1. CDC Update and Sodium Content of Foods Laurence M. Grummer-Strawn, PhD Division of Nutrition, Physical Activity and Obesity Association of State and Territorial Public Health Nutrition Directors June 14, 2009

2. Outline ● Funding ● Key obesity/weight initiatives ● Surveillance ● Target behaviors ● Salt and sodium

3. Dr. Tom Frieden’s top 5 priorities ● Strengthen surveillance & epidemiology ● Strengthen state & local partners ● Better address leading causes of illness/death ● Improve global health ● Do more with less/be more efficient (financial crisis)

4. New day for nutrition ● White House garden ● Asst White House chef working on farmers market ● Prevention central to health care reform ● Frieden’s experience Baby Friendly hospitals Baby Friendly hospitals Trans fat bans Trans fat bans Menu labeling Menu labeling

5. DNPAO Organizational Structure Physical Activity Branch Team Structure: Research Team Surveillance Team Guidelines Development & Recommendations Team Nutrition Branch Team Structure: Research & Surveillance Team Surveillance Systems Team Guidelines Development & Recommendations Team International Unit (M/M) Obesity Prevention & Control Branch Team Structure: Research & Surveillance Team Guidelines Development and Recommendations Team Program Development & Evaluation Branch Team Structure: Program Advancement Team Program Development and Translation Team Evaluation Team Associate Director for Science Associate Director for Policy, Planning & Communications Team Structure Policy Team Communications Team Program Resource Management Office of the Director

6. Funding ● Increasing funding to state cooperative agreement ($17.2 → $18.3 million) Two additional states Two additional states ● Stimulus funds expected States States Communities Communities

7. Weight of the Nation Conference ● July 27-29, 2009 ● Follows on Public Health Law & Communities conferences ● “Place Matters” Community success stories Community success stories Environment influences outcomes Environment influences outcomes Obesity maps by county Obesity maps by county

8. IOM Pregnancy weight gain recommendations, 2009 BMIRecommended weight gain <18.528-40 18.5-24.925-35 25-29.915-25 30+11-20

9. PNSS/PedNSS/WIC Participant Characteristics Consolidation PNSS/PedNSS ● HHS/CDC ● Ongoing data collection ● Reporting to states/communities ● Health/nutrition focus WIC Participant Characteristics ● USDA/FNS ● Biannual data collection ● National report only ● Program operation focus

10. Principal Target Behaviors Reduce sugar-sweetened beverages Decrease television time Decrease high energy-dense foods Increase fruit and vegetable intake Increase breastfeeding initiation, duration and exclusivity Increase daily physical activity

11. CDC Guide to Interventions ● One per behavioral target ● Includes description, evidence of effectiveness, key considerations, program examples, online resources ● Ancillary products to be developed

12. Reduce sugar-sweetened beverages ● Key strategies Apply IOM standards for competitive foods in schools Apply IOM standards for competitive foods in schools Water availability in all venues Water availability in all venues Competitive pricing Competitive pricing Taxes on SSBs Taxes on SSBs

13. Decrease television time ● Key strategy Policy in child care and schools Policy in child care and schools

14. Decrease high-energy dense foods ● Key strategies Healthy food retail Healthy food retail Apply IOM stds to competitive foods in schools Apply IOM stds to competitive foods in schools Apply school standards to CACFP foods Apply school standards to CACFP foods Menu labeling Menu labeling Competitive pricing Competitive pricing Food standards for meetings, cafeteria, and vending machines Food standards for meetings, cafeteria, and vending machines

15. Increase fruits and vegetable intake ● Key strategies Farm to consumer Farm to consumer Farm to institution Farm to institution Healthy food retail Healthy food retail Apply IOM standards for competitive foods Apply IOM standards for competitive foods Competitive pricing Competitive pricing

16. Environmental Surveillance Data Perceptions of physical access to healthy food retail MESA Study, HealthStyles 2009 Community checklists Farmer’s markets, grocery & food stores, restaurants (WI Tool) Consumer environment Nutrition Environment Measures Survey (NEMS) GIS, Spatial analysis Census Tract level data on grocery stores, produce markets, farmers’ markets Organizational survey School Health Policies and Programs Study (SHPPS)

