Got Salt ? It Could Cost You Your Health – Patrice Barrett

The Issue – Excessive Sodium Consumption in Americans

The United States Departments of Agriculture and Health and Human Services recommend a daily intake of no more than 2300 mg. of salt for those older than two years of age. This is the equivalent of one teaspoon of salt. Lower guidelines of just under 1500 mg. a day are recommended for people over 40 years of age, African Americans, elderly and those already diagnosed with hypertension. These populations are already at high risk for cardiac disease and stroke. (1)(2) The average US adult was consuming about one and a half times the maximum recommended 2300 mg. daily at the end of 2006. The highest consumption levels are in the 14 to 50 years old age groups. (3)High salt intake is associated with negative health effects, including hypertension, renal disease, cardiovascular disease and stroke. These illnesses can cause significant physical disability and immediately result in death. Sodium dietary intake levels have been steadily rising since 1971. Some adult males now consume over 4000 mg a day. (4)

The US Institute of Medicine of the National Academies (further known as IOM) released on April 20, 2010 a consensus report on strategic plans the United States government should institute to reduce sodium intake in our citizens. This report was issued in response to a US Congressional request in 2008 to recommend strategies to address the issue. Wide media coverage of the excessive sodium consumption issue in the few days after the release of the report seems to have made the topic more visible to the public. (5-9)

The Public Health Impact of the Issue

Treatment of diseases resulting from the current levels of salt consumed in American diets costs the US health care system annually between $10 and 24 billion. (10)Reducing sodium intake in American diets to about 1500 mg. daily would save between 44,000 to 92,000 lost lives a year .(11)All population segments are projected to benefit from the sodium reduction, especially African Americans, women at high risk for strokes and younger age groups subject to becoming hypertensive early in their lives . (12) Various medical professionals and public health stakeholders have made efforts for over forty years in the US to change high dietary sodium consumption. These have not been very successful to date, given the rising consumption in recent years. (13)(14)

The Current Proposed Intervention – New York State Legislation

A New York State Assembly member introduced a bill on March 5, 2010 to prohibit owners or operators of restaurants in New York state from using salt in the preparation of any food that customers consume in that establishment. (15)This includes food a restaurant may prepare and serve at an off-site location in catering operations. A proven violation of this law would result in a maximum $1,000 penalty for each incident. Each use of salt would constitute a separate violation. Review of the state assembly web site on May 1, 2010 revealed the bill had been referred to the Assembly health committee. No legislative chamber votes were taken on the bill in this session. (16) The bill language states “restaurant” globally with no delineation between different categories of eating establishments.

There is no mention about what government agency is charged with enforcing the legislation if it becomes law. It does not address frozen foods served at restaurants that come prepared with sodium content. This would be a large issue in fast food restaurants. Burger King should not sprinkle salt on the French fries after frying them. Disregard the salt content in the frozen prepackaged French fries ! In Fall, 2009, New York state was home to only 38,596 of the total 578, 353 restaurants in the nation, a mere 6.6%. (17)

Assemblyman Felix Ortiz states the bill he authored is designed to save lives, similar to measures undertaken with banning trans fats in foods. Mr. Ortiz issued a clarification of the bill the day after its introduction. He did not intend to stop restaurants from using salt as a functional part of a recipe, only prohibit it being used on an additive basis when “piling on” large amounts of salt. He hoped the bill would receive enough legislative support to become law. His motivation was reading a recent medical journal article and WHO report about the deleterious health effects of excessive salt use. (18)

The First Problem: Americans Eating at Home

Americans do not consume all of their food at restaurants. Very far from it. I am certain even the wealthiest residents in our nation often have meals prepared for them at home by household staff using ingredients purchased at grocery retailers. Those travelling for work may find themselves eating at restaurants for intermittent stretches of time, but not every day of the year. New York’s proposed legislation to only reduce the use of salt in foods prepared at restaurants leaves the largest venue of food consumption without any intervention at all: Home. The legislation is a mere proverbial drop in the bucket in addressing the behaviors associated with salt ingestion. Restaurant cooks and owners are only two of the many players in the salt consumption story.

