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October 13, 2021

Reducing Sodium Intake in the US: Healthier Lives, Healthier Future

Author Affiliations
  • 1Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, Maryland
  • 2Food and Drug Administration, Silver Spring, Maryland
JAMA. Published online October 13, 2021. doi:10.1001/jama.2021.18611

Good nutrition is a critical foundation for health and well-being. However, many of the leading causes of morbidity and mortality in the US are linked to poor dietary habits, including diseases like cardiovascular disease, obesity, diabetes, and certain forms of cancer.1,2 The morbidity and mortality associated with the COVID-19 pandemic have been exacerbated by the underlying epidemic of poor nutrition.

Because improving dietary practices provides one of the greatest opportunities for improving public health, it is vital to make concerted efforts to help people in the US make healthier food choices and live healthier lives. Arguably, one of the most important steps involves reducing excess sodium intake, which is projected to have substantial benefits in reducing related morbidity, mortality, and health care costs; some projections suggest that reducing sodium intake will improve health outcomes for hundreds of thousands of individuals and could save billions in health care–related spending over the coming years.3 That is why the US Food and Drug Administration (FDA) has announced final guidance for industry on voluntary short-term sodium reduction targets.4 This is a critical first step in ongoing efforts to reduce sodium across the food supply.

Why Is Reducing Sodium Important?

Current average sodium intakes for US residents aged 1 year and older are about 3400 mg/d, approximately 50% more than the Chronic Disease Risk Reduction (CDRR) recommended limit of 2300 mg/d for adults and children 14 years and older, established by the National Academies of Sciences, Engineering, and Medicine.2,5 Most sodium intake in the US is from sodium chloride, which is composed of 40% sodium and 60% chloride (commonly known as “salt”) and ubiquitous in the food supply. More than 90% of people in the US exceed recommended limits across almost all age groups,2 as shown in the Figure. Even the youngest individuals consume excess sodium; more than 95% of children aged 2 to 13 years old exceed recommended limits for their age groups, the consequences of which could track into adulthood and influence later health outcomes.2 Mean population sodium intake can mask even more concerning intake levels among different groups. For instance, mean sodium intake for men aged 19 to 30 years is 4274 mg/d, almost twice the recommended limit.2

Figure.  Mean Sodium Intake in the US by Age, Relative to Recommended Limits
Mean Sodium Intake in the US by Age, Relative to Recommended Limits

Sources: What We Eat in America, National Health and Nutrition Examination Survey (NHANES) 2013-2016; and Dietary Guidelines for Americans, 2020-2025.2

These high sodium intake levels are greatly concerning because excess sodium is a key contributor to high rates of hypertension and cardiovascular disease.5 Hypertension is epidemic in the US and affects more than an estimated 100 million adults, approximately half the adult population. Hypertension is associated with an increased risk for an array of negative health outcomes, including heart disease and stroke, vision impairment, cognitive decline, sexual dysfunction, complications in pregnancy, and kidney disease.6

These sequelae from hypertension are costly in human and economic terms. In 2019, more than 800 000 people died from heart disease and stroke, the first and fifth leading causes of mortality in the US, respectively.1 Furthermore, stroke was the third leading cause of death for women and the leading cause of disability in the US.1,6 The medical costs for hypertension alone are estimated at $131 to $198 billion per year and are projected to increase to more than $220 billion by 2035.6

The prevalence of hypertension varies among racial and ethnic groups. An estimated 57.1% of non-Hispanic Black individuals in the US have hypertension vs 43.6% of non-Hispanic White individuals.7 This difference is greater among women; an estimated 56.7% of non-Hispanic Black women have hypertension, compared with 36.7% of non-Hispanic White women.7

Why Are Federal Approaches to Sodium Reduction Needed?

More than 70% of sodium intake in the US is from packaged food and food prepared away from home, including restaurants and food service operations; just 11% of sodium intake is from sodium added at the table or in cooking at home and almost all of the rest is inherent in foods.8 Even though many people in the US are aiming to reduce their sodium intake (in line with federal recommendations),2 sodium levels in the current US food supply make it extremely challenging to do so.

