E170: Why the US Must Reduce Sodium Intake: It’s Costing Lives
Today, we’re going to talk salt with Dr. Michael Jacobson, former president and co-founder of the Center for Science in the Public Interest. Dr. Jacobson is one of the authors of an important article published recently in the journal Hypertension. The article comes to a startling conclusion that delays in implementing voluntary sodium reduction targets by the food and restaurant industry may result in nearly 265,000 preventable deaths between 2017 and 2031.
So Mike, you’ve been a hero of mine for decades and I really admire the work you’ve done on so many different topics. And you and I have written a thing or two over the years which has been a great pleasure for me to do, but on things like soda taxes and nutrition policy, but you’ve also had a really long standing deep interest in the issue of salt. So let’s start with the following question. Tell us why salt is a problem.
The main concern about too much salt is that it contributes to high blood pressure. That’s a major cause of heart attacks and strokes, kidney disease, and probably some other problems both here in the United States and throughout the world. In almost all cultures, people are drinking/eating excessive amounts of salt far more than what the World Health Organization or the Department of Health and Human Services here in the United States recommends. Hypertension experts have been concerned about excess salt for decades and decades. Back in 1969, there was a White House conference on food, nutrition, and health and one of the recommendations was to reduce sodium intake. Mostly sodium chloride, but also some other ingredients in food besides salt and nothing was done. I first got involved in this in 1977 when a newly minted nutritionist came to Center for Science in the Public Interest, Bonnie Leaman. And I asked her to look into salt and what she found was very disconcerting. It seemed like a wide range of hypertension experts was encouraging people to consume less salt and some people were urgent government action. So in 1978, the Center for Science in the Public Interest petitioned the Food and Drug Administration to restrict levels of sodium and packaged in restaurant foods and require warnings on foods that contained excessive amounts of sodium. Almost nothing was done and the next 45 years or so is just a history of inaction by the most responsible health officials in the country. And similar inaction was occurring worldwide. And there’ve been Institute of Medicine reports, World Health Organization reports and a whole bunch of things like that. But Americans are consuming today just about the same amount of sodium as we were consuming 10, 20, 30 or more years ago. It’s really a sad tale about government in action and we can talk about some of the reasons why that’s happened.
I’d love to hear some of that and boy, it’s pretty disheartening that the scientific evidence has been around so lot, but so is the inaction. So I’d like to get to the why of this in a minute, but let me ask you a question first. Does the problem mainly come from how you and I, and everyone else, uses a salt shaker on foods at home or in restaurants, or is it salt added by the industry to foods that people buy?
Well 100 years ago, it probably would’ve been the salt shaker, but now the vast majority of foods that we eat come in boxes and cans. They come in freezer cases at grocery stores and restaurants. We get about a third of our food from restaurants and that’s really the culprit – and it should make it easier to solve this problem. But instead of having to persuade 330 million people to put down the salt shaker, the government could set limits on the amount of sodium in different packaged foods. Or it could require warning notices on foods to contain excessive amounts of sodium and let me just give you a few examples. This is from my book, Salt Wars, of some restaurant meals and to give you just a benchmark. The government recommends that people consume no more than 2300 milligrams of sodium per day, 2300 milligrams. It’s about a teaspoon worth of salt. So compared to the 2300 milligrams, if you get a spicy chicken sandwich with fries and chicken soup at Chick-fil-A, you’re getting 50% more than that. You’re getting 3,800 milligrams of sodium. A roasted turkey breast sandwich at Jason’s Deli, 4,200. At Chili’s restaurant, honey chipotle crispers and waffles, 4,700, twice as much as the recommendation. At an AMC movie theater, you can get a soft pretzel with more than three times as much sodium. So the amounts are just outrageous and that reflects that it’s cheap and easy to add salt to a food and most people like the taste of salt, it’s built into us genetically and the portions at restaurants are gargantuan. So that’s turned restaurant food into a major problem for sodium.
Mike, I think you’ve started to answer the question about why these changes haven’t been made. It sounds like industry is probably having pretty powerful sway over the lack of action that legislators have had in the past on this issue. Is that true? Are they just thinking we don’t want to make this change because people will like our products more if they’re high in sodium?
Yes, and they’re afraid that if their company lowers sodium, a competitor might not lower sodium. And that’s actually an advantage of having mandatory limits but the issue is the same as getting lead out of gasoline, getting DDT off of farms. Anytime there’s a big corporate interest, big financial interest in the status quo, those companies, those industries don’t want to change. It can be expensive to change – maybe you need new machinery, a new processes. In the case of salt, though, you hardly need to do anything. Obviously, if a company wants to lower sodium, it needs to taste the food before it sends it out on the marketplace. And it might have to replace some of the salt with other seasonings, add or more vegetables or more chicken, depending on the food. But it’s not rocket science at all. It should be something that companies can do and some companies have really made an effort. Remember, nobody’s saying get rid of all the salt. The government recommends that we reduce sodium intake from about 3,400 milligrams a day down to about 2,300. So that’s a one third reduction in intake. And some companies are meeting the FDA’s recommended limits right now, other companies are not. But it’s something that companies just need to say “we’re going to do it.” And usually they can change the food so that there’s no difference in taste whatsoever. And there’s one little trick that more and more companies are using is to replace table salt with potassium salt. Replace sodium chloride with potassium chloride, which isn’t quite as salty as sodium chloride, regular salt. It’s a great replacement and you can replace maybe a third of the sodium in a packaged food simply by using potassium chloride, and that extra potassium is really beneficial in reducing blood pressure and the risk of cardiovascular disease, especially for people who already have high blood pressure.
