Currently browsing posts about: Salt

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.

Grub Street reports that an appeals court has just delayed New York City’s salt warning label.

Oddly, this follows what happened just a few days ago when a state judge denied the National Restaurant Association’s lawsuit to block the warnings.

The NRA is relentless about such things.  Recall how it opposed, successfully, Mayor Bloomberg’s proposal to cap soda sizes at 16 ounces.

The Daily News says nothing will happen on the salt warning until a March 18 hearing before judges at the Appellate Division in Manhattan.

Because most salt in American diets is put into foods by chefs and food processors, the warning label could alert consumers to the huge amounts of salt they add.  Many foods and meals will be affected.  No wonder the NRA doesn’t like it.

That organization ends up on the wrong side of public health all too often.  It needs to back off on this one.

Last month, the New York City Board of Health voted to require chain restaurants to publish warnings when menu items contain more than the recommended daily limit for sodium, thus taking the lead on regulating the amount of salt in foods.

Salt, says the city health department, is a leading cause of cardiovascular disease but also a leading driver of health disparities: blood pressure levels are higher in African-American populations.

The rule, which takes effect December 1, says that chains with 15 or more locations in New York City must display a warning symbol — a salt shaker inside a triangle — if the item has more than 2,300 milligrams of salt.

The policy does not restrict choice or limit how much sodium can be in food.

The New York State Restaurant Association (NRA) called the new rule “burdensome.”

It issued a statement:

This is just the latest in a long litany of superfluous hoops that restaurants here in New York must jump through…Every one of these cumbersome new laws makes it tougher and tougher for restaurants to find success.

The health department estimates the regulation will apply to 10 percent of all menu items.  Some examplesof affected products (For the record, 40% of salt is sodium; for grams of salt multiply by 2.5):

• Panera Bread Smokehouse Turkey Panini (2,590 mg),                  “
• TGI Friday’s sesame jack chicken strips (2,700 mg)
• Regular-size Applebee’s Grilled Shrimp ‘n Spinach Salad (2,990 mg)
• Subway footlong spicy Italian sub (2,980 mg)
• Red Robin monster-size salted caramel milkshake (3,400 mg)

But the Salt Institute, a salt producers’ trade group, called the policy “misguided”:

This is another example of the government creating policy based on outdated, incorrect sodium guidelines that have been refuted by ten years of research. Research shows Americans already eat within the safe range of sodium consumption and population-wide sodium reduction strategies are unnecessary and could be harmful,” said Lori Roman, President of the Salt Institute.

The consumer group Center for Science in the Public Interest said the proposed warnings “will prompt restaurants to use less salt and will help consumers reduce their risk of stroke or heart attack.”

This one will be interesting to watch.  Will people pay attention?  Will chain restaurants take steps to reduce sodium levels?  Will hypertension levels decline?  I hope researchers are hard at work collecting baseline data.

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.