Cardiovascular Disease is Leading Cause of Death in U.S

National Salt Reduction Initiative A Voluntary Framework to Reduce Population Sodium Intake National Conference of State Legislatures Friday, Decembe...
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National Salt Reduction Initiative A Voluntary Framework to Reduce Population Sodium Intake

National Conference of State Legislatures Friday, December 10, 2010 Phoenix, Arizona Christine Johnson, MBA Cardiovascular Disease Prevention and Control Program New York City Department of Health and Mental Hygiene

Cardiovascular Disease is Leading Cause of Death in U.S. 30

Pe ercentage (of all deaths)

25 20

15 10 5 0 Heart Disease

Malignant Neoplasms


Chronic Low . Respiratory Disease

Unintentional Injury

Alzheimer's Disease

Deaths: Final Data for 2007. National Vital Statistics Reports. Vol. 58, No. 19, May 20, 2010.


Blood Pressure Reduction Through Reduced Salt Intake Would Save Lives 4,000 Tens of thousands of lives saved

U.S. adults, 20-74 years m consumption (mg/dayy) Sodium

3,500 3,000 2,500

2005 U.S. Dietary Guidelines recommended limit for adults

2,000 1,500

Proposed 2010 USDG recommended limit for all adults. d l 2005 200 recommended d d limit li i for f people l with ih hypertension, blacks, middle aged and older

1 000 1,000 500 0 NHANES I 1971-74

NHANES II NHANES III NHANES IV NHANES 1976-80 1988-94 1999-00 2003-2006

Data from: Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401-431; Institute of Medicine. Strategies to Reduce Sodium in the United States, 2010.

Most Salt Comes from Processed and Restaurant Foods

Processed and restaurant foods

12% While eating 6%

77% 5%

Source: Mattes, RD. Journal of American College Nutrition, 1991, 10:383-393.


Impact of Annual Reductions: Comparison Across Various Interventions Coron nary Heart Disease Inciden nce


100,000 ,





0 Salt reduction: 3 Salt reduction: 3 g/day (low g/day (high estimate) estimate)

Smoking cessation

Weight loss

Statin therapy

Treatment of Hypertension

Intervention Source: Data from Bibbins-Domingo K et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. 2010. New England Jounral of Medicine. 362:590-9.

IOM Report Strategies to Reduce Sodium Intake Primary strategy: • FDA should initiate process to set mandatory national standards for the sodium content of foods

Endorsed voluntary strategies in the interim • “Voluntary strategies could achieve meaningful reductions of sodium intake prior to implementation off mandatory d t standards.” t d d ” • “Voluntary … public-private partnerships should continue during the time mandatory standards are being established.” Reference: Institute of Medicine. Strategies to Reduce Sodium Intake in the United States, 2010


UK Salt Campaign • Goal: Reduce salt intake by 1/3 from 2005 to 2010 – More than 50 commitments from all sectors of the food industry – Gradual reductions across product categories

• Product salt reductions achieved – – – –

Heinz: 32% to 58% ↓ in some canned products Nestle: 25% ↓ in soup mixes and bouillons K ll Kellogg’s: ’ 50% ↓ in i some cereals l Kraft: 30% ↓ in cheese

• Population salt intake is encouraging: ~ 10% ↓ UK Food Standards Agency website. Accessed on 9/29/10 at Summary Table of Salt reduction Commitments. Accessed on 9/29/10 at

Goal: 20% Reduction in Sodium Intake in 5 Years Decrease sodium content in foods by 25% over 5 years

Decrease population sodium intake by ~ 20% over 5 years

Reductions will vary among food categories


National Salt Reduction Initiative Restaurant Food Partners s

National Health Orgs, Cities States Cities, s

Quick Q i k service i Full service Food service Trade associations

Packaged Food Branded Private label Food service Retailers Trade associations

National Effort National Health Organizations • • • • • • • • • • •

American College of Cardiology American College of Epidemiology American Dietetic Association American Heart Association American Medical Association American Public Health Association American Society of Hypertension Association of Black Cardiologists Consumers Union InterAmerican Heart Foundation International Society of Hypertension in Blacks

• • • • • • • • •

Joint Policy Committee, Societies of Epidemiology Kaiser Permanente National Hispanic Medical Association National Kidney Foundation New York State Chapter, American College of Cardiology Preventive Cardiovascular Nurses Association Society for the Analysis of African-American Public Health Issues Texas Medical Association World Hypertension League

Local and State Health Associations • • • •

Association of State and Territorial Health Officials Council of State and Territorial Epidemiologists National Association of Chronic Disease Directors National Association of County and City Health Officials