The Pew Research Center study on eating habits in 2006 had a nationally representative sample of 2250 adult subjects. It revealed one third ate in a restaurant less than once a week and another one third ate in a restaurant only about once a week. (19) A study commissioned by the US Centers for Disease Control and Prevention in May and June of 2004 had a stratified national random sample of 4345 subjects. These respondents 18 years and older were representative of 2000 Census data with respect to geographic residential region, household income , age, and included a special survey for households with children to evaluate those younger than 18 years old. Subjects were asked to respond based on activities during the previous week. This study revealed 86% made dinner at home 3 to 7 days of the week, 35% ate at home 6 to 7 days of the week. 64% ate less than two meals a week away from home and 59% did not even bring home prepared items from food establishments. (20)

Individuals or families are eating even a conservative ten meals a week at home. This is five times greater than what is consumed in restaurants by a small segment of the population. Citizens in lower socioeconomic classes probably cannot afford to eat meals often in restaurants. 17.1 million US households were food insecure at some time in 2008. They did not have or were unable to acquire enough food for the members of their household because of a lack of financial resources. (21)This large number of people would very likely not benefit from the salt restrictions New York is proposing for restaurants.

The Second Problem: What About the Grocery Foods We Purchase ?

The preceding data reveals Americans do not frequently eat in restaurants. They are buying food to prepare and consume at home. The Centers for Disease Control and Prevention report 77% of our sodium consumption comes from processed foods we consume, 12% of our salt is naturally occurring, 6% is added at the table and only 5% is added during cooking. (22) The proposed New York legislation would at best address 5% of our salt consumption. If salt was banned on the table in restaurants in addition to use in cooking, only a total of 11% of our salt consumption would be addressed.

The foods we buy in grocery stores and other retail outlets are playing the largest role in our risk for cardiovascular disease and stroke. The majority of Americans may very well not understand this danger. Food manufacturers’ addition of salt and other sodium compounds in packaged foods is generally recognized as safe (GRAS) under the US Food and Drug Administration Food, Drug and Cosmetic Act. Sodium is added for flavor, but also as content thickeners, preservatives, and to enhance the texture. The majority of foods have very little naturally occurring sodium.(23)

Foods considered healthy choices in our diets have high sodium content. Some people may know canned foods and those prepared in recipes from boxed ingredients are high in sodium. Other foods are not as obvious. A four inch egg bagel has 449 mg. sodium, each slice of Arnold whole grain bread has 162 mg. for a total of 324 mg. if using two slices, Kellogg’s Complete Wheat Bran Flakes has 207 mg. in ¾ of a cup of dry cereal. Two Eggo waffles have 410 mg. Before Americans even leave the house in the morning, ingesting a prepared breakfast food one may think has good nutrient value contains up to one fourth the Institute of Medicine recommended healthy sodium consumption level of 1500 mg. daily The three Oreo cookies you eat later in the day for a well deserved treat have 160mg of sodium or 11% of the recommended daily ingestion level. Fresh fruits and vegetables all have very low levels of naturally occurring sodium, most with less than 20 mg per one cup serving. (24)

Problem Three: No Consumer Education Component

Consumers do not have control over how much sodium is added to the foods they purchase. They can make healthy choices to consume foods with lower salt content. Social and environmental factors play large roles in shaping human behaviors. This includes food consumption. Prepackaged foods are quicker and easier to prepare at home, even at home. These foods are usually more accessible and less expensive than lower sodium and healthier diet choices. (25) Individual awareness and knowledge about the excessive salt consumption issue will play an important role in the future demand for lower sodium food choices in both restaurants and grocery stores. Consumers need to be educated about the positive benefits of reducing sodium intake and the deleterious effects of continuing it through their lifespan. Mr. Ortiz’s proposed legislation would remove salt from foods cooked in restaurants. It provides for no communication with the consumers about why this is being done or the health benefits they will derive from the measure.

The American palate is accustomed to the taste of salt in foods. There is scientific evidence humans, like other vertebrates, develop a complex neural network in brain centers to trigger hormone signals to maintain certain sodium concentrations in bodily fluids. These concentrations are based on what level the body has become acclimated to. (26) Lahey Clinic cardiologists acknowledge salt is very addicting and patients have a difficult time reducing their consumption for medical reasons. (27) The Institute of Medicine recommends the sodium reduction in packaged and restaurant foods occur in step wise fashion to slowly acclimate American palates. (28)

Plans for A Better Intervention

The recent consensus report by the US IOM took a classic public health approach for strategies to reduce sodium consumption at the population level. A coalition of stakeholders should play a role in designing and implementing a national campaign to accomplish the goal. The coalition includes public health professionals, government agencies, consumer organizations, food manufacturers, restaurants, and medical professionals. The groups should receive leadership at the national level from the US Secretary of Health and Human Services to set a reasonable time line for the goal. (29) The roles of the groups could be designed in a myriad of ways. This is too great a topic to cover in the short length of this paper.

