Michael Jacobson is the Center for Science in the Public Interest's co-founder and senior scientist, and the author of "Salt: The Forgotten Killer." Peter Lurie is CSPI's president.
Salt, those innocent-looking white crystals that can be found in almost every food, may be the single most harmful ingredient in our diet. Hundreds of studies conducted over the past 75 years have shown that diets high in salt boost blood pressure, which in turn boosts the risk of stroke, heart attack and kidney disease.
Thanks to salty diets, the grim reaper takes as many as 100,000 lives per year. Annual medical costs run as high as $20 billion. Major health authorities — from the American Heart Association and American Medical Association to the Centers for Disease Control and Prevention and World Health Organization — have long urged people to slash their sodium intake, 90% of which comes from salt, by around half.
Nevertheless, years of headlines like "Reducing salt to very low levels may be dangerous" and "A low-salt diet may be bad for the heart" have created enormous confusion among consumers and may have delayed efforts by some companies to cut the salt. Many news stories cite results from PURE, an observational study on roughly 100,000 participants from China, India and 15 other countries. PURE reported a higher risk of dying in those who ate lower amounts of salt.
Last month, the National Academy of Medicine cut through the confusion with a new report that painstakingly reviews the rich scientific literature on sodium and health. NAM's bottom-line recommendation mirrored numerous previous major reports: Reduce sodium intake from the current average of 4,000 milligrams per day for adults to 2,300 mg, with lower limits for children under 13.
Furthermore, the NAM committee, which relied largely on randomized controlled trials — the gold standard of scientific evidence — concluded that cutting back on salt lowers both blood pressure and the risk of cardiovascular disease. It rejected studies like PURE because they had flawed estimates of sodium intakes and had a "high risk of bias."
It is time to act on the abundant evidence that salty diets are harmful. For some companies, that would mean a continuation of what they started doing several years ago. Companies as diverse as General Mills, Mars, Walmart, Unilever, McDonald's and Nestlé reduced sodium levels across their product line or in popular products by 10 to 30%. In some cases they simply cut salt levels. In other cases they replaced missing flavor with seasonings or more vegetables. And some companies have replaced one-third to one-half of the ordinary salt in some foods with potassium salt.
However, most companies have moved slowly, if at all. And at least half a dozen major trade associations, including SNAC International, American Bakers Association, American Frozen Food Institute, International Dairy Foods Association, North American Meat Institute and National Restaurant Association, are still trying to thwart FDA action. The food industry's lethargy on, or active opposition to, sodium reduction demonstrates the urgent need for government actions. For starters, the government should finish what it already started:
Finalize the FDA's salt targets: In 2016, the Food and Drug Administration proposed a voluntary approach for reducing sodium levels in packaged and restaurant foods, which supply three-fourths of the sodium we consume. The agency developed two sets of "target" sodium levels for more than 150 food categories. Two-year targets were intended to cut sodium consumption modestly. Targets meant to reduce daily intakes more dramatically to the recommended 2,300 mg of sodium were pegged for 10 years out, giving companies plenty of time to reformulate products and consumers' palates time to adjust to less-salty foods. However, Congress intervened and barred the FDA from working on the 10-year targets until the NAM issued its report. With that report now in hand and recommended intakes for adults left unchanged, the FDA should move swiftly to finalize both the two- and 10-year targets.
Reduce sodium in school meals: In 2012, the USDA established a three-step schedule for protecting children from salty school meals. Almost all schools met the lenient 2014 targets. But last December, USDA granted industry's wish when it delayed the 2017 requirements until 2024 and eliminated the 2022 targets completely. That move may have pleased pizza, soup and other suppliers, but it increased the chances that children will suffer strokes and heart attacks several decades from now.
The U.S. should learn from other countries' sodium-reduction programs. In the mid-2000s, the British government began an initiative that included setting voluntary sodium targets. Two keys to success were pressuring companies to meet those targets and aggressively encouraging consumers to choose less salty products. That program reduced salt consumption by about 15% — an achievement accompanied by a significant decrease in deaths due to cardiovascular disease.
South Africa, Turkey, Chile and others have set limits on sodium in key foods, barred excessively salty foods from school meals or required warning notices on high-sodium foods. Two American cities — New York and Philadelphia — have taken another approach by requiring chain restaurants to put a salt-shaker icon on their menus next to meals that provide more than a day's worth of sodium. That's something that any health-oriented state or local government could do, too.
Now that the National Academy of Medicine's blue-ribbon panel has solidified the foundation for policies that will reduce needless suffering from cardiovascular disease, America and companies across the industry need to follow those sodium-reducing examples. Let's seize the opportunity.