Hypertension affects one-third of American adults; around 67 million people. High blood pressure is the leading risk factor for heart disease and stroke – the first and fourth most common causes of death in the US.
Hypertension is not the inevitable by-product of aging; ‘chronic sodium intoxication’ is a significant contributor, i.e. the large amount of salt in American diets. Estimated daily average sodium intake is 3,300 milligrams, far exceeding the recommended intake of <2,300mg/day. Yet reducing salt intake to this level could prevent 11 million cases of hypertension and save $18 billion in healthcare costs each year.
Around 75% of salt intake comes from processed and restaurants foods, including ‘healthy’ products where we don’t expect it. It’s difficult to reduce salt intake when two slices of bread can contain 400mg of sodium and eight ounces of V8 vegetable juice contain well over 500mg. Education and medical interventions are important, but widespread improvements mean convincing the food industry to remove large amounts of salt from its products.
The US started down this path in 2008, when the New York City Department of Health created the National Sodium Reduction Initiative (NSRI). The NSRI is a partnership of local and state health departments and health organizations that aims to reduce sodium intake by 20 percent over 5 years. It sets voluntary targets for salt levels in 62 categories of packaged food and 25 categories of restaurant foods. Participating companies meet these targets gradually over time.
In 2013, the NSRI made the promising announcement that 21 companies had met salt reduction targets for 2012. But independent research finds that reformulation efforts have been slow and inconsistent. The sodium content of menu items from eight leading fast-food chains actually increased by 23.4% between 1997 and 2010.
One of the NSRI’s biggest problems is limited participation. Only a few large fast-food restaurants have joined the program, and a number of large manufacturers continue to ignore it.
Examples of NSRI participants
Examples of non-participants
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The NSRI is also a relatively weak salt reduction initiative compared to similar programs internationally. It is modeled off an influential salt reduction strategy created by the UK Food Standards Authority, but the UK’s program is much more comprehensive – including consumer education campaigns, interpretive labeling and comprehensive monitoring in addition to reformulation targets.
In response to the slow rate of progress, the FDA is developing a nation-wide plan for gradually reducing salt in foods sold in stores and restaurants. Yet it faces challenges from a powerful food industry opposed to any kind of government action. Here I present 6 recommendations for an effective salt reduction program based on voluntary industry action, but allowing for more coercive interventions if the food industry fails to take action.
A comprehensive suite of salt reduction targets
Voluntary salt reduction targets should encompass a large number of product categories and apply to food manufacturers and retailers, including supermarkets and fast-food restaurants. The FDA should set maximum salt ‘caps’ for each product category, preventing companies from gaming the system by developing reduced-salt foods that ‘off set’ existing high-salt products.
Improved nutrition labeling
The FDA recently announced improvements to the nutrition facts label, which presents information on the sodium content of packaged foods. An improved facts label is good, but interpretive labeling is better. The UK program encourages companies to use ‘traffic light’ labeling, with a red light flagging foods that are high in fat, salt and sugar. Similar initiatives could be used in large restaurant chains, supplementing the Affordable Care Act’s provisions on menu-board labeling.
A key component of effective salt reduction programs is awareness campaigns informing consumers about the importance of reducing salt consumption. Strong, consistent messaging from public health authorities can prompt consumers to choose low-salt products, in turn providing companies with an incentive for reformulation.
Carrots and sticks
Salt plays a critical role in food taste, safety and consistency, providing economic disincentives to sodium reduction. Companies need encouragement to join salt reduction programs and deterrents to prevent ‘bad apples’ from free-riding on the efforts of market leaders. ‘Carrots’ could include tax breaks or positive publicity, while ‘sticks’ include ‘naming and shaming,’ fines, or expulsion from voluntary programs.
Industry must be held accountable for its promises through monitoring and evaluation. Monitoring could include food databanks, 24-hour urinary sodium analysis, and research on changes in consumer behavior. Public reporting on compliance enhances the transparency and accountability of voluntary initiatives; so too does independent evaluation of the scheme’s overall success.
New regulatory approaches
An effective salt reduction program requires clever regulatory strategizing. Mandatory federal standards on sodium content are one option, but a national program could deploy forms of governance like ‘responsive regulation,’ which gradually escalate from voluntary action to more intrusive interventions.
Responsive regulation modeled as a pyramid. Adapted from Ian Ayres and John Braithwaite, Responsive Regulation: Transcending the Deregulation Debate
A ‘responsive’ regulatory approach could begin with voluntary action, but build in mandatory components through ‘legislative scaffolds’ if softer measures fail. An incremental approach allows time for consumers’ palates to adjust to the taste of less salty foods, while the threat of mandatory standards creates a powerful incentive to make voluntary programs work. This threat could be expressed as specific, time-tabled interventions to be introduced incrementally in response to industry inaction: Phase 1: The FDA creates voluntary reformulation targets combined with maximum salt caps for new products on the market. The FDA invites large food manufacturers and retailers to join the program and relies primarily upon incentives for compliance. Phase 2: The FDA mandates participation by large companies, as well as smaller companies that produce high-salt products. Warning labels would apply to all new products exceeding salt caps, and companies that failed to report on progress would be hit with financial penalties. Phase 3: The FDA introduces more stringent regulatory requirements, e.g., setting standards for the safe level of salt use in food. Reformulation targets and salt caps would become mandatory, and poor performers would be subject to enforceable undertakings that commit companies to specific, time-bound actions, with significant fines for non-compliance.
We have a window of opportunity for strong government leadership in sodium reduction, but the FDA will have to play smart if it wants to get tough with Big Food. The FDA could use ‘legislative scaffolds’ to create a salt reduction program that accelerates improvements in the food supply while also navigating industry resistance to public health regulation. Critical to this strategy is a credible threat of government intervention if industry fails to make meaningful, voluntary progress in sodium reduction.
I developed the concept of legislative scaffolding together with Roger Magnusson, and we apply this idea to Australia’s salt reduction program in an upcoming publication: Roger Magnusson and Belinda Reeve, ‘Steering private regulation? A new strategy for reducing population salt intake in Australia,’ (2014) Sydney Law Review (forthcoming).
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.