So Mike, help me understand something. If it’s pretty easy to make these changes for the industry and you say that you can do it in ways that don’t make taste of the foods deteriorate, why in the heck aren’t the companies doing it? You think for no other reason to stay out of the way to litigation might be a good reason to do this, but certainly they could score some public health points by doing this. Why aren’t they doing it?
They certainly could. It takes an effort. They have to assign people. At a big company like ConAgra or General Mills that makes hundreds of products, that means they have to do it methodically. It’s going to take some time and time is money. So maybe they have to hire some extra food technologists, extra dieticians, extra chefs to figure out the right combinations. So there is some expense, it’s not totally free. I talked to ConAgra many years ago about trans fat and they said, when they got rid of trans fat from their foods, partially hydrogenated oil, they also looked at sodium. They found out that in some of their foods, they were using far too much salt and the extra salt wasn’t even detectable. It wasn’t making foods saltier. It was just a waste. And so they were able to cut back on sodium in some of their products like Chef Boyardee. No effect on taste and they saved a little bit of money to boot. And I mentioned potassium salt. Campbell has been using potassium salt in tomato soup. Their regular red label, condensed tomato soup probably their number one seller over the decades, and they didn’t tell anybody. Nobody noticed, they just reduced sodium by I think it was about a third. So the government has known this. Everybody’s known that companies could lower sodium, but the government, I think, was afraid to act because of members of Congress who are so anti-regulatory. And then food and restaurant companies in their districts might lobby them to stop the government from interfering with their businesses and that’s all happened. They put pressure on legislators. It happened in the 1980s, it happened in the 2010s very recently. I can’t emphasize this enough. Excess sodium is causing as many as 100,000 premature deaths every year. That’s an unbelievable number, year after year after year, but it’s silent. Obituaries don’t say he died from eating too much salt, people just accept it and that a heart attack might occur one year or 10 years earlier than it might otherwise have done, but it’s just happening in the background so silently.
So Mike let’s loop back to your paper and hypertension and also your book, Salt Wars. I’m happy you mentioned that and I’ll mention it again at the end. So it sounds like there’s a clear case for action and that the government has done something on this. The FDA has proposed some voluntary targets. Could you talk to us about that and what’s kind of the history of the FDA and what the heck’s taken so long?
First, the major health authorities around the world have said for decades people are eating too much sodium. You’ve got to cut back, especially in packaged foods. So that’s the World Health Organization, American Heart Association and others, but that’s indisputable and you’re right. The government has done something. We have nutrition labels now so people can compare one food to another. And I urge listeners go to the grocery store, look at salad dressings or soups or breakfast cereals or packaged meats. Almost every category of food will show a range of sodium levels. And in most categories, you can lower sodium by 25% or more simply by switching from one good tasting brand to another. So we got nutrition labels but that hasn’t had an overall effect on sodium consumption and probably hasn’t had much effect on industry. So in 2010, the National Academy of Sciences issued a report saying that past efforts to lower sodium intake have been a failure. And now it was time for the Food and Drug Administration to set mandatory limits on sodium in packaged foods in 2010. The Food and Drug Administration immediately said it wasn’t going to do mandatory limits, but would come out with some voluntary targets. It took six years for the FDA to come out with voluntary targets in 2016. That was near the end of the Obama Administration and the administration wasn’t able to finalize the proposed targets. So we go into the Trump years and that’s when Congress stepped in and they told the FDA that it could not move forward with some of the targets that it was proposing or it would lose its funding. So that had an effect, but surprisingly, although the Trump Administration was vehemently anti-regulatory, but the commissioner of the Food and Drug Administration, Scott Gottlieb, was in touch with reality. He was probably the only regulator in the government who was, and in 2018, he said the single most important thing to improve nutrition is to lower sodium levels and that the FDA was going to finalize those voluntary targets in 2019. Well, a few months later, Commissioner Gottlieb quit and the FDA under Trump didn’t do anything. It took the Biden Administration not quite a year in October 2021 to finalize those voluntary targets. And so now we have to see will they work? And I’m skeptical that even these modest targets, which give industry two and a half years to lower sodium by an average of about 12%, I’m skeptical that they’re going to have much of an impact. I don’t see any real effort by the Food and Drug Administration to educate the public or to pound on industry’s door and say, you got to lower sodium. I don’t know if they’re meeting with the big food companies and trade associations, but at least there’s some movement and we should be grateful. But that over four year delay in finalizing the proposed voluntary targets has been deadly and that’s what our paper calculates how many unnecessary deaths will have been caused by that four and a third year delay in finalizing those targets. And as you said earlier, it’s roughly a quarter of a million unnecessary deaths between 2017 and 2031.
