1. Sodium Overview CDC Heart Disease and Stroke Prevention 2010 Grantee Meeting Janelle Peralez Gunn Division for Heart Disease and Stroke Prevention Centers for Disease Control and Prevention September 15, 2010

2. Presentation Overview Brief Overview – Sodium a public health imperative Current Action – US and globally Scope of Opportunity

3. 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 Is it Salt or Sodium?

4. Sodium Reduction: A Public Health Imperative High blood pressure is a primary risk factor for heart disease and stroke, the first and third leading causes of death in the United States. Sodium reduction can have a significant impact on reducing disparities and cardiovascular disease events. Sodium reduction is a population-based strategy to help reduce the prevalence of high blood pressure and improve control.

5. Salt and High Blood Pressure Increased sodium in the diet → increased blood pressure → increased risk for heart attack and stroke. A population shift in SBP of 12-13 points could reduce: heart attacks by 21% strokes by 37% total CVD deaths 25% Even people with blood pressure in the optimal range benefit from sodium reduction and reduced risk for heart attack and stroke.

6. Estimated effects on prevalence of hypertension and its related costs if sodium intake was reduced in U.S. Adults Reducing average population intake to 2300 mg per day (current recommended maximum) may… reduce cases of hypertension by 11 million save $18 billion health care dollars gain 312,000 Quality Adjusted Life Years (QALYs) Even fewer cases of hypertension and more dollars saved if intake was reduced to 1500 mg per day (recommended maximum level for “specific population”) American Journal of Health Promotion. 2009;24:49-57.

7. A few are meeting the target daily intake: Scope Met the 2005 DGA Recommendation All Adults9.6% <2,300 mg/day Recommended18.8% ≤ 1,500 mg/day Recommended5.5% With hypertension5.9% Aged 40 years and older without hypertension 5.1% Black, aged 20–39 years5.7% Source: Source: Centers for Disease Control and Prevention. Sodium Intake Among Adults --- United States, 2005−2006. MMWR. 2010; 59(24);746-749.

8. Sources of Dietary Sodium RankFood Group 1Yeast breads 2Chicken and chicken mixed dishes 3Pizza 4Pasta and pasta dishes 5Cold cuts 6Condiments 7Mexican mixed dishes 8Sausage, franks, bacon, and ribs 9Regular cheese 10Grain-based desserts Source: Sources of Sodium Among the US Population, 2005-06. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute.

9. IOM Strategies to Reduce Sodium Intake  In 2008, CDC received congressional language to support an IOM study  Other sponsors: FDA, ODPHP, NHLBI  Study would examine and make recommendations about various means to reduce dietary sodium intake  Start date : October 2008  Report released on April 2010

10. IOM Recommendations  Primary Strategy  FDA should expeditiously initiate a process to set mandatory national standards for the sodium content of foods Applies to processed and restaurant foods Utilize generally recognized as safe (GRAS) status of salt  Interim Strategy  Food industry should voluntarily act to reduce the sodium content of foods in advance of the implementation of mandatory standards IOM Strategies to Reduce Sodium Intake

11.  Supporting Strategies  Government agencies, public health organizations, consumer organizations, and food industry should carry out activities to support the reduction of sodium in food supply Revise daily value for sodium Re-evaluate sodium claims/disclosures on foods Label foods sold to restaurants Food procurement standards Innovative restaurant initiatives IOM Strategies to Reduce Sodium Intake IOM Recommendations

12.  Supporting Strategies Continued  Government agencies, public health organizations, consumer organizations, health professionals, the health insurance industry, food industry, and public-private partnerships should conduct augmenting activities to support consumers in reducing sodium intake HHS create nationwide campaign to reduce sodium intake Continuation and expansion of existing efforts  Federal agencies should ensure and enhance monitoring and surveillance relative to sodium intake measurement, salt taste preference, and sodium content of foods, and should ensure sustained and timely release of data in user-friendly formats IOM Strategies to Reduce Sodium Intake

13. National CDC – Convenes experts in science, policy, evaluation, communications, and program implementation. – Works with other federal agencies to enhance and expand sodium related surveillance – Expands knowledge/contribute to science base of sodium and health – Supports state and local initiatives – Educate the public – Work with industry

14. National FDA – GRAS status of sodium – Nutrition Facts Panel – Front of Package Labeling – Developing menu labeling regulations USDA/ First Lady’s Initiative Lets Move – Environmental Food Atlas – Healthier US Schools Challenge

15. National Strong National Support – Organizational sodium reduction policies – Support for the NSRI – Several industry groups have made significant public announcements

16. State and Local Activity ARRA Funded Communities Salt Reduction Task Force Menu labeling/ labeling School foods projects

17. Global Sodium Reduction Not just a public health issue for the United States. – HBP is the primary contributor globally to heart disease and stroke. Reformulation of products has occurred in other countries. – Sodium content of identical products in other countries can be significantly lower.

18. CDC Participation in Global Activities WHO: – CDC participated in the WHO forum and technical meeting on sodium and the follow-up meeting on iodine PAHO: – Partners Forum – PAHO Expert Group on Sodium Reduction in the Americas China: – Collaboration with China CDC, George Institute (Beijing and Sydney) and NHLBI on a sodium reduction/ hypertension prevention and control initiative

19. Why Action is Needed at State and Local Levels Strong scientific evidence supports the need for population- wide sodium reduction due to the harmful impact of sodium on blood pressure. Individual behavior change is difficult. The most effective population approach to reducing sodium intake is to reduce the sodium content of restaurant and processed foods, which contribute the vast majority of sodium in the food supply. All current approaches are voluntary.

20. Scope of Opportunity

21. Healthier Food Environment = Healthier Population Changing the food environment gives consumers a broader range of healthful foods from which to choose. Policy and environmental strategies are effective at the state and local level

22. Potential Scope: State and Local Procurement Policies State and local governments can be large purchasers Can impact a variety of settings Model healthier eating Potentially drive reformulation Menu Labeling Inform consumers regarding sodium content May drive some product reformulation More useful with a reference point Innovative Restaurant and Grocery Store Initiatives potential range of strategies is for informational purposes only

23. Potential Scope: State and Local Health Communications Campaign Can be supported by policy and vice versa Can take many forms Tools can aid consumers Venue Based Policy Considers all possibilities for a particular venue potential range of strategies is for informational purposes only

24. Potential Scope: State and Local Tax incentives or Credits Tax credits could be supplied based on volume of lower- sodium foods sold May not result in broad reduction in sodium intake across the population Salt Tax Would be inelastic and may not impact purchasing Would also tax foods that may be otherwise nutritious potential range of strategies is for informational purposes only

25. Potential Scope: State and Local Cap and Trade Traditionally been applied for reducing air pollutants May not result in broad reduction in sodium intake across the population Performance-based Regulation Required to meet government-established targets Retailers have flexibility to adapt potential range of strategies is for informational purposes only

26. For More Information Janelle Peralez Gunn jperalez@cdc.gov Nicole Blair nblair@cdc.gov The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the CDC.