To support Americans' New Year's health and nutrition goals and in advance of American Heart Month, the CDC’s Public Health Law Program (PHLP) has released a series of legal resources on dietary sodium reduction. According to the CDC, excess dietary sodium raises the risk for high blood pressure and its cardiovascular health consequences, including heart disease and stroke, the first and fourth leading causes of death in the United States. Further, although the 2010 Dietary Guidelines for Americans recommend reducing sodium intake to less than 2,300 mg of sodium per day, the average adult consumes over 3,400 mg. Persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease are recommended to further reduce sodium intake to 1,500 mg per day.
As part of a longstanding collaboration with the Division for Heart Disease and Stroke Prevention (DHDSP) in the CDC's National Center for Chronic Disease Prevention and Health Promotion, the PHLP highlights six legal resources and six policy toolkits for practitioners seeking to reduce dietary sodium in discrete populations. The PHLP provides resources on state governments’ laws and policies related to dietary sodium and sodium intake in various populations.
The PHLP provides legal resources and policy toolkits focused on government procurement, school foods, and institutional settings. Additionally, there are specific legal resources on nutrition labeling of sodium; legislative actions to commend, support, or gather information on sodium reduction; and pricing strategies for low-sodium foods. Also, the PHLP developed policy toolkits aimed at strategies for sodium reduction in the hospital environment and worksites.
The goal of healthful food procurement laws and policies may be to increase availability of and demand for healthful foods and products. For example, in Utah, the policy applied to the meals, snacks, and drinks purchased only by the Department of Health, but other jurisdictions could apply the same principle broadly to include other public departments and agencies. New York City provides another example. There, the local government uses its purchasing power to model a healthy food environment, potentially drive the reformulation of foods, and have an impact on a large population of city employees through city-wide healthful food procurement standards. For public health and legal practitioners exploring procurement policies as a strategy to reduce populations’ sodium intake, these laws and policies highlight examples of jurisdictions currently engaged in this activity.
Foods served, sold, and made available in schools can be a significant source of dietary sodium, which may increase children’s risk of high blood pressure, heart disease, and stroke throughout life. School meals may contain more than double the recommended amount for sodium, and snacks and competitive foods can be calorie dense and nutrient poor. School environments can be settings where children learn about health and eating habits, gain access to and knowledge about healthful foods, and practice healthy eating habits. A patchwork of federal and state laws governs the serving and sale of foods in schools, thereby impacting the amount of sodium children consume every day.
The Healthy Meals for Healthy Americans Act of 1994 required schools participating in the National School Lunch and Breakfast Programs (NSLP and NSBP) to serve meals consistent with the Dietary Guidelines for Americans (DGA). The DGA, produced every five years by the US Department of Agriculture (USDA) and Department of Health and Human Services, have recommended reducing dietary sodium since 1995. In response to the Healthy, Hunger-Free Kids Act of 2010, the USDA, which administers NSLP and NSBP, issued a final rule, Nutrition Standards in the National School Lunch and Breakfast Programs in January 2012. The final rule set sodium reduction benchmarks, among those for meeting other nutrient standards, which schools participating in the programs must meet by 2020.
The current standards vary greatly in specificity, scope, and target population. Therefore, few generalizable standards or authorities exist for states to use until 2013 or later, when full implementation of the Healthy, Hunger-Free Kids Act of 2010 will result in federal requirements that change targets for nutritional content in school foods across the country.
State laws and policies address dietary sodium reduction for people in institutional settings, an estimated four million people in the US in 2010. These laws target improved nutrition for patients or inmates of institutions, including:
- Elder or congregate care facilities (long-term acute care and congregate and home-delivered meal settings)
- Health care facilities (mental and psychiatric hospitals, inpatient hospice)
- Residential schools for people with disabilities, halfway houses, and juvenile training schools
- Correctional facilities (federal detention centers, federal and state prisons, jails, correctional residential facilities, and community-based facilities)
These populations depend on the quality and healthfulness of the food provided to them because they typically have no outside options.
States vary greatly in their approaches to reduce sodium in institutional settings, but the laws and policies provided can serve as rich examples for jurisdictions comparing, creating, or amending provisions to reduce dietary sodium.
