"The most recently daily recommendation of 2,300 milligrams of sodium or lower is not being followed," says Dr Angell. So, who's to think that people will follow new recommendations of intake of no more than 1,500 milligrams?
How much is it about individual choice? Clearly, sodium intake is much higher in the U.S. than recommended, she says. What can industry do?
Many clinicians spend enormous amounts of time supporting high-risk populations, but what can be done about the overall population?
She asks, "How do we support choices?" Then she shows an example of two billboard signs placed next to each other, ironically: one advertising blood pressure readings, one advertising fast food.
Lewington et al showed that there is a linear increase of hypertension and cardiovascular disease. And the DASH study (Sacks, NEJM. 2001) shows clearly that by reducing sodium intake, we can make an impact on blood pressure.
One single intervention, salt reduction, says Angell, can save more lives than reducing smoking, statin therapy, and weight loss.
Where does salt come from? About 77 percent comes from processed and restaurant foods, which explains why it becomes so difficult for people to reduce it in their diets.
Even if one reduces caloric intake, people still end up with too much sodium because of the density of sodium in foods at home and when eating out.
"Sodium reduction initiatives are not new," says Angell, noting that scientists have been trying regulate salt intake since 1983.
The UK Salt Campaign had the goal of reducing salt intake by one third from 2005 to 2010 with gradual reductions throughout the food industry. The U.S. strategy is based on the UK successes with targeted goals of reductions in sodium in processed foods.
Decreasing sodium in foods by 25 percent over five years will reduce total sodium intake in population by 20 percent.
The National Salt Reduction Intake initiative includes creation of packaged and restaurant food databases, more than 100 meetings with industry, and targeted achievements.
They just finished a baseline evaluation in populations of New York City and will report again in 2014.
The message that Angell is delivering is that reducing sodium in foods doesn't mean that processed food will not sell as well. She then showed us a broad list of all the categories of foods where sodium is used. By setting targets on different products where reducing sodium is most feasible, industry can "shift the curve" of the food supply so that products overall consumed contain less sodium.
For example, they created 25 restaurant food categories. They analyzed for top 50 quick-service restaurants selling common items such as hamburgers, chicken sandwiches, etc. They set targets for key food categories to reduce sodium by amounts feasible by certain dates.
On April 26th, NSRI announced first company commitments including Unilever, Boar's Head, Kraft, Heinz, Starbucks, Subway, LiDestri, and Mars. They also got very good press. Angell praised these companies for showing leadership in improving the health of their customers.
Then, Angell began to explain next steps of NSRI to continue collaborations with national health organizations and the opportunities of having a strong, national database with mandated industry-reported nutrition information.
She says the NSRI has a planned announcement this fall of more collaboration with chief food companies.
To conclude, she says that national sodium reduction is crucial, that reduction initiatives are happening, and that collection of data (e.g. urinalysis) is feasible.
In the Q and A section there were plenty of questions about how industry responded to NSRI.
It has been a challenge for some companies, Angell notes (specifically companies like Burger King and McDonald's), so more education is necessary to increase the pressure on certain companies.
There was also a question of just how important salt intake would be on the population, since some people have no problems with sodium intake. Do we need more randomized, controlled trials.
Angel handled these questions very well, stating that "if reducing sodium in food doesn't make a difference in flavor, then no one really loses" and there is great evidence showing that the "majority of the population" will benefit.
She also answered my question about whether or not there were any salt substitutes that stood out to her as possible opportunities in the future. She answered that unlike with artificial sweeteners, there has been little development of artificial salt substitutes.
However, she adds that food manufacturers are beginning to discover ingenious ways of using salt crystals to give the impression of saltiness without over-concentrating the amount of sodium in processed foods.
When I asked about what reducing iodizdd salt intake would do to levels of iodine in the population, she cleared up some confusion: the message should not be to discontinue use of normal amounts of table salt, which supplies important iodine.
The mesage of NSRI is to reduce amount of sodium in processed foods ("processed foods don't use iodized salt") to reduce overall sodium intake in the diet.
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