The New York City Department of Health and Mental Hygiene started a coordinated national effort in 2008to address the goals – The National Salt Reduction Initiative. The federal government might use this as a model to gain insights. The department joined with now forty state and city health departments and other organizations to try and realize a twenty percent reduction in sodium consumption over five years. This will be through voluntary efforts from restaurants and packaged food manufacturers and based on a model in the United Kingdom. Restaurants in New York are part of this agenda. Mr. Ortiz’s proposed legislation would have some benefit here. The Initiative already gained commitments from Goya and Kraft Foods, Boar’s Head meats, Au Bon Pain, Subway, Starbucks and other food manufacturers. (30) These commitments demonstrate some success of the initiative to date.

A More Effective Intervention

This course was designed to learn about the effects of social and behavioral factors on health behaviors. The final assignment requires a proposal for an intervention to help reduce American dietary sodium ingestion. Consumer education about excessive salt consumption has been very successful in Finland and the United Kingdom. One third of the population understands the need to lower salt intake to reduce health risks. (31) Salt is ubiquitous in most of the foods Americans consume. Federal agencies may enact measures for manufacturers to follow for reducing salt in the foods they produce. The public must be educated about why this is a necessary goal and the health benefits gained from doing it.

The traditional individual models of behavior change stand out as not at all suitable for the issue of excessive dietary sodium consumption. Large numbers of people need to be targeted. Strategic use of marketing principles can help public health practitioners effectively market population based preventive programs when there may be little demand for it.(32) The use of branding can be a very effective marketing tool to create an association in consumers’ lives with an issue. It can influence changes in behaviors by offering an external ideal consumers can aspire to and associate with imagery. Research has shown there have been significant effects of branded messages on health behaviors. (33)Reductions in salt consumption at the US population level require promoting nutritious eating behavior in the media.

I watch very little television and rarely read mass media publications. One branded campaign has repeatedly caught my attention despite my limited exposure to the usual popular media avenues : the Got Milk ? campaign with celebrities wearing milk mustaches. The most recent celebrity to be part of the campaign is Christie Brinkley. The branded philosophy of the milk campaign is interesting. “Drink well. Live well. Recognize what’s really important. Feel good inside and out. Making sure that milk is always on the table can ……..” (34)The word drink can easily be replaced by eat, with additional messages related to reducing sodium consumption with what foods are offered on the meal tables in American homes. Christie Brinkley and the celebrities from many different professions preceding her in the campaign have represented health, vitality, and success.

I recommend a widespread campaign modeled after Got Milk ? in print, television and internet media channels to reach large portions of the American public. This would attract attention to the issue of lower sodium consumption in a positive way and can offer opportunity to learn more about the issue. The IOM acknowledged the need for a gradual reduction in sodium in foods to change consumer palate preferences. A campaign similar in quiet tone to this one would draw attention to the sodium issue. It may need to be followed by other campaigns at later times with different tones. One caveat is that the campaign should feature some celebrities that are significant to children. The sodium consumption issue is one that needs to be addressed in all age groups. Even young people are at risk for developing hypertension at early ages from ingesting large quantities of salt. Hypertension places them at risk for more serious disease as they age. The guidelines for healthy consumption levels specifically referred to those two years of age and older.

References

1. Applications of lower sodium intake recommendations to adults – United States 1999-2006. MMWR. Morbidity and Mortality Weekly Report. 2009. 58: 281-283
2. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010
3. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
4. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
5. Neumann, William. FDA Is Urged to Set Limits for Levels of Salt in Food. The New York Times. April 21, 2010. http://www.nytimes.com/2010/04/21/us/21salt.html?src=mv. Accessed April 30, 2010
6. Marsh, Bill. Stealth Salt in the Pantry. The New York Times. April 24, 2010. http://www.nytimes.com/2010/04/25/weekinreview/25marsh.html?ref=us. Accessed April 30, 2010
7. At A Glance: Changes in Sodium Levels in Food. The Miami Herald. April 21, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=NN6MxXG3fWm0RM
8. Matthews, Karen. Salt Taking Cut in Groceries. The Washington Post. April 26, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=GEylyANncLPO0M
9. Healy, Melissa. FDA Calls for Salt Cutbacks. The Los Angeles Times. April 21, 2010. http://fastflip.googlelabs.com/view?q=sodium%20in%20food&a=Ab6fnARAXr7EXM
10. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
11. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010
12. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
13. Bibbins-Domingo, Kirsten, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. The New England Journal of Medicine. 2010. 362:590-9. http://content.nejm.org.ezproxy.bu.edu/. Accessed February 8, 2010

