Sodium Reduction: A Public Health Imperative Darwin R. Labart he, MD, MPH, PhD Director, Division for Heart Disease and Stroke Prevention National Center for Chronic Disease Prevention and Health Promotion Sodium Reduction Webinar ASTHO December 15, 2010 National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention
5 Questions About Sodium Where is it and how much is there? Why is it so important? When is it time to act? Who is concerned? What makes sodium reduction a public health imperative?
5 Questions About Sodium - 1 Where is it and how much is there?
salt = sodium chloride Salt or Sodium? 90% of the sodium we consume is in the form of NaCl It s the sodium that s the problem
Major sodium source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.
Main sources are commonest foods: Percentage of Daily Sodium Intake 45 40 35 30 25 20 15 10 5 0 All Adults <2,300 mg <1,500 mg USDA Major Food Categories Source: CDC NHANES unpublished data.
Sharp increase in sodium consumption: Source: Briefel and Johnson (2004) for 1971-2000 data; NHANES for 2003-2006 data.
Sodium in the food supply: a matter of choice?
Sample Food Label, U.S.
Product Variability - Domestic
Sodium Recommendation: DGA 2005 2005 Dietary Guidelines for Americans (DGA) recommendation: <2,300 mg/day. Specific populations recommended to consume 1,500 m g/day: Hypertensives Blacks Middle-aged or older Americans Source: Ayala C, et al. Application of lower sodium intake recommendations to adults United States, 1999 2006. MMWR Morb Mortal Wkly Rep. 2009;58(11):281 283.
Sodium intake exceeds recommendations: Recommended intake Average intake 2300 mg/d or 1500 mg/d 3466 mg/d Source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383 93.
5 Questions About Sodium - 2 Why is it so important?
Salt and Hypertension Nearly one in three U.S. adults has hypertension and >50% of people with hypertension do not have it under control. Lifetime risk of developing hypertension is 90%.* Excess sodium intake causes hypertension and, subsequently, cardiovascular events. Sodium, through hypertension, is a major contributor to death, disability, disparities and costs attributable to cardiovascular diseases.** *Vasan, JAMA 2002;287:1003 **American Heart Association. Heart Disease and Stroke Statistics 2010 Update. http://circ.ahajournals.org/cgi/content/full/121/7/e46.
Lowest sodium intake means lowest BP: 9.7 mmhg
Small BP predicts major deaths:
Estimated Effects of Sodium Reduction in the U.S. Reducing average population intake to 2300 mg per day (current recommended maximum) may reduce cases of hypertension by 11 million save $18 billion health care dollars gain 312,000 Quality Adjusted Life Years (QALYs) Even fewer cases of hypertension and more dollars saved if intake was reduced to 1500 mg per day (recommended maximum level for specific populations ) American Journal of Health Promotion. 2009;24:49-57.
5 Questions About Sodium - 3 When is it time to act?
Some Previous Sodium Initiatives: 1969 White House 1979-2006 AMA 1970-2009 NRC/ IOM 1980-2005 USDA/HHS 1972-2006 NHLBI 1982-2007 WHO 1973-2008 AHA 1993-2008 USDA 1975-2007 FDA 2002 APHA 1977 Senat e 2007 ADA 1979-2000 HHS 2008-2009 State and local agencies
Institute of Medicine Report and Recommendations - 2010
Findings 1: Adverse health effects excess sodium intake is strongly associated with elevated blood pressure, a serious public health concern related to increased risk of heart disease, stroke, congestive heart failure, and renal disease.
Findings 2: Excess dietary intake The current level of sodium added to the food supply by food manufacturers, foodservice operators, and restaurants is simply too high to be safe for consumers.
Sodium in the food supply: Not Safe
Findings 3: Individual change limited instructing consumers to select lower-sodium foods and making available reduced-sodium niche products cannot result in intakes consistent with the Dietary Guidelines for Americans.
Primary Strategy IOM Recommendations FDA should expeditiously initiate a process to set mandatory national standards for the sodium content of foods Applies to processed and restaurant foods Utilize generally recognized as safe (GRAS) status of salt Interim Strategy expeditiously Food industry should voluntarily act to reduce the sodium content of foods in advance of the implementation of mandatory standards
www.cdc.gov/salt What is CDC doing about sodium?
