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Job number two for the FDA: Reducing salt

Job number two for the FDA: Reducing salt
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It is crystal clear that job number one for the U.S. Food and Drug Administration (FDA) is helping tackle the coronavirus pandemic. However, that doesn’t mean that the FDA, particularly its Center for Food Safety and Applied Nutrition, should ignore other major causes of rampant illness and death. 

We’re thinking of salt. Yes, salt, innocent crystals of which are in half of all packaged foods and practically every factory, restaurant and kitchen in America.

The federal government’s Dietary Guidelines for Americans recommends that Americans consume about one-third less sodium. That would cut intake from 3,400 to 2,300 mg per day (the equivalent of about one teaspoon of salt ). Nutritionists and cardiologists are concerned about people consuming too much sodium because that increases blood pressure and raised blood pressure is a major cause of strokes and heart attacks. Indeed, high blood pressure, which is more prevalent in Blacks than whites, also might increase the risk of severe illness from COVID-19.

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Excess sodium is responsible for about 50,000 to 100,000 premature deaths and $10 to $24 billion in avoidable health care costs in the United States every year. Globally, excess sodium causes about one million premature deaths annually. That enormous harm amounts to a pandemic, albeit a slow motion one.

Calls for cutting salt began a half century ago at a White House nutrition conference. In 1978 the Center for Science in the Public Interest formally petitioned the FDA to lower sodium levels and require warnings on high-sodium foods. The next year the FDA’s own advisory committee concluded that salt was not “generally recognized as safe” at the levels then in use. However, no change in that status or focused effort to reduce sodium ensued, and sodium consumption stayed constant, although the concerns about salt contributed to the impetus for the nutrition facts labels on food packages. 

The most full-throated, authoritative appeal to reduce sodium in the food supply came in 2010 from the Institute of Medicine (now the National Academy of Medicine). It recommended that the FDA set mandatory limits on sodium, reducing the amounts allowed stepwise over time to gradually bring sodium down to safe levels. Because the taste for salt is malleable, gradual reductions would support consumer acceptance of the reduced-sodium foods. Again, the FDA responded to those recommendations by saying it would support voluntary reductions.

Meanwhile, beginning in 2006 the United Kingdom began a voluntary, but vigorous, campaign to reduce sodium. It first set specific goals for about 80 categories of food. Then it mounted a high-profile campaign to spur consumers to read labels and choose lower-sodium brands. It also did some arm-twisting of executives at companies and trade associations to encourage them to reduce sodium. Over the first five years, the campaign achieved a 10 to 15 percent reduction in sodium consumption, but then a change in government virtually ended the program and the progress.

Back in the United States, the Obama administration developed a sodium-reduction program modeled on the British effort and a similar one spearheaded by New York City. It took six years, but in 2016 the FDA finally issued a proposal that divided the food supply into 158 categories and set two-year and 10-year goals for each. Unfortunately, the administration ran out of time to finalize the goals.  

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Despite the Trump administration’s focus on deregulation, FDA Commissioner Scott Gottlieb said in 2018 that, “There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet.” Gottlieb said that the FDA would finalize the two-year targets in 2019. But then Gottlieb resigned, and — 10 years after the IOM’s recommendations — the 2016 proposal has never been finalized. 

It’s high time for action. To truly tackle the pandemic caused by salt, the FDA should put sodium-reduction near the top of its agenda and:

  • Appoint a “Salt Czar” who would use the agency’s bully pulpit to exhort companies to achieve the recommended decreases and ensure that sodium reduction stayed a top agency priority  

  • Periodically monitor sodium levels in the overall food supply and in the categories of foods subject to its targets

  • Require products that after two years still exceeded the FDA’s “upper bound” goals to bear a front-label notice stating, “U.S. FDA Notice: The sodium content of this food exceeds the FDA’s recommended limit”  

  • Issue an intermediate set of targets to take effect between the proposed two- and 10-year levels to maintain pressure on companies

  • Extend labeling to chain restaurants by requiring saltshaker icons on menus next to items that contain more than a certain amount of sodium, as New York City and Philadelphia require

Besides the FDA, other agencies and individuals could help:

  • USDA should lower children’s sodium intake by restoring the Obama-era school meal improvements that the Trump administration undid

  • Federal, state and local agencies should use their purchasing power to encourage companies to market lower-sodium foods.

  • Local, state and federal health agencies should sponsor hard-hitting media campaigns emphasizing the risks of high-sodium diets and encouraging people to read labels and choose lower-sodium foods.  

The Biden administration has a golden opportunity to save tens of thousands of lives and countless billions of health care dollars over the next decade and reduce health inequities. Let’s hope that sodium reduction is a high priority.

Michael F. Jacobson, Ph.D., is the 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." Marsha N. Cohen is a professor at the University of California Hastings College of the Law and was a member of the 2010 Institute of Medicine committee on sodium reduction.