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On October 13, the FDA finally got around to finalizing its guidance for the food industry for voluntary, short-term (2.5 year) sodium reduction targets for lots of processed, packaged and prepared foods.

In a statement, the FDA says its new guidance

provides voluntary, short-term sodium reduction targets for food manufacturers, restaurants, and food service operators for approximately 160 categories of processed, packaged and prepared foods. The targets seek to decrease average sodium intake from approximately 3,400 milligrams (mg) to 3,000 mg per day—about a 12% reduction—over the next 2.5 years.

Reducing sodium has been on the FDA agenda for years.  It issued draft guidance in 2016.  On this, it received about 200 comments.  

The FDA’s idea for this first target is to reduce average daily sodium intake by about 12%—from approximately 3,400 milligrams (mg) to 3,000 mg per day—in 2.5 years.

This is still higher than the recommended 2300 mg.  Why so limited?

Politics, of course.

The FDA believes

• These targets are feasible.
• Gradual reduction will accustom people to lower sodium intake.
• Food companies might be willing to do this.

A quick review of the basics:

• Salt is 40% sodium (2300 mg sodium means about 6 grams of salt or 1.5 teaspoons).
• High salt diets are strongly associated with high blood pressure and stroke.
• We require less than 500 mg sodium a day; average diets are greatly in excess.
• Most salt in the diet comes from pre-prepared foods (70%); 20% is added at the table; 10% is innate in foods.
• The taste for high-salt is acquired; the more salt you eat, the more salt it takes to make foods taste right.
• For people used to high-salt diets, low-salt makes food taste bland.  It takes about three weeks to get used to low-salt.
• Once accustomed to low-salt, typical levels of salt make food taste too salty.

Thus, the FDA’s strategy is to gradually accustom people to lower salt intake.

The guidance is voluntary: “This voluntary, iterative approach is similar to approaches successfully implemented in other countries.”

By other countries, the FDA must mean Great Britain.  The UK did a big voluntary salt reduction campaign some years ago and got enough buy in from food companies to see a real difference in salt intake and blood pressure.

When the government changed and laid off the pressure, companies put back most of the salt (not all though). That history is here.

So this could work if food companies cooperate.  Presumably, the FDA will assess the results of this voluntary effort in 2.5 years.

The stick?  The implied threat of mandatory reductions if the voluntary ones don’t work.

2.5 years is a long time to wait for voluntary compliance.

My view

• These should have been mandatory to begin with.
• The target levels should be lower.
• The time scale should be faster.

Other than that, the FDA’s plan could be a useful first step.  We shall see.

Statements

• From FDA officials
• The American Heart Association  
• Center for Science in the Public Interest

Documents

• The FDA constituent update on sodium is available here.
• An FDA web page, “Sodium Reduction,” is available here.
• The FDA guidance for industry is available here.
• Dietary Guidelines for Americans  fact sheet on sodium
• A paper in JAMA from FDA officials on reducing sodium in the US

That’s my question when I see what food companies are trying to do to reduce the content of sugar and salt in their ultra-processed junk food products.

To put it another way, does making an ultra-processed food or beverage slightly better for you convert it to a good choice?

We can argue about this, but companies really are trying hard, as this collection of articles from FoodNavigator.com indicates.

Special Edition: Nutrition and reformulation strategies

Most shoppers say they want to reduce consumption of products that are high in fat, salt and sugar. But many struggle to cut HFSS foods and beverages from their diets and reformulation efforts often face the headwind of perceived quality issues. Meanwhile, the fortified food market in Europe is expected to see a CAGR of 5.2% through to 2025. While reformulation efforts take out the ‘baddies’ is there also an opportunity to add positive nutrients through fortification?

