Thursday, January 21, 2010

New England (Journal of Medicine) and New York City Agree on Salt

Big news hit headlines this week as the result of a study published yesterday in the New England Journal of Medicine. Big news, yes. Surprising? Not really.

The study, available for personal use on the NEJM website, found that, "Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target." There is no doubt that excessive salt in one's diet can lead to a host of medical problems. The study also highlighted the drastic cost savings of $10-$24 BILLION dollars annually, which are sure to gain attention in this economy.

I will admit that I have not yet read the full article, but I plan to as it fits right into what I'm reading about in my current research class. The big thing that sticks out to me is the "modest reduction" of salt intake. It's nothing drastic and certainly doable; this small reduction adds up to big benefits over the course of a lifetime. An editorial in the same issue of the NEJM by Appel and Anderson does mention that this still would not place people within the recommended zone for sodium intake:

"The findings by Bibbins-Domingo and colleagues support a population-wide reduction in salt intake, but is such a reduction achievable? To answer this question, one first needs to understand currentlevels of intake. Mean salt intake in the United States is extremely high in most age groups, including children, and is well above the current daily recommended upper limit of 5.8 g (2300 mg of sodium) (Figure 1).6 In several age groups, reducing salt intake by 3 g per day would not achieve the recommended upper limit of intake for U.S. adults, much less the goal of 3.8 g (1500 mg of sodium) per day, which applies to 69% of U.S. adults.7"

Interestingly, earlier this month New York City announced that it was leading an initiative to assist with companies voluntarily reducing salt levels in both packaged foods and restaurant foods by 25% over five years. Although not finalized yet, similar programs have had success in other countries, notably the United Kingdom. Appel and Anderson also mention similar programs in Ireland and Finland.

New York City seems to be spearheading quite the effort for improving overall health! It first eliminated trans fats from all city restaurants and also implemented a high tax on cigarettes in recent years. They even require calorie information on chain-restaurant menus! Their recent salt effort to reduce is a substantial effort that has gained support from numerous organizations, a full list of which can be found here. The newly published study in the NEJM serves as further evidence to the importance of their initiative.

Also of note is how sodium reduction fits into both Healthy People 2010 and Healthy People 2020, both of which are major health initiatives. For Healthy People 2010, focus area 19-10 was aimed at decreasing total sodium intake. The following was found:

"For the objective aimed at decreasing total sodium intake (19-10), 1999–2000 data suggested that average intake by persons 2 years of age and older remains well above the Dietary Guidelines' recommendation to consume less than 2,300 milligrams daily.2 Most of Americans' sodium intake comes from salt added by manufacturers to processed and prepackaged foods rather than from the natural salt content of foods or salt shakers used at the table or in cooking.2 With respect to objectives 19-8, 19-9, and 19-10, consumers need access to information about the fat (including saturated fat and trans fat) and sodium content of the foods they eat, both at home and away from home."

Based on this information for Healthy People 2020, objective NWS HP2020-10 is to "reduce consumption of sodium in the population aged 2 years and older." It is a retained, yet modified, version of objective 19-10 from Healthy People 2010.

It's clear that with the original objective, not enough was being done to help accomplish the goal of decreasing total sodium intake. I believe that initiatives such as the one in New York City (aimed at packaged food and restaurant foods, which data found is where most Americans get their sodium) are taking a huge step in the right direction. Access to information is not enough to change behavior. By actually changing the sodium content of foods, we get somewhere. Most people will not want or be able to eat all fresh, natural foods due to convenience or cost, so changing processed foods that the majority of the population consumes makes total sense. The editorial mentioned above notes that:

"In broad terms, there are two complementary strategies that could be used to lower salt intake: a public health approach, in which food manufacturers reduce levels of salt in processed and prepared foods, and an individual approach, which relies on each person to select and prepare foods with little or no salt. Given that approximately 75% of dietary salt comes from processed foods, the individual approach is probably impractical."

I couldn't agree more!

It will be interesting to follow this over the next few months and years. Can people change on a large scale? Will companies comply? If major medical organizations and large corporations can work together, everyone can benefit!

As Appel and Anderson concluded in their editorial:

"As we deliberate health care reform, let us not neglect this inexpensive, yet highly effective public health intervention for the prevention of disease."

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