Population Health

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Salt Reduction Works. The FDA Should Be Allowed To Set Tougher Limits, LDI Experts Say

Reduction Limits Save Lives and Money, and Even Food Firms Back Them. So Why Doesn’t Congress Act?

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The following first appeared in Health Affairs Forefront on August 16th, 2024.

Setting sodium reduction targets for the food supply is a rare example of a public health policy that reduces health care costs, saves lives, and is even supported by many food companies. In 2016, the Food and Drug Administration (FDA) embarked on a sodium reduction strategy, only to meet repeated political hurdles. By funding the FDA’s existing work to set sodium reduction targets for the food industry, the White House and Congress could help to bring salt intake to recommended levels, preventing about 450,000 new cases of cardiovascular disease and saving $41 billion in health care costs over 20 years.

Americans’ Sodium Intake Is Astonishingly High

Americans eat too much sodium—about 70 percent more than is recommended by the World Health Organization. Sodium intake above recommended levels accounts for nearly 10 percent of deaths from heart disease and stroke in this country. The science is clear: For most Americans, reducing sodium intake will substantially improve heart health. But most sodium in our diets comes from packaged and restaurant food, making dietary changes virtually impossible without changes to the food supply.

In 2021, the FDA launched a program that set short-term, voluntary sodium reduction targets for packaged and restaurant foods. The program aims to slowly reduce sodium in the food supply by setting achievable benchmarks for food companies to meet. The rationale for this program is simple: Americans eat too much sodium, but even highly motivated people cannot limit sodium easily because most salt is added to food long before it reaches our plates. Nearly half of the sodium in the US diet comes from just 10 foods, with pizza, bread, and deli meats topping the list. Some of these foods are outrageously high in salt. For example, Chili’s six-piece Nashville hot chicken tenders, without sides, has 6,520 mg of sodium—three times what should be eaten in an entire day. What’s so powerful about setting progressive targets for industry is that consumers barely notice small, gradual reductions in sodium. Even children are accepting of familiar foods that have been reformulated to reduce salt. Because sodium targets can be met without hurting sales, it is one of the few nutrition policies that many large food companies support.

Reducing Sodium In The Food Supply Saves Lives

Setting sodium targets that industry can adopt is considered a best practice for reducing salt intake worldwide, and more than 40 countries have established targets. In 2006, the United Kingdom developed a national salt reduction strategy that included progressively lower sodium targets for processed foods, industry engagement to help food companies achieve the targets, and a robust monitoring and evaluation strategy. That program led to a 15 percent decline in sodium intake over seven years and is estimated to have prevented 6,000 deaths from heart disease and stroke each year. UK consumers can still buy products very similar to those sold in the US market, only the products are lower in salt. For example, a box of Kellogg’s Corn Flakes sold in London is nearly 40 percent lower in sodium than an almost identical product sold in New York.

The National Salt Reduction Initiative Proved Sodium Reduction Is Feasible

The Institute of Medicine (now the National Academy of Medicine) has recommended a strategy similar to the UK’s for the US food supply since 2010. And while we know this is achievable, progress has been slow. In 2009, the New York City Department of Health and Mental Hygiene coordinated with more than 100 health organizations to launch the National Salt Reduction Initiative to reduce sodium in the US food supply. This initiative set short- and medium-term targets for packaged and restaurant foods, solicited public commitments from food companies, and monitored progress over time. In just five years, the National Salt Reduction Initiative achieved a nearly 7 percent reduction in sodium in packaged foods.

This effort helped spur the FDA in 2016 to propose two- and 10-year sodium reduction targets for packaged and prepared foods. But after the proposed targets were released, progress stalled. Although many food companies supported FDA action on sodium, others opposed government interference in their businesses—a sentiment that appealed to anti-regulatory members of Congress. Congressional appropriations riders repeatedly blocked the FDA from advancing sodium reduction targets, resulting in nearly five years of inaction. Modified, short-term (2.5-year) voluntary targets were finalized in 2021, but there has been little industry engagement, minimal public reporting, and no consequences if targets are not achieved. Yesterday, the FDA released a second phase of short-term targets, which, if adopted, would further delay their initial 10-year objectives. These delays are not without consequence. Even if the 10-year targets were finalized today, the FDA’s delays will cost us more than 250,000 unnecessary deaths from heart disease and stroke by 2031.

The FDA Needs Congressional And White House Support

Sodium reduction targets are one of the most cost-effective means to improve Americans’ health, but the food industry must be held accountable to meeting the targets. It is therefore critical that the federal government support the FDA in rigorously evaluating the short-term targets and continuously setting longer-term targets. Additionally, Congress must dedicate funds to support the FDA in soliciting public commitments from industry and creating a public database to monitor sodium levels in the food supply. If companies cannot demonstrate meaningful voluntary progress, the targets should be made mandatory. These are achievable policy goals. Forty other countries have done this. And the National Salt Reduction Initiative’s success is proof it is doable. We just need Congress to support the FDA in fully implementing what they’ve already started.

Authors’ Note: Alyssa Moran has received consultancy fees from the New York City Department of Health and Mental Hygiene.

Read the piece in Health Affairs Forefront here.

Authors

Alyssa J. Moran, ScD, MPH

Director, Policy and Research Strategy, Psychology of Eating and Consumer Health Lab (PEACH Lab), Perelman School of Medicine

Marlene Schwartz, PhD

Director, Rudd Center for Food Policy and Health and Professor of Human Development and Family Sciences, University of Connecticut

Christina Roberto

Christina Roberto, PhD

Mitchell J. Blutt and Margo Krody Blutt Presidential Associate Professor, Medical Ethics and Health Policy, Perelman School of Medicine; Associate Director, Center for Health Incentives and Behavioral Economics

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