Sodium Reduction Strategies: State-level Opportunities. Jill Birnbaum Vice President, State Advocacy & Public Health

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1 Sodium Reduction Strategies: State-level Opportunities Jill Birnbaum Vice President, State Advocacy & Public Health 1

2 AHA 2020 impact goal By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.

3 Life s Simple 7 Poor Intermediate Ideal Blood Pressure Adults >20 years of age SBP 140 or DBP 90 mm Hg SBP or DBP mm Hg or treated to goal <120/<80 mm Hg Children 8-19 years of age >95th percentile 90th-95th percentile or SBP 120 or DBP 80 mm Hg <90th percentile Physical Activity Adults > 20 years of age Children years of age None None min/wk mod or 1-74 min/wk vig or min/wk mod + vig >0 and <60 min of mod or vig every day 150+ min/wk mod or 75+ min/wk vig or 150+ min/wk mod + vig 60+ min of mod or vig every day Cholesterol Adults >20 years of age Children 6-19 years of age 240 mg/dl 200 mg/dl mg/dl or treated to goal mg/dl <170 mg/dl Healthy Diet Adults >20 years of age Children 5-19 years of age 0-1 components 0-1 components 2-3 components 2-3 components 4-5 components 4-5 components Healthy Weight Adults > 20 years of age Children 2-19 years of age 30 kg/m 2 >95 th percentile kg/m2 85th-95th percentile <25 kg/m 2 <85 th percentile Smoking Status Adults >20 years of age Children (12 19) Current Smoker Tried prior 30 days Former 12 mos Never /quit 12 mons Blood Glucose Adults >20 years of age Children years of age 126 mg/dl or more 126 mg/dl or more mg/dl or treated to goal mg/dl Less than 100 mg/dl Less than 100 mg/dl

4 Definition of Cardiovascular Health 5 Primary Components of Diet Metric In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASHtype eating plan, including but not limited to: 1. Fruits and vegetables: 4.5 cups per day 2. Fish: oz servings per week (preferably oily fish) 3. Fiber-rich whole grains ( 1.1 grams fiber per 10 grams carbohydrate): 3 1-oz-equivalent servings per day 4. Sodium: <1500 mg per day 5. Sugar-sweetened beverages: 450 kcal (36 oz) /week

5 Definition of Cardiovascular Health In light of the CDC data [MMWR released in 2009] and keeping within the definition of ideal cardiovascular health, the committee has chosen to use the IOM AI for sodium of 1500 mg/d for defining ideal cardiovascular health.

6 Reducing Salt, Improving Cardiovascular Health and Reducing Mortality By decreasing the population intake of sodium from 3,500mg/day to 1,500mg/day it s estimated there would be a 30% decrease in hypertension prevalence (CJC :437) Reducing sodium levels in packaged foods and restaurant foods by half would save about 150,000 American lives per year from fatal heart attacks and strokes (AJPH 2004;1:19-22).

7 State Level Opportunities for Sodium Reduction IOM Recommendations Procurement Menu Labeling/Restaurant Policies Nutrition Standards in Schools State-level Committees/Task Forces Monitoring and Surveillance Population Industry

8 IOM Recommendations Recommendation 1 (Primary) The FDA should expeditiously initiate a process to set mandatory national standards for the sodium content of foods Recommendation 2 (Interim) The food industry should voluntarily act to reduce the sodium content of foods in advance of the implementation of mandatory standards. Recommendation 3 (Supporting) Government agencies, public health and consumer organizations and the food industry should carry out activities to support the reduction of sodium levels in the food supply Recommendation 4 (Supporting) Government agencies, public health and consumer organization, health professionals, the health insurance industry, the food industry, and public-private partnerships should conduct augmenting activities to support consumers in reducing sodium intake. Recommendation 5 (Supporting) Federal agencies should ensure and enhance monitoring and surveillance relative to sodium intake measurement, salt taste preference and sodium content of foods and should ensure sustained and timely release of data in user-friendly formats.

9 National Regulatory Opportunities FDA is currently considering the regulatory status of salt FDA s authority to regulate food labeling is provided in three laws, as amended: Federal Food, Drug, and Cosmetic Act Fair Packaging and Labeling Act Public Health Service Act *slide adapted from FDA

10 National Regulatory Opportunities Salt is Salt in foods is considered Generally Recognized as Safe (GRAS) Salt was part of the original 1958 GRAS list In congressional language salt was specifically listed as an example of a GRAS food A formal review was done in 1982 FDA is again considering salt s GRAS status

11 Sodium and the DGA Released by HHS and USDA every 5 years 2005 Dietary Guidelines for Americans Consume <2,300mg of sodium per day EXCEPT individuals with hypertension, blacks, and middle-aged and older adults, consume 1,500 mg 2010 Dietary Guidelines for Americans Released at the end of 2010

12 Voluntary Action Industry has voluntarily taken some action to reduce sodium Several companies have salt workgroups Increase in introduction of lower sodium foods

13 National Salt Reduction Initiative: A national partnership of local and state health departments and national health organizations working with industry to support voluntary reductions in the salt content of packaged and restaurant foods 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 22 manufacturers, restaurants, and supermarkets have publicly committed to work toward NSRI packaged food and restaurant food targets

14 NSRI Partnership Partner Requirements Publicly support the NSRI commitment to a 20% reduction in population sodium intake through a transparent, public process. Partner Benefits Part of a national network of cities, states, and national health organizations committed to reducing sodium Support for approaching local and regional food companies on behalf of the NSRI Access to consumer education and related materials Receive updates on sodium reduction activities at the national level To Learn More Contact Julie Felder, NSRI Partnership Coordinator jfelder@health.nyc.gov (212) Visit our website at:

15 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

16 National Effort Alaska Department of Health and Human Services Arkansas Department of Health 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 Baltimore City Health Department Boston Public Health Commission Broome County Health Department Chicago Department of Public Health District of Columbia Department of Health State Health Departments City/Local Health Departments New Mexico 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 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 Los Angeles County Department of Public Health Northern Illinois Public Health Consortium NYC Department of Health and Mental Hygiene Philadelphia Department of Public Health Public Health, Seattle and King County

17 State Procurement Policy Massachusetts Tennessee

18 Restaurant Menu-labeling Menu labeling considerations at the federal, state, local levels and within industry Consider Preemption

19 School Competitive Food Policy Increase the number of states that have statewide nutrition standards for schools that are consistent with beverage, snack, and reimbursable meal guidelines for the Healthy Schools Program or IOM. 19 Snacks and Beverages Snacks Only Beverages Only Source: AHA State Advocacy Program

20 State HDPS program leadership The majority of resources and effort should be used to address the ABCS of heart disease and stroke prevention, with the main focus on preventing and controlling high blood pressure and reducing sodium intake. Create a task force or subcommittee of an existing task force Educate stakeholders Develop a position statement Review landscape regarding food policies and readiness Clarify jurisdictions/ preemption restrictions Look at procurement policies/ options Surveillance Other Ideas for States

21 Jill Birnbaum Contact Information