National Salt Reduction Initiative - Elizabeth Leonard, MPH, Project Coordinator, New York City Department of Health and Mental Hygiene Plenary VI Sodium: Actions and Insights from National Forum Members and Stakeholders

Insights from the National Salt Reduction Initiative Elizabeth Leonard Nutrition Strategy Program Bureau of Chronic Disease Prevention and Tobacco Control New York City Department of Health and Mental Hygiene October 9, 2013

NSRI Overview Decrease sodium content in foods by 25% over 5 years Decrease population sodium intake by 20% over 5 years Reduce risk of heart attack and stroke – the leading cause of death in US Partnership of 95+ city and state health authorities and national health organizations Voluntary sodium targets following 100+ meetings with industry Almost 30 companies committed to NSRI targets

National Salt Reduction Initiative Deaths Attributable to Total Effects of Individual Risk Factors -50,000 450,000 250,000 350,000 50,000 150,000 Source: Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, et al. (2009) The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors. PLoS Med 6(4). b. Effect of high dietary salt on cardiovascular diseases was estimated through its measured effects of systolic bp.c. Protective effects of alcohol use on cardiovascular diseases are its net effects. Regular moderate alcohol use is protective for IHD, ischemic stroke, and diabetes but any use is hazardous for hypertensive disease, hemorrhagic stroke, cardiac arrhythmias, and other cardiovascular diseases.

Most Salt Intake Comes from Processed and restaurant foods Processed Foods Processed and restaurant foods 77% 12% While eating 6% 5% Mattes, RD. Donnelly D. Relative Contributions of Dietary Sodium Sources. Journal of American College Nutrition, 1991, 10:383-393. 5

International Attention to Salt Finland Requires high salt warnings for products that exceed a category-specific level, beginning in the 1990s United Kingdom Coordinated voluntary national effort with sodium targets across 80 food categories for 2008 and 2010 50+ commitments from all sectors of industry, future planning underway Australia Food and Health Dialogue is currently releasing targets by category, on a rolling basis Pan American Health Organization / World Health Organization Established an Expert Group that developed recommendations to reduce population-wide dietary salt intake

US Context Institute of Medicine published report on Strategies to Reduce Sodium Intake in 2010: Primary recommendation: mandatory limits on sodium Interim recommendation: coordinated voluntary approach

NSRI Partners Across U.S. State Health Department State Health Association City or County Health Department State & City Health Departments Health Organizations Academy of Nutrition and Dietetics (ADA) American College of Cardiology American College of Epidemiology American Heart Association American Medical Association American Public Health Association American Society of Hypertension Association of Black Cardiologists Consumers Union Health Power for Minorities (Health Power) InterAmerican Heart Foundation International Society on Hypertension in Blacks Kaiser Permanente National Forum for Heart Disease and Stroke Prevention National Hispanic Medical Association National Kidney Foundation Partnership for Prevention Preventive Cardiovascular Nurses Association Public Health Law Center at William Mitchell College of Law Society for the Analysis of African-American Public Health Issues World Hypertension League State & Local Associations Association of State and Territorial Health Officials Association of State and Territorial Public Health Nutrition Directors California Conference of Local Health Officers Council of State and Territorial Epidemiologists Mississippi Task Force on Heart Disease and Stroke Prevention Missouri Activity for Activity and Nutrition National Association of Chronic Disease Directors National Association of County and City Health Officials New York State Chapter, American College of Cardiology Northern Illinois Public Health Consortium Northwest Kidney Centers South Carolina Institute of Medicine & Public Health Texas Association of Local Health Officials Texas Medical Association Texas Salt Reduction Collaborative Wisconsin Heart Disease and Stroke Alliance

Determining Baseline Sodium Levels Built Databases: Contains nutrition and sales data for thousands of packaged and restaurant foods Analyze Databases: Collecting this data exposed the variation of sodium across similar products Whole Wheat Bread 480mg sodium Whole Grain Bread 160mg sodium 3X amount of sodium

NSRI Strategy Set Targets: Sodium targets set for 2012 and 2014 for each of the 62 packaged food and 25 restaurant food categories Invite Commitments: 28 food companies are committed to the NSRI Monitor changes: Analyze changes in sodium in foods over time

Category Sodium Distribution 2014 400 mg 2012 480 mg Mean 530 mg

21 Companies Met 2012 NSRI Targets Packaged Food Butterball Furmano Foods Goya Foods Heinz Ken’s Foods Kraft Foods LiDestri Foods/ Francesco Rinaldi Mars Food McCain Foods Mondelēz International Red Gold Snyder’s-Lance Unilever White Rose Restaurant Food Au Bon Pain Starbucks Subway Uno Chicago Grill Food Retailers Delhaize America FreshDirect Target Corporation

How We Assess Progress Track changes in sodium content of packaged and restaurant food in 2012 and 2014 using: Packaged and Restaurant Food Databases Industry-reported data Implement baseline and follow up 24-hour urinary evaluation

Next Steps for the NSRI Track changes in sodium content of packaged and restaurant food Invite companies to commit to 2014 targets Expand NSRI partnership through continued collaboration with national health organizations, cities, and states and continued coordination with federal agencies

Thank You Elizabeth Leonard eleonard1@health.nyc.gov