Several states and three localities pursued regulations that required nutrition labeling from food and beverage retailers (restaurants) in order to address a public health issue exempted by the Federal Food Drug and Cosmetic Act of 1990. These laws mandated that nutritional information of products sold be displayed on menu boards and food tags, or on other written formats available on site, such as menus, to encourage consumers to make healthier food choices. The nutritional information could include sodium content or the percentage daily value of sodium in foods and beverages listed, although including the complete set of nutrition facts was not required under every such “menu labeling” law in effect. The laws that required listing foods’ sodium content on the menu or menu board face preemption by the Patient Protection and Affordable Care Act of 2010 (ACA), which requires that restaurants with 20 or more locations as defined under the law post calorie information alone on menu boards.
Legislatures can commend, support, or gather sodium reduction information by publishing legislative findings, supporting various programs and projects, educating the public, and studying the health issue. The state laws and policies found in legislative history and policy archives, while not exhaustive, present opportunities that legislatures have taken to ensure that sodium is a factor in the health decisions the public makes. Other laws have brought attention to the issues of high blood pressure, cardiovascular disease, and general nutrition promotion, but the scope of this research only includes those laws that have expressly address sodium.
While pricing and taxing strategies have been explored in other areas of nutrition policy, only two states have explored pricing strategies to affect dietary sodium reduction in distinct populations. “Pricing strategies” in this context means providing government entities or individuals with incentives to offer low-sodium foods or disincentives to offer higher sodium foods in specific contexts.
- Maryland’s regulations require food store or food store/pharmacy combination vendors to accept and redeem coupons from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for low-sodium canned fruits and vegetables.
- Pennsylvania’s Department of Education has a policy specifying that reimbursement will be given to schools that implement the Nutrition Standards for Competitive Foods in Pennsylvania Schools, which requires choosing foods for classroom parties that are moderate in sodium and limiting foods for fundraisers that are high in sodium.
Both policies provide incentives to offer foods that lower sodium consumption, but neither policy provides sodium limits or standards for the quantity of sodium consumed. Taxing strategies addressing sodium in foods were not found in this research, however.
Exposure in the hospital setting to foods full of sodium can lead to increased salt consumption in already sick and immune-compromised populations as well as their families, hospital staff, and the public. Currently, the percentage of healthful foods and beverages offered as well as what defines “healthy” is determined by individual hospitals or hospital systems. A 2005 survey of 17 hospital entrees reported as “healthiest” found the sodium content per serving varied greatly from 61 milligrams (mg) to 1,450 mg. According to the survey, many of the recipes submitted as the “healthiest” meals also were exceedingly high in fat, saturated fat, and cholesterol and low in fiber.1 Recommendations from an expert panel convened by CDC’s Division of Nutrition, Physical Activity, and Obesity reported significant variance in today’s hospital food environment, supporting the need for comprehensive, population-based environmental change strategies that may be adopted by independent hospitals and hospital systems across the country.
Heart disease and stroke, the primary types of cardiovascular disease, are among the leading causes of death and disability as well as the most expensive medical conditions for businesses in our nation. High blood pressure (hypertension) affects approximately one in three U.S. adults, and prehypertension affects nearly one in four U.S. adults. Importantly, having high blood pressure increases the risk for heart disease and stroke. Employees at risk for heart disease and stroke can increase the cost of doing business through increased absenteeism, workers’ compensation, health benefits, and lost productivity. In 2002, employers paid an average of $18,618 per employee for all costs related to health and lost productivity; four of the five most costly health conditions for employers are related to heart disease and stroke: high blood pressure, heart attack, diabetes, and angina (chest pain).
Importantly, in a study of more than 46,000 employees from six large U.S. companies, employees at a high risk for heart disease and stroke had significantly higher health care expenditures (228% higher for heart disease, 85% higher for stroke) than employees not at risk. Further, an analysis of insurance claims for roughly 4 million individuals covered by employer-based benefits at large U.S. companies found that the average annual payment for those with heart-related health care claims exceeded $4,000 per patient, which is more than double the average payment for other conditions.
See the CDC Policy Resources and Toolkits