Reducing sodium content in processed and prepared foods from current levels, while maintaining consumer acceptance, is technically feasible. For example, some multinational food corporations sell essentially the same product, except with markedly different sodium levels, in different countries. Even in the US there is a wide range of sodium levels among top-selling brands within food categories such as white bread, which can range from 300 to 700 mg of sodium per 100 g of bread. Although reducing sodium content in foods is possible, reductions must be carefully considered: sodium has many important properties from a food technology perspective, providing flavor, but also development of texture, fermentation, color development, and antimicrobial properties. Reformulation to reduce sodium content in foods can be a complex process and in many cases is not as straightforward as simply adding less sodium to foods. In addition, those reductions need to be acceptable to the population, so they continue to consume lower-sodium options. Sodium is an adaptive taste; individuals’ palates can adjust to lower sodium in foods, but the change needs to be broad and gradual.

Nearly 100 other countries have taken action to reduce sodium at the population level, almost 60 of which have acted to reduce sodium in the food supply and the majority of those have implemented voluntary sodium reduction targets.9 For example, the UK has published 5 iterations of voluntary sodium reduction targets for food categories starting in 2006 and most recently in 2020.10

The Importance of Ongoing Sodium Reduction

FDA has issued final short-term (2.5-year) voluntary sodium reduction targets for industry across approximately 160 categories of food.4 The targets, which were issued first as draft in 2016, are intended to result in reductions of average sodium intake to 3000 mg/d. Although average intakes would still be above the recommended limit, even modest improvements made across the population could produce large public health benefits, resulting in reduced morbidity and mortality as well as cost savings. Going forward, FDA will monitor progress, engage with stakeholders such as the food industry and consumer and public health groups, and issue revised targets to further encourage sodium reductions through an iterative process. This action supports initiatives across the federal government to encourage healthier foods for all, to improve nutrition and reduce risk for hypertension and cardiovascular disease.

This action by the FDA may represent one of the most important public health interventions in a generation. As the COVID-19 pandemic has revealed, the importance of population approaches to improve health and make the population healthier and thus more resilient cannot be overestimated. The FDA is one agency in a complex nutrition ecosystem supporting this approach to reduce sodium intake across the US population. Many in industry have already begun the process of reformulation to reduce sodium in their offerings. Health care professionals can have an important role in talking with their patients and clients about healthy eating routines. From a federal perspective, the US Department of Agriculture is focusing on school meal standards to provide healthy and tasty options that are lower in sodium; the Centers for Disease Control and Prevention has an array of initiatives to support lower sodium consumption; and local health systems, hospitals, and community organizations have programs in place to support not only sodium reduction but to help people achieve healthier eating patterns. Now FDA is providing benchmarks all in industry can aim for, facilitating and amplifying others’ efforts. These initiatives acting in concert to reduce average sodium intake are anticipated to have a profound effect on the health and well-being of the nation—supporting all in living healthier lives.

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Article Information

Corresponding Author: Robin A. McKinnon, PhD, Center for Food Safety and Applied Nutrition, Food and Drug Administration, 5001 Campus Dr, College Park, MD 20740 (robin.mckinnon@fda.hhs.gov).

Published Online: October 13, 2021. doi:10.1001/jama.2021.18611

Conflict of Interest Disclosures: None reported.

References
1.
Kochanek  KD, Xu  JQ, Arias  E. Mortality in the United States. CDC National Center for Health Statistics; 2019. NCHS Data Brief No. 395.
2.
USDA and DHHS. Dietary Guidelines for Americans, 2020-2025. Accessed September 30, 2021. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf
3.
Pearson-Stuttard  J, Kypridemos  C, Collins  B,  et al.  Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation.   PLoS Med. 2018;15(4):e1002551. doi:10.1371/journal.pmed.1002551PubMedGoogle Scholar
4.
FDA. Voluntary Sodium Reduction Goals: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods: Guidance for Industry. 2021. https://www.fda.gov/sodiumreduction
5.
National Academies of Sciences, Engineering, and Medicine.  Dietary Reference Intakes for Sodium and Potassium. National Academies Press; 2019.
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 The Surgeon General’s Call to Action to Control Hypertension. Office of the Surgeon General; 2020.
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Ostchega  YFC, Nwankwo  T, Nguyen  T. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018. National Center for Health Statistics; 2020. NCHS Data Brief No. 364.
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Harnack  LJ, Cogswell  ME, Shikany  JM,  et al.  Sources of sodium in US adults from 3 geographic regions.   Circulation. 2017;135(19):1775-1783. PubMedGoogle ScholarCrossref
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Santos  JA, Tekle  D, Rosewarne  E,  et al.  A systematic review of salt reduction initiatives around the world.   Adv Nutr. 2021;nmab008. doi:10.1093/advances/nmab008PubMedGoogle Scholar
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