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Institute of Medicine (US) Committee on Strategies to Reduce Sodium Intake; Henney JE, Taylor CL, Boon CS, editors. Strategies to Reduce Sodium Intake in the United States. Washington (DC): National Academies Press (US); 2010.

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Strategies to Reduce Sodium Intake in the United States.

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Appendix BGovernment Initiatives and Past Recommendations of the National Academies, the World Health Organization, and Other Health Professional Organizations

TABLE B-1Government Initiatives

DateProgram/Initiative/Report TitleRecommendations/Initiatives/ActionsTarget Population (if specified)
White House Conference
1969Conference on Food, Nutrition, and Health: Final Report (White House Conference, 1969)Provided advice on the desirability of reducing sodium intakeHypertensive individuals
Encouraged food processors to minimize the amount of salt in processed foods
Identified a need for food labeling of sodium		Food processors
U.S. Senate—Select Committee on Nutrition and Human Needs
1977Dietary Goals for the United States, 2nd edition (Select Committee on Nutrition and Human Needs, 1977)Decrease salt intake to about 5 g/dAll Americans
U.S. Department of Health and Human Services—Centers for Disease Control and Prevention (CDC)
2009The Congressional Omnibus Appropriations Acta (2009) included language encouraging CDC to work with major food manufacturers and chain restaurants to reduce sodium content in their products and to submit to the Committee on Appropriations and the House of Representatives and the Senate an evaluation of its sodium-reduction activities within 15 months of enactment of the act, and annually thereafterCDC plans to explore existing national and international public and private initiatives to reduce sodium in the food supply
In fiscal years 2009–2010, CDC plans to convene public and private stakeholders to build relationships and partnerships to investigate approaches for reducing sodium consumption
CDC will explore knowledge gaps, utilizing its data systems to analyze and release pertinent sodium related data (CDC, 2009)		Food manufacturers and chain restaurants
U.S. Department of Health and Human Services—Surgeon General
1979Healthy People: Surgeon General’s Report on Health Promotion and Disease Prevention (Public Health Service, 1979)Consume less salt; cook with only small amounts of salt, avoid adding salt at the table, avoid salty prepared foodsAll Americans
1988Surgeon General’s Report on Nutrition and Health (Public Health Service, 1988)Reduce intake of sodium by choosing foods relatively low in sodium and limiting the amount of salt added in food preparation and at the tableAll Americans
U.S. Department of Health and Human Services—Public Health Service
1980Promoting Health and Preventing Disease: Objectives for the Nation (Public Health Service, 1980)By 1990:
  • Reduce the average daily sodium ingestion (as measured by excretion) foradults to at least the 3,000–6,000 mg range
  • > 75% of the population should be able to identify the principal dietaryfactors for high blood pressure and three other diseases
  • 70% of adults should be able to identify the major foods that are low insodium
  • Sodium in processed foods should be reduced by 20% from present levels
All Americans
1990Healthy People 2000 (NCHS, 2001)Increase % of persons preparing foods without adding salt from 43% (baseline) to a target of 65%
Increase % of persons rarely or never using salt at the table from 60% (baseline) to 80%
Increase % of persons regularly purchasing foods with reduced salt and sodium content from 20 (baseline) to 40%		All Americans
2001Healthy People 2000 Review (NCHS, 2001)During the mid-1990s, overall the percent of persons rarely or never using salt at the table ranged from 56–62%, and the % of persons regularly purchasing foods with reduced salt and sodium content was 19%All Americans
2000Healthy People 2010 (HHS, 2000)Increase the percentage of persons who consume ≤ 2,400 mg/d sodium from baseline (21% based on the National Health and Nutrition Examination Survey [NHANES] 1988–1994) to 65% (only 13% met target in 2003– 2004 [Public Health Service, 2008])Persons 2 or more years of age
U.S. Department of Health and Human Services—National Heart, Lung, and Blood Institute (NHLBI), the National Institutes of Health
1972National High Blood Pressure Education Program (NHLBI, 2010)Cooperative effort among professional and voluntary health agencies, state health departments, and many community groups with the goal to reduce death and disability related to high blood pressure through programs of professional, patient, and public educationAll Americans
1993Working Group Report on Primary Prevention of Hypertension (National High Blood Pressure Education Program) (Whelton et al., 1993)Reduce salt intake to no more than 6 g per dayAll Americans
1995, 1999Statement from the National High Blood Pressure Education Program Coordinating Committee (NHLBI, 1999)Moderate salt and sodium intake
Establish 2,400 mg/d sodium as a national dietary goal
1996Workshop: Implementing Recommendations for Dietary Salt Reduction: Where Are We? Where Are We Going? How Do We Get There? (NHLBI, 1996)Develop public and professional education activities within the primary prevention campaign to convey the rationale for and benefits of lowering dietary salt/sodium for hypertension prevention to the appropriate target audiences
The salt/sodium messages must be consistent with and often integrated into overall healthful lifestyle diet messages, such as the Dietary Guidelines, USDA Food Guide Pyramid, and FDA food labels
Experiences with intervention studies should be transferred to clinical and/or community settings after reviewing or evaluating and adapting, if necessary, strategies, methods, and materials