Sodium Reduction Communities 2010 California Department of Public Health Kansas Department of Health and Environment Los Angeles County Department of Public Health New York City Department of Health and Mental Hygiene New York State Health Department
CDC s Sodium Monitoring and Surveillance USDA Food and Nutrient Databases Commerci al Databases Gladson UMN Publix Nielsen State and Local Agencies NYC DOHMH LA County DOH FDA Monitoring and Surveillance CDC/NCHS NHANES NHIS CDC/NCCDP HP BRFSS CVH Exam CDC/NCHM and Porter Novelli HealthStyles DocSt yles ConsumerStyles
Who is concerned? 5 Questions About Sodium - 4
2009 Congressional Language A diet high in sodium is a major cause of heart disease and st roke. CDC is encouraged to work with major food manufacturers and chain restaurants to reduce sodium levels in their products. The agency is directed to submit to the Committees on Appropriations of the House of Representatives and the Senate an evaluation of its sodium-reduction activities by no later than 15 months after the enactment of this Act, and annually thereafter.
Physicians Advise Patients to Consume Less Salt Disease Category Prehypertension 77.7% *Hypertension 86.8% Chronic kidney disease 74.4% Diabetes 49.3% Race/Ethnicity *African American 43.3% American Indian 18.4% Asian 13.8% Hispanic 22.5% Age *Over 40 years 22.3% All adults 31.4% n = 1,250 *DGA 2005 subgroup advised to consume no more than 1,500 mg/day of sodium Source: DocSt yles, 2009.
People receive and act on low-salt advice: 100 80 Prevalence (%) 60 40 20 50% 18-44 45-64 65 0 Advised to change eating habits Changing eating habits among those advised Advised to reduce salt intake Reducing salt intake among those advised Source: Behavioral Risk Factor Surveillance System
Percentage 60 50 40 30 20 10 People read the Nutrition Facts Panel: 2005 2008 50% 0 Calories Total Fat Saturated Fat Carbohydrates Cholesterol Sodium Fiber Categories on Nutrition Facts Label Protein
Many purchasers do buy Low Salt : 47.3% of all shoppers Frequency of Buying Low Salt Items by Gender Always Often Sometimes Rarely Never Don t Shop for Food All 11.7% 12.8% 22.8% 17.3% 27.0% 8.4% Male 10.5% 11.4% 19.9% 16.0% 27.8% 14.4% Female 12.8% 14.0% 25.4% 18.5% 26.3% 2.9% SOURCE: NHIS unpublished data.
Most people don t often add salt 82.4% / 64.5% Frequency of Use Never Rarely Occasionally Very Often Don t Know Table salt use 28.2% 30.6% 23.6% 17.5% 0.1% Salt use in food preparation 9.6% 19.1% 35.8% 34.6% 0.9% (n = 5,005) Source: CDC NHANES unpublished data.
5 Questions About Sodium - 5 What makes sodium reduction a public health imperative?
Sodium Reduction: A Public Health Imperative High blood pressure is a major cause of heart disease and stroke, the first and third leading causes of death in the United States. Sodium reduction can have a significant impact on reducing cardiovascular disease events. Reducing sodium in the food supply is the best population-based strategy to reduce the prevalence of high blood pressure.
Sodium Reduction: A Public Health Imperative Sodium reduction can reduce the public health burdens of deaths, disability, disparities and costs saving lives, promoting healthy aging, improving health equity, and producing health care savings. The federal government, states and localities can provide significant leadership to sodium reduction efforts, with a major impact on the health of all Americans.
Sodium Reduction: A Public Health Imperative The mission of public health is to assure conditions in which people can be healthy. The sodium content of the food supply is not safe, is not necessary, and is not defensible. Reduction of sodium in the food supply is a public health imperative.
Janelle Peralez Gunn jperalez@cdc.gov For More Information Nicole Blair nblair@cdc.gov Andrea Neiman aneiman@cdc.gov
Thank You Darwin R. Labart he, MD, MPH, PhD Director, Division for Heart Disease and Stroke Prevention dil3@cdc.gov For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention