The deadly coronavirus pandemic has, appropriately, captured much of the public’s attention. But we should not forget other long-standing pandemics, such as those caused by opioids, alcoholic beverages, cigarettes, and salt.
Salt? Diets heavy in salt can raise blood pressure and increase the risk of non-fatal and fatal heart attacks and strokes. And the magnitude of that harm puts salt among the major killers in the United States and many other countries.
Americans consume an average of 1.5 teaspoons of salt a day, which translates into 3,400 milligrams (mg) of sodium That’s 50% more than the government’s recommended 2,300 mg for the general public and more than twice the 1,500 mg recommended for all adults by the more-precautionary American Heart Association. Consuming too much sodium causes as many as 100,000 deaths each year in the U.S. and $20 billion in health-care costs. The Global Burden of Disease study estimates that high sodium intake causes between 1 million and 5 million deaths per year globally.
Those enormous costs have for decades spurred health experts to call for lower-salt foods and diets. The Dietary Guidelines for Americans, the government’s basic nutrition recommendations, has urged people to consume less salt since its first edition in 1980. But polite admonitions go only so far: salt consumption has not budged over at least the last 30 years.
Almost 75% of the sodium we consume comes from the salt and other ingredients that companies add to packaged and restaurant foods. Less than 15% comes from the salt that people add when cooking or at the table. That is why public health officials typically focus on getting companies to cut the salt, rather than on persuading several hundred million people to do that.
But food manufacturers and their trade associations have resisted change out of fear that consumers would reject lower-salt products and because testing and reformulating lower-sodium versions of thousands of products would be expensive.
Those fears are unfounded.
Beginning in 2006, the United Kingdom waged a campaign to lower sodium consumption. The program was voluntary so as to side-step expected industry opposition to legal limits. But thanks to high-profile creative ads directed at consumers and strong, persistent pressure on companies, consumption had declined by 10% to 15% by 2011. But then a change in government halted the progress, well shy of the goal of reducing sodium consumption by 33%.
Other countries have adopted different strategies. Turkey and Belgium, for instance, set legal limits on sodium in bread, a major source of sodium. Chile required prominent warning notices on food labels, spurring many companies to reduce sodium significantly. The percentage of “high in sodium” savory spreads, cheeses, ready-to-eat meals, soups, and sausages dropped by two-thirds.
In the late 1970s, my organization, the Center for Science in the Public Interest, began urging the U.S. Food and Drug Administration to limit sodium in packaged foods. The agency declined to do so, but in 1981 Commissioner Arthur Hull Hayes told a congressional committee, “I have made it abundantly clear [to industry executives] that if sufficient positive action is not forthcoming [voluntarily], I would feel compelled to pursue a mandatory solution.” No industry action came forth, intakes did not change, and FDA did not pursue meaningful solutions.
That inaction eventually led to a 2010 recommendation by the Institute of Medicine (now the National Academy of Medicine) that the FDA set gradually decreasing mandatory limits on sodium. Again, though, then-FDA Commissioner Margaret Hamburg chose to avoid antagonizing industry, which could have lobbied Congress to stop any legal requirements, saying, “We believe we can achieve some substantial voluntary reductions.” [Emphasis added.]
As the U.K. showed, a vigorous voluntary program can reduce sodium consumption. But in the U.S., implementing even a voluntary approach has proven difficult. Some six years after the Institute of Medicine report, the FDA finally proposed modest voluntary reductions in sodium for 158 food categories — from flavored potato chips to frozen pizza — for the food industry to achieve in two years, plus much more ambitious targets to be met in 10 years. Full compliance with the proposal was calculated to reduce average sodium intake to 2,300 mg per day.
The FDA’s targets are clearly feasible because many products already meet the two-year marks and some meet the 10-year targets. Companies often replaced the lost taste due to less salt with ingredients, such as the somewhat salty-tasting potassium chloride and various herbs and spices, that can reduce a food’s sodium level by at least one-fourth to one-third.
Remarkably, in the context of the anti-regulatory Trump administration, in 2018 FDA Commissioner Scott Gottlieb recognized the public health importance of lowering sodium, stating, “There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet.” He planned to finalize the two-year targets in 2019. But then Gottlieb resigned and the FDA did not follow through. More than four years after being proposed, the targets are still languishing.
The case for reducing sodium has only gotten stronger since Gottlieb’s comment. A 2019 National Academy of Medicine report concluded, based on randomized, controlled trials and other evidence, that intakes of sodium above 2,300 mg per day were causally linked to an increased risk of cardiovascular disease. That is the gold standard in science.
To finally tackle the sodium pandemic, the FDA should immediately finalize its two-year targets. It should appoint a sodium “czar” who would publicly applaud companies making progress and call out the laggards, twisting their CEOs’ arms to do better. The FDA also should mount a major public-education campaign to encourage consumers to read labels and cut their sodium intakes while they wait — likely many years — for the food supply to be improved.
If some products do not reach their targets, the FDA should impose limits on at least the main sources of dietary sodium, such as breads and processed meats, or require warning labels on foods and restaurant meals that exceeded the targets. Philadelphia and New York City, for example, already require high-salt alerts on menus identifying items that contain more than a day’s worth of sodium.
Job one is to crush the horrific coronavirus pandemic. But we must also address the pandemic caused by salt, which may act more slowly but is relentlessly killing tens of thousands of people a year, year in and year out.
Michael Jacobson is a co-founder and senior scientist at the Center for Science in the Public Interest and author of “Salt Wars: The Battle Over the Biggest Killer in the American Diet” (MIT Press, October 2020). [email protected] @CSPI