Gradual “silent” or “transparent” lowering of salt or sodium in the food supply will need to occur along with the opportunity for effective marketing strategies and the promotion of reduced-sodium as well as low-sodium, low-salt, and no-salt food products. These recommendations are applicable to the food production industry, as well as restaurant, catering, and foodservice industries
Data from completed clinical trials should be analyzed for the adequacy of simpler methods (e.g., casual urine collections, chloride titrator strips) as measures of sodium intake and for the validity of dietary recalls in order to consider the best feasible methods for individual and national-level assessments of sodium intake
Other research needs identified in the areas of food technology; basic mechanisms of salt taste; and knowledge, attitudes, and skills of the public
1997The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NHLBI, 1997)Reduce sodium intake to ≤ 100 mmol/d (2,400 mg sodium or 6 g sodium chloride)
2002National High Blood Pressure Education Program (update of 1993 report) (NHLBI, 2002)Reduce dietary sodium intake to no more than 100 mmol/d (approximately 2,400 mg of sodium or 6 g of sodium chloride)All Americans
2003The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NHLBI, 2004)Reduce sodium intake to no more than 100 mmol/d (2,400 mg sodium or 6 g sodium chloride)
2005Prevent and Control America’s High Blood Pressure: Mission Possible (NHLBI with CDC and the American Heart Association [AHA] as supporting partners; 22 states participated) (NHLBI, 2005)Promoted awareness and education materials to help the public health community attract new partners and revitalize relationships with existing partners to fight high blood pressurePersons at high risk for hypertension
States distributed materials to public health departments; hospitals and clinics; schools; senior centers; refugee centers; faith-based organizations; work sites; primary care practices; emergency medical service groups; state health benefit plans; and disease-related organizations, such as diabetes, kidney failure, and cancer groupsLow-SES (socioeconomic status) and minority populations
2006NIH Radio (NIH, 2006)Produced a broadcast-ready public service announcement about fighting high blood pressure through dietAll Americans
U.S. Department of Agriculture and U.S. Department of Health and Human Services (USDA/HHS)
1980Dietary Guidelines for Americans (USDA/HHS, 1980)Avoid too much sodium“Most Americans”
1985Dietary Guidelines for Americans (USDA/HHS, 1985)Avoid too much sodium“Most Americans . . . those who are already healthy”
1990Dietary Guidelines for Americans (USDA/HHS, 1990)Use salt and sodium only in moderationHealthy Americans 2 or more years of age
1995Dietary Guidelines for Americans (USDA/HHS, 1995)Choose a diet moderate in salt and sodium. “The Nutrition Facts Label lists A Daily Value of 2,400 mg”Healthy Americans 2 or more years of age
2000Dietary Guidelines for Americans (USDA/HHS, 2000)Choose and prepare foods with less saltHealthy Americans 2 or more years of age
2005Dietary Guidelines for Americans (USDA/HHS, 2005)Consume < 2,300 mg/d of sodium (~1 tsp salt)
Choose and prepare foods with little salt, and consume potassium-rich foods, such as fruits and vegetables		Americans 2 or more years of age
Individuals with hypertension, African Americans, and middle-aged and older adults: Aim to consume no more than 1,500 mg/d of sodium, and meet the potassium recommendation (4,700 mg/d) with foodHigh-risk populations
2010Dietary Guidelines for AmericansConvened expert Advisory Committee to update the Dietary Guidelines for Americans for the year 2010. Sodium intake is included as a topic area for discussion (results pending)
U.S. Food and Drug Administration (FDA)
1973Food labeling (HHS/FDA, 1973)Required specific format when a nutrition claim was made in labeling or advertising or when a nutrient was added to a food
Better information about the sodium content of foods was an early focus
1979Evaluation of the health aspects of sodium chloride and potassium chloride as food ingredients (SCOGS, 1979)Consumption of sodium chloride should be reduced
Guidelines should be developed for restricting salt in processed foods
The sodium content of processed foods should be labeled
1981Initiative with NHLBI (Derby and Fein, 1995)Educate the public about sodium
Encourage manufacturers to display the sodium content on food labels
1982Rejected petitions requesting reclassification of salt’s status from “GRAS” (generally recognized as safe) to “food additive” and the addition of warning labels to high- sodium foods and salt packets by deferring action on GRAS status of salt (HHS/FDA, 1982)Deferred action pending assessment of the impact of
  • Sodium labeling regulations
  • Manufacturer efforts to voluntarily reduce salt
Indicated that a voluntary program would produce the desired results with less regulatory burden and affirmed that the food industry was in the best position to reduce sodium levels in processed foods and should be given a chance to do so
1984Sodium labeling (HHS/FDA, 1984)Sodium added to mandatory list of nutrients to be declared on food labels
Defined the terms for sodium content claims
1993–2005Nutrition Labeling Final Rules (HHS/FDA, 1993a, 1994, 2005)Established a Daily Value (DV) of 2,400 mg for sodium labeling
Mandated declaration of sodium content on all foods (mg and % DV)
Established labeling rules:
  • Nutrient content claims for “free” (< 5 mg sodium per serving), “low”(≤ 140 mg sodium per serving), and “reduced or less than” (≥ 25% lesssodium per serving than an appropriate reference food)
  • Foods labeled as “healthy” to contain ≤ 480 mg sodium per serving untilJan. 1, 1998, at which time sodium levels were to decrease to ≤ 360 mgper serving
  • Health claim: “Diets low in sodium may reduce the risk of high bloodpressure” (foods ≤ 140 mg per serving)
  • Disqualifying or disclosure levels (≤ 480 mg per serving)