17. States that introduced FV legislation 2001-2008 47 58

18. Fruit and Vegetable Report Card Process Indicators The DRAFT process indicators measure different types of support for F&V in 6 difference strategic areas: Food Policy Council Farmers Markets Healthy Food Retail Land Acreage Farm to School School Food Environment

19. Increase breastfeeding initiation, duration and exclusivity ● Key strategies Maternity Care Practices and Policies Maternity Care Practices and Policies Teaching mothers Teaching mothers Workplace Support Workplace Support Peer Support Peer Support Educating Mothers Educating Mothers Professional Support Professional Support Media and Social Media and SocialMarketing

20. National Breastfeeding Trends and Related Federal Activities 1984 Surgeon General’s Workshop on BF 2001 USBC Strategic Plan on Breastfeeding 1998 Nat’l BF Policy Conference US Breastfeeding Committee launched 1990 Breastfeeding Promotion Consortium formed Healthy People 2000 BF Goals established 2000 HHS Blueprint for Action on Breastfeeding 2010 HHS Call to Action? 2006 1 st Nat’l BF Coalitions Conference 1991 Second Follow- up Report on SG Workshop

21. CDC Survey on Maternity Practices in Infant Nutrition and Care (mPINC) Biannual national census of facilities with registered maternity beds Biannual national census of facilities with registered maternity beds August – December 2007 August – December 2007 Based on WHO/UNICEF Ten Steps Based on WHO/UNICEF Ten Steps Anonymous Anonymous Benchmark reports Benchmark reports MMWR, state reports MMWR, state reportswww.cdc.gov/mPINC

22. Increase physical activity ● Key strategies PE in schools PE in schools Physical activity regulations Physical activity regulations in child care Safe Routes to School Safe Routes to School Incentives Incentives Access to places for pa with informational outreach Access to places for pa with informational outreach Social supports for change Social supports for change Comprehensive community campaigns Comprehensive community campaigns

23. Healthy People 2010 Physical Activity Objective 22-2 Increase the proportion of adults who engage in: –Moderate physical activity for at least 30 minutes per day 5 or more days per week; or –Vigorous physical activity for at least 20 minutes per day 3 or more days per week Increase the proportion of adults who engage in: –Moderate physical activity for at least 30 minutes per day 5 or more days per week; or –Vigorous physical activity for at least 20 minutes per day 3 or more days per week http://www.healthypeople.gov/

24. 2008 Physical Activity Guidelines for Americans – Adult Guidelines Aerobic Physical Activity Guidelines –≥ 150 minutes of moderate- intensity aerobic activity per week; or –≥ 75 minutes of vigorous- intensity aerobic activity per week; or –Equivalent combination of moderate- and vigorous- intensity physical activity http://www.health.gov/paguidelines

25. Comparison of age-adjusted prevalence estimates from the 2008 Physical Activity Guidelines and the Healthy People 2010 objectives, BRFSS - 2007 15.7%

26. Difference in Estimates Reasons for shift  Removal of frequency or duration requirement  Combination of minutes Breakdown of shifts  15.7% difference in prevalence estimates ► 5.4% - removal of frequency or duration requirement ► 4.3% - combination of moderate- and vigorous- intensity minutes ► 6.0% - for either reason

27. Trends: 2008 Guidelines and Healthy People 2010 Criteria 17.2%16.7%15.7%

28. Sodium and Hypertension

29. Burden of Heart Disease and Stroke Heart disease is the leading cause of death in the United States Stroke is the third leading cause of death in the United States In 2009, –~ 785,000 people will have a new coronary attack –~ 610,000 people will have a new stroke Marked disparities persist Source: Lloyd-Jones D, et al. Heart Disease and Stroke Statistics—2009 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21-e181.