• What reformulation really looks like in 2021: ‘Reformulated products need to be better nutritionally and equally tasty, if not tastier’: With calls to reformulate food and drink products to reduce fat, sugar and salt, we explore: What influences prompt brands to reformulate? What does the process really entail? And can it be done successfully during a global pandemic?.. Read
• ‘No added sugar’: Fibre and stevia predicted to ‘shake up’ sugar reduction:  Fibre and next-generation stevia are expected to play key roles in sugar reduction as a growing number of manufacturers seek out ‘no added sugar’ claims, according to Mintel… Read
• How UK brands are reformulating to avoid the HFSS ad ban:  UK food brands are currently digesting planned government legislation coming next year which will prevent marketing and advertising of HFSS being shown on TV (pre-9pm) and online from 2022 and limit where these products can be placed in bricks and mortar stores… Read
• What does the future hold for reformulation?  With the impending publication of part two of the National Food Strategy in the UK, IGD convened major retailers, manufacturers, food service companies and members of the National Food Strategy team to discuss reformulation, the challenges, and opportunities. Here Hannah Pearse, Head of Nutrition and Scientific Affairs at IGD, shares an overview of the conversations from a series of roundtable discussions… Read
• Kellogg cuts sugar and salt across Europe and UK: ‘The process is trial and error’:  The Kellogg Company has pledged to remove at least 10% of sugars and 20% of salt from its children’s cereals across European and UK brands… Read
• Does the UK’s proposed junk food ad ban reduce the motivation to reformulate?  The Food and Drink Federation says UK plans to restrict in-store promotions of foods high in fat, salt and sugar will deter companies from developing lower sugar and fat alternatives… Read
• Cereal Partners Worldwide talks breakfast renovation: ‘Innovation can be less, rather than more’:  The joint venture between Nestlé and General Mills is taking a ‘dual strategy’ approach to cereal renovation that is ‘both reductionist and increasing’, says Gharry Eccles, Vice President UK and Oceania of Cereal Partners Worldwide… Read
• Snack sector looks to lentils, beans and insects as ‘health by stealth’ hits limit:  As the snack sector reaches its technological limits in cutting salt and fat from products, European manufacturers are accelerating reformulating efforts using lentils, beans, other vegetables — and even insects — as a way of meeting consumer demand for healthier snacking options… Read

New York City is taking big steps to improve its food system.   Two reports are worth noting, one from the Mayor’s office and one from the Health Department.

I.  Mayor Bill de Blasio and Kate MacKenzie, Director of the Mayor’s Office of Food Policy (MOFP) have released Food Forward NYC: A 10-Year Food Policy Plan.

Here’s how they introduce this impressive report:

Food Forward NYC is the City’s first ever 10-year food policy plan, laying out an comprehensive policy framework to reach a more equitable, sustainable, and healthy food system by 2031.

Food Forward NYC emphasizes the importance of equity and choice – enabling a food system where everyone should be able to access the food they want wherever they may want it. To enable this choice, we need to support both our food workers and our food businesses. To strengthen the sustainability and resiliency of our food system, we need to rethink our food infrastructure and deepen our connections with the region.

Food Forward NYC is organized around five overarching goals:

1. All New Yorkers have multiple ways to access healthy, affordable, and culturally appropriate food.
2. New York City’s food economy drives economic opportunity and provides good jobs.
3. The supply chains that feed New York City are modern, efficient, and resilient.
4. New York City’s food is produced, distributed, and disposed of sustainably.
5. Support the systems and knowledge to implement the 10-year food policy plan.

The full report is here.  It was prepared in response to Local Law 40 of 2020 and recommendations from the New York City Council’s 2019 report, Growing Food Equity in New York City.  

New York City is a complicated place and it’s wonderful to have all this information put together in such a coherent way.  Let’s hope everyone gets behind this and puts the recommendations into action.

II.  The Bureau of Chronic Disease Prevention at the NYC Health Department has an update on its  National Salt and Sugar Reduction Initiative (NSSRI).

In October 2018, the Bureau announced draft sugar reduction targets.  Now they have updated them and added targets for salt reduction, as well.  As I was informed in an e-mail,

The NSSRI is a partnership of over 100 local city and state health departments, associations, and health organizations, convened by the NYC Department of Health. We have set voluntary sugar reduction targets for 15 categories of food and beverages. The targets represent a 10% reduction in sugar content of products by 2023, and a 20% reduction by 2026 for food with a 40% reduction for beverages.