2005Final rule regarding sodium levels in foods labeled as “healthy” (HHS/ FDA, 2005)Retained 1993 level of ≤ 480 mg sodium per serving; eliminated requirement that this level drop to ≤ 360 mg
Rationale:
  • Technological barriers to reducing sodium in processed foods
  • Poor sales of products meeting lower-sodium levels
  • More restrictive sodium levels would inhibit the development of new “healthy” food products
2007Public hearing in response to a 2005 petition (CSPI, 2005) requesting rulemaking regarding salt and a House of Representatives’ Committee on Appropriations 2005 statement encouraging the agency to focus on ways—both voluntary by the food industry and regulatory by FDA and USDA—to reduce salt in processed and restaurant foods (HHS/FDA, 2007a)The petition specifically requested FDA to
  • revoke the GRAS status of salt
  • amend any prior sanctions for salt
  • require food manufacturers to reduce the amount of sodium in all processed foods
  • require health messages on retail packages of salt (0.5 oz.+); reduce the DV for sodium from 2,400 to 1,500 mg
Issues discussed—GRAS vs. food additive status:
  • Could a food additive regulation be constructed to prescribe limitations for uses of salt? If so, how?
  • Would reducing the salt content of food, even in a modest way, impact the safety or quality of various foods given the wide variety of technical functions for which salt is used in food? How feasible would it be to mitigate this impact, if true? Could it be mitigated by the addition of other ingredients?
  • If you agree that the sodium content of processed foods should be reduced, what actions (other than those suggested by the petitioner) would you recommend?
  • How could FDA partner with interested stakeholders regarding the development of appropriate recommendations or other information to reduce the salt content of processed foods?
Issues discussed—food labeling:
  • What is the effectiveness of FDA labeling regulations in reducing salt intake by the public?
  • What data are available regarding the potential for label statements about the health effects of salt to reduce salt intake?
  • To what extent could FDA’s labeling policies provide incentives to manufacturers to reduce the salt content of processed foods?
2007Advanced Notice of Proposed Rulemaking (ANPR): Nutrition Labeling (HHS/FDA, 2007b)Requested comments on questions including:
  • Should the Daily Reference Value (DRV) for sodium be based on the Tolerable Upper Intake Level (UL) for sodium (2,300 mg) or on the Adequate Intake (AI; 1,500 mg/d) using the population-coverage approach?
  • If the UL is used, should it be adjusted using the same approach (population-weighted or population-coverage) as the other Dietary Reference Intakes (DRIs)?
2007Public Hearing (HHS/FDA, 2007c)Discussed: use of symbols to communicate nutrition information, consideration of consumer studies and nutrition criteria
U.S. Department of Agriculture (USDA)
1993Nutrition Labeling (USDA, 1993)Adopted similar food labeling provisions as FDA for USDA-regulated products (notably meat and meat products)
1995Commodity Distribution Program (provides 15–20% of school lunch program foods)Recommended specific sodium reductions for 10 commodity food categories in USDA’s Commodity Distribution Program: canned beef, pork, poultry, luncheon meat, refried beans, salmon, tuna, ready-to-eat cereals, ham, and carrots
Excluded many other products due to the assumption that school children would find modifications unacceptable (USDA, 1995)		Children consuming school meals
2004Healthier US School Challenge (encourages elementary, middle, and high schools to improve the nutrition content of foods provided to children and youth) (FNS, 2010)Rewards changes in the school nutrition environment, including providing lower-sodium foods to all children and youth:
  • Gold, silver, or bronze recognition: Foods with ≤ 480 mg sodium per non-entrée or ≤ 600 mg sodium per entrée
  • Gold award of distinction: Non-entrées with ≤ 200 mg sodium and entrées with ≤ 480 mg
Children and youth consuming school meals
2007Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (provides vouchers to participants for the purchase of specific food items to meet nutritional needs) (USDA/FNS, 2007)Requires that in certain food categories, foods must be lower in sodium or not have added sodium to qualify as a product that can be purchased with WIC vouchersLow-income, nutritionally at-risk, pregnant and postpartum women; infants and children up to 5 years
2008Commodity Distribution Program (FNS, 2008)Plans to purchase low-sodium canned vegetables with the goal to reduce sodium levels of all canned vegetables to ≤ 140 mg per serving by school year 2010Children consuming school meals
State and Local (Sodium Labeling Initiatives)b
2008CaliforniaRequires restaurant chains with ≥ 20 outlets statewide to disclose sodium information at point of sale
2008King County (Seattle)Requires posting of sodium content on menus for restaurant chains with ≥ 15 outlets nationwide or $1 million in annual sales (collectively for the chain); if a menu board is used, nutrition information (including sodium) must be provided at point of ordering
2008PhiladelphiaRequires posting of sodium content on menus for restaurant chains with ≥ 15 outlets nationwide
2009Montgomery County (Maryland)Requires restaurant chains with ≥ 20 outlets nationwide to disclose sodium information (in writing) on the premises, upon request
2009OregonRequires restaurant chains with ≥ 15 outlets nationwide to provide sodium information on the premises, upon request
Government/Non-government Organization Partnership
2009National Salt Reduction Initiative (see Appendix G)Partnership of over 45 cities, states, and national health organizations working to reduce U.S. population salt intake by 20% over 5 years by working with industry to set salt reduction targets that are designed to allow for gradual reductions in the sodium content of packaged and restaurant foodsU.S. population
a

