Imagine a mysterious but pervasive substance that contributed to tens of millions of deaths around the world. Imagine that simple new public rules limiting human exposure to this substance could prevent almost nine million deaths in the developing world in the next ten years. Wouldn’t you expect that governments around the word would implement such rules? Well, these facts describe the current scientific situation on salt. 
To answer the question requires a closer examination of the ongoing clashes on salt policy. On one side are health, scientific and advocacy bodies such as the American Medical Association, [2-3] the National Academy of Sciences,  the World Health Organization, [1,5] Consensus Action on Salt and Health,  and Center for Science in the Public Interest, [7-10] all arguing for global and national regulations to lower salt content in processed food. On the other side are groups such as the European Union Salt Producers Association and The Salt Institute, a U.S.-based salt industry trade association, who claim in scientific, policy and legal settings that excess salt intake is not harmful to human health. [11-13]
Late last year, the US Food and Drug Administration held a public hearing on this issue with a request for public comments.  (The transcript of this hearing will soon be available at http://www.fda.gov/ohrms/dockets.) If the FDA decides to reclassify salt (also known as sodium chloride) as a food “additive,” then it can place limits on the amount of sodium contained in prepared foods and foods served in restaurants.
In this report, Corporations and Health Watch reviews the evidence on the adverse health consequences of excess dietary salt, describes some of the policy proposals to reduce salt intake and the extent to which various jurisdictions have implemented such policies, and analyzes the political strategies that the salt industry has used to oppose or delay new limits on dietary salt.
The adverse health consequences of excess dietary salt consumption
How much salt does the average adult in the United States consume a day? Although many people consider only the amount of salt that they add to their food while cooking or at the dinner table, approximately 75% of the sodium we consume is already in the food we buy. The National Academy of Sciences recommends that adults consume no more than 2,300 milligrams of sodium daily, roughly one teaspoon of salt. The recommended maximum intake for people at risk of high blood pressure, such as adults over age 50, is 1,500 milligrams of sodium per day.
The average U.S. adult consumes about 4,000 milligrams of sodium per day—as noted above, about 75% of this intake comes from sodium added by food manufacturers and restaurants. Canned and processed foods often contain 1,000 milligrams or more per 8 ounce serving, and typical meals served in restaurants contain between 2,300 and 4,600 milligrams of sodium.  In addition, sodium is present in foods such as bread, diced tomatoes, and cereals,8 important sources of sodium intake often overlooked by consumers. Jeremiah Stamler, M.D., professor emeritus of Preventive Medicine, Northwestern University Medical School in Chicago, observed, “If we reduce our salt intake [at the table] that won’t solve the problem. There’s salt in bread, processed meat, cheese, canned vegetables—these are all hidden sources of salt.” 
Although experts debate the precise threshold for maximum daily salt intake, there is little controversy that excess salt intake is a major contributor to high blood pressure, a major risk factor for stroke, heart failure, heart attack, and kidney and vision problems. [16-18] In the United States alone, it is estimated that nearly 30% of all adults are affected by hypertension, with another third of adults affected by pre-hypertension.  One important way to control hypertension is to lower salt intake.
Policy proposals to reduce dietary salt intake
Many scientific and professional organizations have come to the consensus that the public would benefit from a reduction in the sodium in products sold by the food and restaurant industries. For example, in November 2002, the American Public Health Association called for a 50% reduction in the nation’s food supply over the next 10 years.  In June 2006, the American Medical Association also advocated lower levels of salt in processed food, observing “[i] n the continued absence of voluntary measures adopted by the food industry, new regulations will be required to achieve lower sodium concentrations in processed and prepared foods.”
Similar positions have been reached by the National Institutes of Health, National Academy of Sciences, U.S. Department of Agriculture, U.S. Department of Health and Human Services, and at least 40 other professional organizations in the U.S.  The American Medical Association states that “substantial public health benefits accrue from small reductions in the population blood pressure distribution.” The AMA noted that a 1.3 grams per day lower lifetime sodium intake is estimated to save 150,000 lives annually as individuals advance form age 25 to 55. 
Policy recommendations include: (1) broad public and consumer education on salt, new food labeling systems, e.g. the use of red, yellow and green traffic light symbols to show levels of salt in a product, (2) a requirement that some foods must be labeled as high sodium, or (3) regulations that would limit the amount of sodium in processed and some restaurant food.
What has been the national and international response to excess dietary salt consumption?