The current public health landscape demonstrates that diet remains critical, even during a public health emergency like COVID-19. Diet-related health conditions such as diabetes and heart disease, which can increase the risk of severe illness from COVID-19, are important to address right now.

Here’s what one of the sugar reduction targets looks like:

The objective of NSSRI is this:

To promote gradual, achievable and meaningful reductions in sugar content in packaged foods and beverages. This is because intake of added sugars is associated with increased risk of excess weight, type 2 diabetes, hypertension, stroke, heart disease and cavities.

The targets are indeed gradual; the hope it that they will be met by 2026.

The targets are, of course, voluntary.  The best NSSRI can do is to encourage companies to comply and hold them accountable.

It’s a start.

Michael F.  Jacobson.  Salt Wars: The Battle Over the Biggest Killer in the American Diet.  MIT Press, 2020.

Michael Jacobson was one of the founders of the Center for Science in the Public Interest, which he directed for more than 40 years.

His book comes with an introduction by Tom Frieden, former head of New York City’s Health Department and Director of the CDC.

I wrote a blurb for it:

Public health authorities advise eating less salt as a way to prevent high blood pressure, but a few scientists disagree. For anyone confused by these arguments, Salt Wars is a must read.  Michael Jacobson has been fighting these wars for decades, and his assessment of the research on both sides—and the policy implications–is exceptionally fair, balanced, and fascinating.

Here are a few excerpts:

• One reason that the debate has been so vigorous is that most journalists treat new reports supporting the conventional view on salt with a yawn.  Dog bites man?  Big deal.  What does capture the attention of journalists and headline writers are the man-bites-dog reports—those suggesting that eating less salt would be harmful—especially when they are conducted by credentialed researchers at prominent universities and published in respected journals…The poor consumer, lacking an advanced degree in epidemiology or nutrition, can get dizzy trying to follow the arcane biomedical and statistical jousting (p. xvi).
• I was sorely disappointed that the FDA was not setting mandatory maximum sodium levels.  Such limits for all foods in a category…have at least three advantages over a voluntary approach.  First, they would have teeth and ensure that all companies actually trimmed sodium in their saltiest products.  Second, the FDA could easily enforce them.  And third, they would provide a level playing field…I have since been persuaded that the voluntary approach was inevitable (p. 139).
• The process to propose sodium reductions was frustratingly slow, but there was no villain or cabal that sought to undermine the FDA’s effort to lower sodium consumption.  Rather, it was a case of how the Washington policy-making apparatus works when it comes to anything that is complicated, controversial, and consequential…It took the administration so long to propose the guidelines that there was no time to finalize them and the matter has languished for four years  (p. 143).

I never thought I would live to see this day, but the Salt Institute announced that it is ending operations at the end of this month.

I first learned about the Institute in the late 1980s when I was Senior Policy Advisor to the Office of Disease Prevention and Health Promotion (ODPHP) editing the 1988 Surgeon General’s Report on Nutrition and Health.  The Institute visited us regularly to try to discourage the report from advising “eat less salt.”

Since then, the Salt Institute has been relentless in following the industry playbook to:

• Cast doubt on science linking high salt intake to disease risk
• Argue that the current high levels of salt intake are just fine for health
• Maintain that only a small portion of the population is salt-sensitive
• Promote science arguing that low salt intake is harmful

The Institute has a lot to answer for.  It has been responsible for confusing the science and creating a most peculiar situation: noisy public debate about salt science while every expert committee examining the relationship of salt to health concludes that we should be consuming much less.

It can hardly be a coincidence that the most recent and most authoritative review of salt and health came out just a few days before the Institute’s announcement .  That review by the National Academies of Science, Engineering, and Medicine reaffirmed what Dietary Guidelines have been saying for years: the upper recommended limit of sodium intake is 2300 milligrams per day, or about 6 grams of salt (a bit more than a teaspoon).