Public Law 111-8, Joint Explanatory Statement: Division F—Labor, Health and Human Services, and Education, and Related Agencies Appropriations, 2009.

b

Implemented or passed into law as of February 16, 2010. See Appendix J for more information.

NOTE: d = day; g = gram; mg = milligram; tsp = teaspoon.

TABLE B-2Past Recommendations from the National Academies and the World Health Organization

DateProgram/Initiative/Report TitleRecommendations/Initiatives/ActionsTarget Population (if specified)
The National Academies
1970Safety and suitability of salt for use in baby foods (NRC, 1970)Recommended ≤ 0.25% salt be added to commercial baby foodInfant food manufacturers
1980Toward Healthful Diets (NRC, 1980a)Use salt in moderation; adequate but safe intakes are considered to range between 3–8 g/d salt (1,200–3,200 mg/d sodium)
1980Recommended Dietary Allowances, 9th ed. (NRC, 1980b)Estimated Safe and Adequate Daily Dietary Intake of sodium: 1,100–3,300 mgAdults
1989Recommended Dietary Allowances (NRC, 1989a)Estimated minimum requirements for sodium of 500 mg/dHealthy persons ≥ 10 years of age
1989Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989b)Limit total daily intake of salt (sodium chloride) to ≤ 6 g, although ≤ 4.5 g would probably confer greater health benefits
Limit use of salt in cooking and avoid adding it to food at the table
Salty, highly processed salty, salt-preserved, and salt-pickled foods should be consumed sparingly
2005Dietary Reference Intakes for Sodium (IOM, 2005)Established Adequate Intake:
  • 1.5 g/d for persons 9–50 y
  • 1.3 g/d for persons 51–70 y
  • 1.2 g/d for persons > 70 y
Established Upper Limit:
  • 2.2 g/d for persons 9–13 y
  • 2.3 g/d for persons >13 y
2010Strategies to Reduce Sodium Intake (IOM, 2010)Recommended a coordinated approach to set standards for safe levels of sodium in food using existing FDA authorities to modify the generally recognized as safe (GRAS) status of salt and other sodium- containing compounds
Recommended a nationally organized campaign to educate the public about the risks of excess sodium intake and healthful food choices, build support for government and industry activities, and support consumers in making behavior changes to reduce sodium intake		U.S. population
World Health Organization (WHO)
1990Diet, Nutrition, and the Prevention of Chronic Diseases (WHO, 1990)Upper limit 6 g/d salt
Lower limit not defined
2003Diet, Nutrition, and the Prevention of Chronic Diseases (WHO, 2003)< 5 g/d salt

NOTE: d = day; g = gram; mg = milligram; y = years.