30. Salt and High Blood Pressure Generally, higher consumption of salt means higher blood pressure Sodium intake is related to levels of blood pressure and the prevalence of hypertension across populations Within the span of a few weeks, most people experience a reduction in blood pressure when salt intake is reduced

31. Salt and High Blood Pressure The lower your blood pressure, the lower your risk of heart disease even if you do not have hypertension. Decreasing sodium intake from 3,500 mg/day to 1,500 mg/day could lead to a 30% decrease in hypertension prevalence.* *Source: Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol 2007 May 1;23(6):437-43.

32. Lower Pressure = Lower Risk Data Source: Lewington, Lancet 2002;360:1903-13, Using population risk estimates for ages 50-59 years old. Lower BP, Lower Risk Higher BP, Higher Risk Risk of ISD Death Systolic Blood Pressure

33. Sodium Recommendation 2005 Dietary Guideline recommendation: <2,300 mg/day “Specific Populations” recommended to consume ≤1,500 mg/day –Hypertensive –Black –Middle or Older American Average intake: 3,466 mg/day

34. Too much sodium The Loop. Crispy Chicken Salad w/ Lite Ranch –722 kcal/ 1,527 mg of sodium Panera Low-fat Chicken Noodle Soup –160 kcal/ 1,670 mg of sodium Little Caesars Slice of Pepperoni Pizza –280 kcal/ 520 mg of sodium Progresso Microwave Bowl of Minestrone Soup - 180 kcal/ 1,860 mg of sodium

35. Is it Salt or Sodium? Sodium Chloride is the chemical name for salt –90% of the sodium we consume is in the form of salt –Other food additives contain sodium –Some amount of sodium is naturally occurring in foods

36. Relative Amounts of Dietary Sodium in the American Diet Source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.

37. International Perspective Elevated blood pressure and high sodium intake are global issues Sodium content of foods differ by country Several countries have implemented strategies to reduce sodium intake

38. U.K. sodium/serving = 160mgU.S. sodium/serving = 210mg U.K. sodium/serving = 120mgU.S. sodium/serving = 220mg Similar Foods Have Less Sodium in U.K. Slide borrowed from Dr. Angell, NYC

39. *Slide borrowed from Dr. Angell, NYC Chicken Sandwich 830mg sodium (143g) Chicken Sandwich 640mg sodium (178g) U.S.U.K. 190mg more sodium per serving Sodium Content Varies Widely Internationally

40. World Health Organization, 2007 Interventions should focus on three main pillars: product reformulation (the main focus should be on the highest reduction possible in the salt content of commercialized foods and meals) consumer (including improving nutritional education about the deleterious effects of excessive salt consumption on how to read the labels and choose healthier foods) the environment (by building an environment where choosing the healthiest foods is the easiest and most affordable option to population groups at all socioeconomic levels).

41. AMA Policy Recommendations Minimum of 50% reduction of sodium in processed and restaurant foods over the next decade Removal by the FDA of the GRAS status of sodium Better sodium product labeling; warnings for foods high in sodium Exploration by FDA of all options to reduce sodium National consumer education initiative on sodium Source: Report 10 of the Council on Science and Public Health (A-06) Promotion of Healthy Lifestyles I: Reducing the Population Burden of Cardiovascular Disease by Reducing Sodium Intake

42. Industry Response Industry has voluntarily taken some action to reduce sodium –Several companies have salt workgroups –Increase in introduction of lower sodium foods –Some companies, such as Burger King, have made commitments

43. CDC Activities to Lower Sodium Consumption Ongoing Sodium Workgroup IOM study –Aug 2008-May 2010 –Focus on means to reduce intake (regulation, labeling, education, incentives, health professional role, industry codes of conduct) –Tactics to address manufacturers, restaurants, grocers, schools, institutions) –Include implications for iodine deficiency Comment/testimony on sodium as GRAS, labeling Guidance to state DHDSP programs Consultation with WHO and others

44. Thank you! Acknowledgments: William Dietz Janelle Peralez Heidi Blanck Janet Fulton Rosanne Farris www.cdc.gov/nccd/dnpa