent in suggesting that excess sodium intake should be reduced, and this is likely to have significant public health effects. Accomplishing such a reduction will require efforts to decrease sodium in the food environment….

The bottom line, Bittman says (and I enthusiastically agree), is that

Salt intake — like weight, and body mass index — is a convenient baseline for public policy people to talk about. If you focus on eating less salt — and, indeed, less sugar — you will inevitably eat less processed food, fast food, junk food (it’s all the same thing.) If you eat less processed food (etc.) you eat more real food. If you eat more real food, not only are you healthier, but you probably don’t have to pay attention to how much salt you’re eating. Wowie zowie. 

Dietary sodium continues to generate much talk but little action.

The CDC issued a recent Vital Signs report on dietary sodium with this graphic:

In translation from the data tables:

• 90% of Americans consume too much salt.
• 44% of salt comes from 10 foods: breads and rolls, cold cuts and cured meats, pizza, poultry, soups, sandwiches, cheese, pasta dishes, meat dishes, and snacks.
• 65% of salt comes from retail processed foods.
• 25% comes from food served at restaurants.
• 10% comes from salt added at the table.
• 10% occurs naturally in foods.
• $20 billion a year is the cost of salt-related chronic disease.

The bottom line?  Americans would be better off eating less salt.

But from the standpoint of the food industry, reducing dietary sodium is a big problem.  See, for example,  FoodNavigator-USA.com‘s recent articles about sodium in foods and health:

Sodium reduction: The science, the technology… and the business case It’s expensive, risky, and difficult, but manufacturers have made huge progress on sodium reduction in recent years. But how much further can they go, and where is the ROI if consumers are at best indifferent to their efforts, or at worst downright suspicious?.. Read Bakers on sodium reduction: We can’t afford to make products consumers won’t buy Reducing sodium is expensive and difficult, and many bakers are beginning to wonder whether it is worth investing millions into reformulating products that consumers do not want to buy, according to the Association of Bakers (ABA)… Read Risks of slashing sodium levels in cheese could outweigh benefits, US researcher A prominent US researcher says that government pressure to cut sodium in cheese could have serious food safety, taste and labeling consequences, and questions the necessity of such a move given minimal evidence of positive health effects and muted consumer demand… Read Sodium reduction: To boldly go… lower and lower Food manufacturers are under increasing pressure to reduce sodium, but surveys suggest many shoppers are, well, not that bothered. So where does this leave firms plugging sodium reduction solutions? Elaine Watson asks Mariano Gascon, R&D chief at seasonings, flavors and spice specialist Wixon for his take on it… Read Law professor: Sodium reduction only works if there is a level playing field If consumers are not demanding lower-sodium products, and the government does not mandate reductions, the food industry has “no incentive to be at the forefront of change”, according to one legal expert… Read National Dairy Council: Low sodium cheese is not taking the market by storm While cheese makers remain committed to salt reduction, demand for low-sodium cheese remains pretty lackluster, according to the National Dairy Council (NDC)… Read Academic: Government sodium targets are incompatible with rest of dietary guidelines Further evidence that government healthy eating guidelines are more ‘aspirational’ than achievable has been uncovered by researchers testing how easy it is to meet low sodium targets and get the rest of the nutrients we need… Read IFT urges government to take a cautious approach to sodium reduction The Institute of Food Technologists (IFT) has submitted comments to government agencies suggesting that actions to reduce sodium should not go “too far, too fast”, and has raised concerns about consumer acceptance and the safety of reduced sodium foods… Read American Heart Association blasts industry sodium reduction skeptics Suggestions by the Salt Association and other industry associations that sodium reductions could hurt rather than improve health are “not supported by science”, the American Heart Association (AHA) has insisted… Read ‘Processed’ foods are often high in sodium – but what’s a processed food? About 75% of the sodium in our diets comes from processed foods. It’s a regularly cited figure – but what exactly is a ‘processed’ food? Consumers might be surprised… Read

But this one just in:

•  Salt intake during pregnancy may alter heart structure of offspring: Rat study