TABLE B-3Past Recommendations from Health Professional Organizations

DateProgram/Initiative/Report TitleRecommendations/Initiatives/ActionsTarget Population (if specified)
American Heart Association (AHA)
1973Diet and Coronary Heart Disease (AHA, 1973)Moderate sodium intake
1986Dietary Guidelines for Healthy American Adults (AHA, 1986)Consume no more than 3,000 mg/1,000 kcal/d sodiumAdults
1988Dietary Guidelines for Healthy American Adults (AHA, 1988)Consume no more than 3,000 mg/d sodiumAdults
1996Dietary Guidelines for Healthy American Adults (Krauss et al., 1996)Consume no more than 6 g/d salt (2,400 mg/d)Adults
1998Dietary Electrolytes and Blood Pressure (Kotchen and McCarron, 1998)Consume ≤ 6 g/d saltAdults
2000Dietary Guidelines (Krauss et al., 2000)Limit salt intake to 6 g/d, ~100 mmol/d of sodiumGeneral population
2006Diet and Lifestyle Recommendations (Revision) for CVD Risk Reduction (Lichtenstein et al., 2006)Choose and prepare foods with little salt
“In view of the available high-sodium food supply and the currently high levels of sodium consumption, a reduction in sodium intake to 1,500 mg/d (65 mmol/d) is not easily achievable at present. In the interim, an achievable recommendation is 2,300 mg/d (100 mmol/d)”
Information dissemination program		Adults and children over 2 years of age
2006Alliance for a Healthier Generation (joint initiative of AHA and the William J. Clinton Foundation) (Alliance for a Healthier Generation, 2009)Established voluntary nutrition guidelines (based on the 2005 Dietary Guidelines and AHA’s 2006 Diet and Lifestyle Recommendations) for competitive school foods (e.g., foods in vending machines) as part of its goal to reduce prevalence of childhood obesity; leading industry groups have signed on
American Medical Association
1979Concepts of Nutrition and Health (Council on Scientific Affairs, 1979)Moderate intake of salt to less than 12 g/d (4,800 mg/d sodium)
2006Report of the Council on Science and Public Health (Dickinson and Havas, 2007; Havas et al., 2007)Recommended a stepwise, minimum 50% reduction in sodium in processed foods, fast food products, and restaurant meals over the next decade; recommended that FDA revoke GRAS (generally recognized as safe) status of salt
American Dietetic Association
2007Nutrition Fact Sheets and web page (www​.eatright.org)Provided sodium guidance on the meaning of sodium label claims and food purchasing or preparation techniques to reduce sodium intake
American Public Health Association
2002Policy Statement: Reducing sodium content in the American diet (APHA, 2002)Urged manufacturers to reduce the sodium content of processed foods by 50% over the next decade at a suggested rate of 5% per year
American Institute for Cancer Research and World Cancer Research Fund
1997Food, Nutrition, and the Prevention of Cancer: A Global Perspective (WCRF/ AICR, 1997)Limit salt from all sources to < 6 g/d

Limit consumption of salted foods and use of cooking and table salt		Adults
2007Food, Nutrition, and the Prevention of Cancer: A Global Perspective (WCRF/ AICR, 2007)Limit consumption of salt
Population average consumption of salt from all sources to be < 5 g/d (2,000 mg/d sodium)
Proportion of the population consuming more than 6 g salt (2,400 mg sodium)/d should be halved every 10 years
World Action on Salt and Health
Annually since 2008World Salt Awareness Week (World Action on Salt and Health, 2009)The 2009 awareness week focused on the often high amount of hidden salt in foods obtained and consumed outside the home, and highlighted the importance of adding less salt to food and the long- term health implications of eating a high salt diet
World Hypertension League and World Action on Salt and Health
Annually since 2005World Hypertension Day (World Hypertension League, 2009)The 2009 day urged health experts and chefs to raise awareness of two “silent killers”: salt and high blood pressure

NOTE: d = day; g = gram; kcal = calorie; mg = milligram.

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Copyright © 2010, National Academy of Sciences.
Bookshelf ID: NBK50955
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