National Effort State Health Departments • • • •

• • • •

Alaska Department of Health and Human Services Arizona Department of Health Services California Department of Public Health Colorado Department of Public Health and Environment Delaware Department of Health and Social Services, Division of Public Health Hawaii State Department of Health Idaho Department of Health and Welfare, Heart Disease and Stroke Prevention Program Maine Center for Disease Control and Prevention Maryland Department of Health and Mental Hygiene Massachusetts Department of Public Health Michigan Department of Community Health Minnesota Department of Health New Mexico Department of Health

• • • • •

Baltimore City Health Department Boston Public Health Commission Broome County Health Department Chicago Department of Public Health District of Columbia Department of Health

• • • • •

• • • • • • • • • • • •

New Jersey Department of Health and Senior Services New York State Department of Agriculture & Markets New York State Department of Health North Carolina Department of Health and Social Services, Division of Public Health North Dakota Department of Health Northern Illinois Public Health Consortium Ohio Department of Health Oregon Department of Health and Human Services, Division of Public Health Pennsylvania Department of Health Tennessee Department of Health Washington State Department of Health West Virginia Department of Health and Human Resources; Bureau for Public Health

City/Local Health Departments • • • •

Los Angeles County Department of Public Health NYC Department of Health and Mental Hygiene Philadelphia Department of Public Health Public Health, Seattle and King County

Timeline 2009






Meetings to set 2012 and 2014 category targets

Announce targets and industry commitments

January 15th Interim target date

January 15th Target date

IIndustry d submits b i baseline data

E l Evaluate 2012 category target achievements

E l Evaluate 2014 category target achievements

Baseline Evaluation

Follow up Evaluation

Measure NYC Population Sodium Intake

Measure NYC Population Sodium Intake


Packaged g and Restaurant Food Strategies

Wide Range of Sodium in Similar Products

Raisin Bran 350mg sodium

Cinnamon Raisin Cereal 115mg sodium

3X amount of sodium


Databases • Packaged Food Database • Merges national sales data and nutrition data data, • Analyzed top 80% of items by sales • Calculated sales-weighted mean and range of sodium

• Restaurant Food Database • Merges national market share data and publiclyavailable il bl nutrition t iti d data t ffor 50 llargestt quick i k service i restaurants (ranked by sales) • Calculated market share-weighted mean and range of sodium

Targets • 2012 and 2014 targets • 62 packaged food categories • 25 restaurant categories • Restaurant item maximum

• Proposed targets announced January 2010 • Final targets announced April 2010 with first set of company commitments


Sample Category Sodium Distribution 40

2014 2012 400 mg 480 mg

Mean 531 mg



30 25 20 15 10 5 0 0-100












Sodium (mg/100g)

Maximum Comparison to Top 10 QSR Chains 3000 2800 2600

Sodium (mg) per item

2400 2200 2000 1800

2012: 1,500 mg

1600 1400

2014: 1,200 mg

1200 1000 800 600 400 200 0 0












Note: One product (sodium = 3,540 mg) was omitted for clarity.


Committing to Targets Commitments to a food category target i di t th indicate thatt a company’s ’ sales-weighted l i ht d mean sodium will be at or lower than the target by the target date. • Companies must commit to at least one target that they do not already meet • Companies must submit monitoring forms to track progress

NSRI Company Commitments Packaged Food: • • • • • • • • •

Boar’s Head Butterball Delhaize America Fresh Direct Furmano’s Goya Hain Celestial Heinz Hostess Brands

• • • • • • • • •

Kraft LiDestri Mars Food McCain Foods Premio Red Gold Snyder’s of Hanover Unilever White Rose

Restaurants: • • • •

Au Bon Pain Starbucks Subway Uno Chicago Grill


Monitoring and Evaluation Food Content Monitoring • Packaged Food and Restaurant Food Databases • Baseline and target year • By food category and by company

• Industry data • Baseline and target year • Unit sales and nutrition data

Evaluation • 24-hour urinary sodium analysis from representative adult population • Baseline and target year

National Nutrition Database • IOM Recommendation • Key components: • Creation of a national database • Mandated industry reporting of nutrition information • Updated annually • Interface for easy public access • Able to be merged by UPC


Conclusion • National sodium reduction through a comprehensive p p plan to engage g g industry y is crucial • If you want to learn more about participating in the NSRI, please let me know

• Databases that incorporate nutrition and sales data can assess changes in the food supply • Population sodium intake can successfully be measured through 24-hour urine collection

NYC Food Standards • Goal: To improve the nutrition quality of meals served by city agencies • Executive Order in 2008 • 260+ million meals and snacks per year

• Standards for all meals and snacks served by NYC agencies • Standards for all beverage vending machines on city property


National Salt Reduction Initiative A Voluntary Framework to Reduce Population Sodium Intake

For NSRI Partnership Information Contact Julie Felder

[email protected]


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