On average, Americans consume much more and, as the Center for Science in the Public Interest (CSPI) has demonstrated for years, single restaurant meals easily exceed that much.

CSPI’s former director, Michael Jacobson, issued a statement.

It might seem the stuff of satire that there is a trade association devoted to defending the amount of salt in our food supply—which contributes to hypertension and cardiovascular disease—and on our roads.  Or at least there was: the Salt Institute will close its doors at the end of this month. And it will not be missed.

Rest in peace.

This tweet certainly got my attention:

It referred to Alex Kotch’s article in the International Business Times about how White House lawyer Donald McGahn has granted a waiver of conflict of interest rules to allow Kailee Tkacz, a former lobbyist for the Snack Food Association and, more recently, for the Corn Refiners Association, to advise the USDA about the forthcoming 2020 dietary guidelines.

Ms. Tkacz also was food policy director for the Corn Refiners Association, which represents producers of high fructose corn syrup (HFCS).

McGahn explained that this waiver would allow Ms. Tkacz “to advise the Secretary of Agriculture and other senior Department officials with respect to the Dietary Guidelines for Americans process.”

He says “it is in the public interest to grant this limited waiver because of Ms. Tkacz’s expertise in the process by which the Dietary Guidelines for Americans are issued every five years.”

The dietary guidelines historically have issued recommendations to consume less salt and sugar.  Snack foods are major sources of salt in U.S. diets.  Soft drinks sweetened with HFCS are major sources of sugars.

USDA is the lead agency for the 2020 guidelines.

Want to make some bets on what they will say about salt and sugar (a wild guess: the science isn’t firm enough to suggest eating less of either).

Yesterday, the FDA opened for public comment its long-awaited guidance for industry about reducing salt in processed food products.  The guidance affects about 150 products.  It gives baseline data for those products and sets targets for salt reduction.

Please note that I am using the word salt, not sodium.  The targets are for sodium reduction.  Most dietary sodium comes from salt added to processed foods and pre-prepared foods.  Salt is 40% sodium.  The target dietary intake of 2300 mg sodium comes to just under 6 grams of salt a day, which is not particularly low.  It is, however, lower than current intake levels.

In a blog post, FDA official Susan Mayne said the link between sodium intake and blood pressure is “strong and well documented,” but

In fact, it’s very difficult in the current marketplace NOT to consume too much sodium. The average intake today is over 3,400 milligrams—significantly more than the 2,300 milligram limit recommended by federal guidelines. And it’s not just adults who are eating too much sodium: Children and teens consume more than is recommended.

Vox, for example, provides a terrific chart on the amounts of sodium in foods.  It starts with this:

Susan Mayne goes on to explain that

the FDA assessed the sodium content of thousands of products in the marketplace and engaged with experts in industry, academia, and government to get the best available scientific and technical input. We know that sodium has important functions in many foods, such as taste, texture, and microbial safety… Our approach encourages gradually reducing sodium in the majority of foods that contain it…Moreover, our draft targets apply to processed and prepared foods that are eaten both at home and outside the home.

Despite the voluntary nature of the guidance and the lengthy timeline (up to ten years) for implementation, the makers of processed foods are sure to object.  At their urging, the House committee on appropriations, in draft report language, urged the FDA to postpone guidance on salt until the CDC and Institute of Medicine update the Dietary Reference Intake standards for sodium intake.

The Salt Institute, the trade association for the salt industry, issued a press release charging malpractice:

The issuance today of new “voluntary” sodium reduction mandates by the FDA is tantamount to malpractice and inexcusable in the face of years of scientific evidence showing that population-wide sodium reduction strategies are unnecessary and could be harmful. This effort will limit the food choices of Americans, not increase them as the FDA claims. It will make our food less safe and endanger public health.