It’s so discouraging to hear that. Now we face another period of some years that will be necessary to prove that the voluntary guidelines won’t be met by the industry and then there will be a long process of talking about whether government should do anything, that’ll depend of course, on who’s in the White House. So, oh boy, it doesn’t sound like anything’s going to happen soon.
Not going to happen soon. So the FDA set targets for April 2024. It won’t get the data on the effectiveness of the targets until probably 2025, 2026. And then what’s it going to do if industry didn’t do much? Then surely that would set the stage for mandatory limits, but to get those mandatory regulations will take many more years, probably five more years. And it’s distressing how long it takes government to act on anything that touches somebody’s interests, landowners, banks, food manufacturers. I’ve urged the Food and Drug Administration to immediately start developing mandatory limits and or warning notices for food packages so that if the targets are not met in 2024 or 2025, the FDA could immediately propose these stricter regulations and hopefully get them adopted within a couple of years, but to wait three years or four years before building that hammer to require action is naive.
So let me ask you this. So often the case that public health innovation does not begin in the United States and other countries are way out ahead of us on some of these things, is that true in the case of sodium and are there examples from other countries of things that have been done?
Well, the Britains consume about as much sodium as we do, but back in 2005 or so, the British government said people are consuming too much salt. And so it came up with voluntary targets that served as a model for the Food and Drug Administration 10 years later. And so the British government published these voluntary targets and it simultaneously mounted a major public health campaign, urging the public to read labels and reduce their sodium intakes to choose the lower sodium brands. And it also called out major companies that were lowering sodium and major companies that were not lowering sodium. So it really created an issue. And then it more quietly met with the big companies and tried to persuade them to lower sodium. And when the government looked five years later or so, it discovered that there’d been a 10 or 15% reduction in sodium intake. And remember, we don’t have to stop consuming sodium, we need to make a about a one third reduction in sodium. And so that the British government got people down about one third of the way that they wanted to go. But then the government changed hands, there’s been a conservative government in there and the campaign has just fallen by the wayside, but you could look at other countries. Turkey of all countries has set limits on sodium in bread, one of the major sources of sodium. South Africa has set limits on sodium, mandatory limits in bread, breakfast cereals, potato chips, cured meats, and a bunch of other categories. Israel and Chile have taken a different route. In Mexico, they require warning notices on foods that are high in sodium. So you can go around the world and at least 30 countries, maybe more have adopted either voluntary or mandatory programs to reduce sodium intake and that’s partly because of the World Health Organization taking a very strong stand on this and other countries are looking at a place like Britain. Finland has achieved very significant reductions in sodium. So the examples from around the world show that it’s feasible to make these really modest reductions in sodium levels and in packaged foods and people are perfectly content. I don’t know if any consumer outrage about lowering sodium because people don’t know the difference. It tastes just the same.
It’s nice to hear some optimism in your voice when you talk about what’s happened in other countries and let’s hope that they will form models for the US to follow when the political will finally comes. So right now, what can consumers do? Is there anything?
Yes. The easiest thing is when you’re shopping, look for lower sodium brands of just about any category of food. Jesus, there’s a huge difference between Swiss cheese that’s rated really low in sodium and Muenster and mozzarella and other cheeses, cheddar cheese. So just read labels carefully and you could make major reductions. At restaurants though, it’s really tough because just about every meal is loaded with sodium. So the main trick I think is to use less condiments, less salad dressing, don’t eat salt, avoid soup, which is just a salt bomb and then bring half of your meal home. Split the high sodium meal at least over two days, rather than eating it all at once. And then at home just when you’re cooking, use less salt, use light salt where the sodium content is about half the usual and Martin and other companies make light salt. So it’s within somebody’s control, but it takes so much effort to compare all these labels when you’re going to the store to always be adjusting the recipes that we use from cookbooks. So it’d be so much easier, so much more helpful if the food industry said, okay, we’re going to really take this on, make a major public health contribution to the country.
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Michael Jacobson holds a Ph.D. in microbiology from MIT and has dedicated his life to advocating sound nutrition and food safety policies. He co-founded the Center for Science in the Public Interest, was its long-time executive director, and now serves as Senior Scientist. He has written numerous books and reports. He’s been honored with such awards as the Centers for Disease Control and Prevention’s Hero Award (2010), the American Public Health Association’s David P. Rall award for advocacy in public health (2011), and the Food Marketing Institute’s Esther Peterson Consumer Service Award (1992).