In the United States, the Center for Science in the Public Interest has petitioned since 1978 for measures to regulate sodium. In 1994, in a partial victory, the US Food and Drug Administration required that food manufacturers disclose to consumers sodium the amount of sodium and its percent of Daily Value.  The FDA also established guidelines for using sodium- and salt-related food claims such as “sodium free,” “low sodium,” “reduced sodium,” “salt free,” and “unsalted.” Back in 1982, the FDA had recommended that food manufacturers voluntarily reduce the amount of added salt in processed foods. However, despite these measures, it is estimated that salt intake has actually increased by in the United States by 55% from the early 1970s to 2000, [17,19] during which time the age-adjusted prevalence of high blood pressure increased substantially. 
Efforts are underway in several countries to reduce the amount of sodium consumed. For example, in the UK, The Food Commission has launched a campaign for safer, healthier food called the Healthy Hexagon, Eat less salt project.  This project aims to provide healthy eating education to more than 3,000 residents of the Hexagon Housing Association in south east London. Also, in the UK, the Sainsbury’s supermarket chain has voluntarily reduced the sodium content of its store brand products without protest by consumers. 
The government in the UK has divided foods into approximately 70 categories and has set target sodium reductions for each of these categories. The government hopes that sodium consumption in the UK will decrease by 33% in 5 years with these measures. The UK is also encouraging a “traffic light labeling system” for use by the food industry—with high sodium products being labeled with a red light, medium sodium products a yellow light, and low sodium products a green light.
The governments of Ireland, New Zealand, Australia and France have set similar standards to reduce the sodium intake in their populations. Finland’s government, which has focused on reducing sodium since the 1970s, has achieved a 30% reduction in average sodium consumption, from approximately 4,700 milligrams daily to approximately 3,300 milligrams daily. Researchers credit these efforts with decreasing deaths among 30 to 59-year-old men and women by 60%. [14, 21]
Strategies used by salt industry groups to oppose or delay new limits on dietary salt
The current FDA salt review was sparked by a petition filed in November 2005 by the Center for Science in the Public Interest (Docket No. 2005P-0450). [9,10] The petition seeks to have the GRAS (Generally Regarded as Safe) status of salt modified so that salt may be regulated. CSPI argues that voluntary measures over the past two and a half decades have not lowered the sodium content of foods and that more aggressive regulatory action is needed.
Under current law, sodium would need to be reclassified as an “additive” in order for it to be legally regulated. The CSPI petition further calls for food labeling requirements and ceilings on the amount of sodium in processed foods, among other measures.
Several salt industry groups, notably the European Union Salt Producers’ Association and The Salt Institute (a U.S.-based salt industry trade association) have argued against the scientific evidence and claimed that excess salt intake is not harmful to human health. [11, 12] In a clear conflict of interest, these salt industry groups have paid for medical and scientific opinions from “experts,” and they have used their popular websites to misinform the public. People without medical backgrounds may view their statements on salt and hypertension and make decisions that are contrary to medical advice. For example, the European Union Salt Producers’ Association, which represents salt producers in the EU who currently produce 45 million tons of salt per year, has issued several position papers on salt and health. In their position paper Salt and blood pressure: Controversial and misunderstood they state that “alarmist media reports and general recommendations to reduce salt intake” have the potential to cause harm. And The Salt Institute, which represents the interests of all major U.S. salt producers who produce approximately 46 million tons of salt per year, has similar statements on salt and health on its consumer website, including recommendations to adhere to a salty, Mediterranean diet.
In the December 2007 newsletter published by The Salt Institute, the authors comment on the proposed FDA regulations, likening them to the actions of Joseph Stalin, Adolf Hitler, Orwell’s “Big Brother,” and The Spanish Inquisition. In this newsletter, they denounce “pathological science,” quoting John Horgan who said: “Pathological science kills people and ruins lives. Such fake science is still peddled by the PC establishment in Europe and America.” The proposed federal regulations, which would impose labeling requirements and limit the amount of sodium in processed foods, would not interfere with the ability of consumers to purchase salt and use it as they wish. The proposed regulations would simply protect U.S. adults from processed foods that increasingly contain excessive amounts of sodium. By reducing hypertension, the new rules would also reduce the burden of chronic disease in the United States. [1, 17]
In May 2007, the European Salt Producers’ Association held a conference that promoted their scientifically questionable views on salt. David McCarron, a hypertension specialist, spoke at the European Union Salt Producers’ conference. He is the same person hired by The Salt Institute to request immediate access to the complete data from the DASH study.  The DASH study, published in the New England Journal of Medicine in January 2001, demonstrated that reducing dietary salt could lower blood pressure, even in people without hypertension.  The Salt Institute filed a petition under the Data Quality Act, claiming that the researchers must turn over their data so that a “qualified member of the public” can reconduct the analysis.  A district court dismissed The Salt Institute’s petition, and when The Salt Institute appealed to the U.S. Court of Appeals for the 4th Circuit the petition was again dismissed. [22,24]
In the case of salt, industry opposition has prevented governments from instituting simple policies that could, over the years, prevent millions of premature deaths. In the coming weeks, the FDA has an opportunity to change the ending of this familiar story.
1. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007; 15;370(9604):2044-53.
2. American Medical Association. “AMA calls for measures to reduce sodium intake in U.S. diet: urges FDA to revoke ‘generally regarded as safe’ status.” June 13, 2006. Accessed December 22, 2007 at http://www.ama-assn.org/ama/pub/category/print/16461.html
3. CRohack, JJ. Letter from AMA to Boston Globe: Cutting sodium beneficial to Americans’ health. July 3, 2006 (published).
4. Institute of Medicine, Food and Nutrition Board. Accessed January 9, 2008 at http://www.iom.edu
5. World Health Organization, Global Strategy on Diet, Physical Activity and Health. Cardiovascular Disease: Prevention and Control. Accessed January 9, 2008 at http://www.who.int/dietphysicalactivity/publications/facts/cvd/en/
6. Consensus Action on Salt and Health. Accessed January 9, 2008 at http://www.actiononsalt.org.uk
7. Center for Science in the Public Interest. Salt: the forgotten killer. . . and the FDA’s failure to protect the public’s health. Accessed December 22, 2007 at http://www.cspinet.org/salt/saltreport.pdf
8. Salt Assault: Brand-Name Comparisons of Processed Foods. Washington, DC: Center for Science in the Public Interest.http://www.cspinet.org/salt/updated_saltreport.pdf
9. Center for Science in the Public Interest. Petition to Revoke the GRAS Status of Salt, to Set Ceilings on the Amount of Sodium in Processed Foods, to Require a Health Warning on Packaged Salt, and to Reduce the Daily Value for Sodium (Docket no. 2005P-0450, U.S. Department of Health and Human Services Food and Drug Administration). Submitted November 8, 2005 by Michael F. Jacobson, Ph.D.
10. U.S. Food and Drug Administration (FDA). October 19, 2007 Notice of Public Hearing: Salt and Sodium. Petition to Revise the Regulatory Status and Establish Food Labeling Requirements Regarding Salt and Sodium. Docket No. 2005P-0450. Accessed December 22, 2007 at http://www.cfsan.fda.gov/~comm/registe7.html
11. EU Salt, European Salt Producer’s Association. Accessed December 22, 2007 at http://www.eusalt.com
12. The Salt Institute. Accessed December 22, 2007 at http://www.saltinstitute.org/2.html
13. The Salt Institute. December 2007 Newsletter. Accessed December 22, 2007 at http://www.saltinstitute.org/news07-dec.html#article1
14. Havas SH, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium. Am J Public Health. 2004; 94(1):19-22.
15. Greeley A. A pinch of controversy shakes up dietary salt. FDA Consumer Magazine, November-December 1997.
16. Food and Nutrition Board. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Institute of Medicine, 2004.
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18. Cappuccio FP. Salt and cardiovascular disease: Reducing sodium intake improves cardiovascular outcomes but few countries have effective policies. BMJ. 2007; 334: 859-860.
19. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004; 24: 401-431.
20. The Food Commission, Healthy Hexagon Eat Less Salt Project. Accessed December 22, 2007 athttp://www.foodcomm.org.uk/hexagon.htm
21. Krappanen H, Mervaala E. Adherence to and population impact on non-pharmacological and pharmacological anti-hypertensive therapy. J Hum Hypertens. 1996;10(Supp 1): S57-S61.
22. Kaiser J. Data access. Industry groups petition for data on salt and hypertension. Science. 2003 May 30;300(5624):1350.
23. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER, Simons-Morton DG, Karanja N, Lin PH; DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. NEJM. 2001; 344: 3-10.
24. Raeburn P. A regulation on regulations. Sci Am. 2006 Jul;295(1):18, 20.
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