In JAMA, CDC Director Thomas Frieden rebuts the scientific arguments point by point and, in my view, demolishes them.  He explains how important this initiative is to public health:

Thirty-nine countries have established sodium targets for foods and meals, with 36 of those adopting voluntary approaches. Setting targets helps create a level playing field for the food industry, supporting reductions already begun by companies such as Walmart, Darden, Unilever, PespsiCo, General Mills, Mars, Nestlé, and others. The United Kingdom set voluntary sodium reduction targets in 2003; from 2003 to 2011 sodium intake decreased 15%. During this same period, average blood pressure decreased, and, following no change in prior years, deaths from ischemic heart disease and stroke decreased by approximately 40% [the reference for this last statement is BMJ Open. 2014;4(4):e004549].

Most people would be healthier cutting down on salt intake.  Food company executives know this.  Politico Morning Agriculture points out that some Big Food companies have joined the public health community in supporting the FDA’s proposal.

The band of strange bedfellows – the American Heart Association, Mars, Academy of Nutrition and Dietetics, Nestlé, PepsiCo, American Public Health Association, Unilever and the Center for Science in the Public Interest – all signed on to a letter last month to Senate Appropriations ag subcommittee Chairman Jerry Moran and ranking member Jeff Merkley to support the FDA on sodium. Find that here.

From a public health perspective, the FDA initiative is a step in the right direction but could go further.  It should have required mandatory salt reduction.  Judging from the Salt Institute’s reaction, this is still a big step.  The New York Times quotes Michael Jacobson:

“The F.D.A. found a sweet spot between doing nothing and regulating…This will at least give the public benchmarks against which we can gauge sodium content of foods.”

FDA resources:  

• Federal Register Notice.  The home page explains how to submit comments by October 31 to Docket No. FDA-2014-D-0055
• Draft Guidance Document in PDF (132KB)
• Draft Food Categories and Draft Voluntary Targets for Sodium Reduction (Appendix Table 1) (XLSX: 43KB)
• Summary Explanation of the Draft Food Categories and Draft Voluntary Targets for Sodium Reduction (Appendix Table 1) (PDF: 277KB)
• Sodium Reduction At A Glance
• Presentation: FDA’s Voluntary Sodium Reduction Initiative (PPTX 3MB) 
• Constituent Update: FDA Issues Draft Guidance to Industry for Voluntarily Reducing Sodium
• Blog: Reducing Sodium in the Food Supply
• At a Glance: Lowering Sodium in the Food Supply
• Frequently Asked Questions on FDA’s Sodium Reduction Strategy
• Additional Information and History of Actions on Sodium Reduction

Mars, the very same company that has been trying for years to position chocolate as a health food, appears to be joining the food movement, and big time.

Take a look at its GMO disclosure statement on the back of this package of M&Ms.

If it’s too small to read, the statement is in between MARS and the green Facts Up Front labels)

PARTIALLY PRODUCED WITH

GENETIC ENGINEERING

And this is before Vermont’s GMO labeling rules come into effect in July.

Mars also has come out in support of the FDA’s proposals on voluntary sodium reduction.  The company explains that through its “new global Health and Wellbeing Ambition,

Mars Food will help consumers differentiate and choose between “everyday” and “occasional” options. To maintain the authentic nature of the recipe, some Mars Food products are higher in salt, added sugar or fat. As these products are not intended to be eaten daily, Mars Food will provide guidance to consumers on-pack and on its website regarding how often these meal offerings should be consumed within a balanced diet. The Mars Food website will be updated within the next few months with a list of “occasional” products – those to be enjoyed once per week – and a list of “everyday” products – including those to be reformulated over the next five years to reduce sodium, sugar, or fat.

Last year, the company supported the FDA’s proposal to require added sugars labeling with a Daily Value percentage on the Nutrition Facts panel.

It also said it would stop using artificial dyes in its candies.

How to interpret these actions?  I’m guessing they mean that the movement for good, clean, fair food has gained enough traction to put long-established food brands on notice: make your products healthier for people and the environment, or else.