14. Sacks, Frank M., et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. The New England Journal of Medicine. 2001. 344: 3-10. http://content.nejm.org.ezproxy.bu.edu/. Accessed April 29, 2010
15. Goldsmith, Samuel. Brooklyn Dem Felix Ortiz wants to ban use of salt in New York restaurants. The New York Daily News. March 11, 2010. http://www.nydailynews.com/ny_local/2010/03/11/2010-03-11_assault_on_salt_an_insult_chefs.html. Accessed April 27, 2010
16. The New York State Assembly. Bill A10129 Summary. http://assembly.state.ny.us/leg/?default_fld=&bn=A10129&Summary=Y&Actions=Y&Votes=Y&Text=Y. Accessed April 27, 2010 and April 29, 2010
17. National Restaurant Association. Research and Insights: State Statistics. http://www.restaurant.org/research/state/
18. Benjamin, Elizabeth. Reports of Salt’s Death Have Been Greatly Exaggerated. The New York Daily News. March 12, 2010. http://www.nydailynews.com/blogs/dailypolitics/2010/03/reports-of-salts-death-have-be.html? Accessed May 1, 2010
19. Pew Research Center. Eating More; Enjoying Less. April 19, 2006. http://pewresearch.org/pubs/309/eating-more-enjoying-less. Accessed May 1, 2010
20. Kruger, Judy, et al. Dietary Practices, Dining Out Behavior and Physical Correlates of Weight Loss Behavior. Prevention of Chronic Diseases. 2008. 5:1-14. http://www.cdc.gov/pcd/issues/2008/jan/06_0158.htm. Accessed May 1, 2010
21. The United States Department of Agriculture Economic Research Service. Food Security in The United States. Updated November 16, 2009. http://www.ers.usda.gov/Briefing/FoodSecurity/stats_graphs.htm#food_secure. Accessed May 2, 2010
22. Marsh, Bill. Stealth Salt in the Pantry. The New York Times. April 24, 2010. http://www.nytimes.com/2010/04/25/weekinreview/25marsh.html?ref=us. Accessed April 30, 2010
23. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
24. United States Department of Agriculture Agricultural Research Service. USDA National Nutrient Database for Standard Reference Release 22. Last modified 11/20/2009. http://www.ars.usda.gov/Services/docs.htm?docid=8964. Accessed May 1, 2010.
25. Mohan, Sailesh, et al. Effective population wide public health interventions to promote sodium reduction. Canadian Medical Association Journal. 2009. 181:605-609. www.cmaj.ca. Accessed May 1, 2010
26. McCarron, David, et al.Can Dietary Sodium Intake Be Modified by Public Policy ? Clinical Journal of the American Society of Nephrology. 2009. 4: 1878-1882
27. Marsh, Bill. Stealth Salt in the Pantry. The New York Times. April 24, 2010. http://www.nytimes.com/2010/04/25/weekinreview/25marsh.html?ref=us. Accessed April 30, 2010
28. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
29. Institute of Medicine of the National Academies. Strategies to Reduce Sodium Intake in the United States. 2010. Released April 20, 2010. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx. Accessed April 29, 2010
30. New York City Department of Health and Mental Hygiene. Cutting Salt, Improving Health. 2010. http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml. Accessed May 1, 2010
31. Mohan, Sailesh, et al. Effective population wide public health interventions to promote sodium reduction. Canadian Medical Association Journal. 2009. 181:605-609. www.cmaj.ca. Accessed May 1, 2010
32. Marketing public health – an opportunity for the public health practitioner. In Siegel, M, Doner, L. Marketing Public Health: Strategies to Promote Social Change. (2nd edition). Sudbury, MA. Jones and Bartlett Publishers, Inc. 2007.
33. Evans, WD, Hastings G. Public health branding: Recognition, promise and delivery of healthy lifestyles. In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008
34. Got milk ? Mild Mustache Celebrities. Milk: Building Strong Families. http://www.whymilk.com/celebrity/christie_brinkley. Accessed May 2, 2010