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Over the past several decades, the evidence of the harmful effects of sodium on health has grown insurmountably. in humans and animals have consistently shown that excess sodium consumption raises blood pressure, which is a leading risk factor for cardiovascular disease (CVD). Indeed, a of the dietary risk factors associated with ill health and death found that excess sodium consumption was a key risk factor, accounting for approximately 2 million deaths in 2019.

Many people are eating much more sodium than they are aware of, as of the sodium we eat has already been added to products such as bread, breakfast cereals, processed meats, and ready meals, in addition to food from restaurants and fast food outlets. The World Health Organization (WHO) recommends that we eat no more than , but intakes worldwide are much higher than this -- up to double in some countries -- and in the U.S., average intake is 3,400 mg/day.

In the U.S., the question becomes: do recent efforts toward curbing sodium intake go far enough and what can we learn from global efforts aimed at this goal?

The Best Approach to Lowering Sodium Intake

Simply telling people to eat less sodium won't be effective if all the food people eat is already filled with it. This is where public health policies come in: the best policy to bring down sodium intake is setting sodium reduction targets.

The concept behind targets is that food manufacturers and chefs gradually lower the levels of sodium they add to their products and dishes to meet that target level. Ideally, the targets should then be reset to a lower level to continue this process. And over time, sodium levels in products and dishes will be low enough to help populations achieve lower sodium intake. When sodium is lowered in this gradual, step-wise manner, our taste buds adapt to the changing taste of products, so we can continue buying the same products as always. A win-win-win for public health, food companies, and consumers.

FDA Sodium Reduction Targets

In October, the U.S. began the process of with the release of sodium reduction targets, joining more than 90 countries in the global effort to cut down sodium intake.

The FDA's sodium reduction targets cover more than 150 categories of food, which the food industry will voluntarily work towards by 2023. These targets are intended to reduce average sodium intake to 3,000 mg/day. While this is obviously higher than the WHO's recommended limit, it is a good interim goal that will allow for monitoring and evaluating the impact of the targets.

The U.K.'s Sodium Reduction Program

This approach of setting sodium reduction targets is based on the U.K.'s reduction programme, which was established in 2006. The U.K. set targets across more than 80 categories of food and then reset the targets in 2009, 2011, 2014, and 2020. Sodium levels in many food products decreased by 20% to 40%, which led to a in population sodium intakes, average population blood pressure, and deaths from CVD. The same could be possible in the U.S. -- but in order to see success, the FDA should take some important lessons from the U.K.'s experience.

Voluntary public health policies, like the FDA's targets, are only successful with clear political leadership and transparent monitoring. The U.K.'s sodium reduction programme was initially overseen by the independent Food Standards Agency (FSA), which released regular monitoring reports and called out companies that did not make progress. In recent years, however, the U.K. government has regularly moved responsibility for sodium reduction between various departments, which has contributed to waning progress.

Alongside the targets, the U.K. has implemented other measures that have helped support the goal of sodium reduction. In 2013, the government to standardize color-coded front-of-pack nutrition labels, which are now displayed on three in four packaged products. Products have to display a red colour if it is high in salt (more than 1.5 g per 100 g or more than 1.8 g per portion), which has helped encourage many companies to reduce salt levels to avoid the red label. The FSA also developed a , which ran across TV, radio, and billboards from 2004 to 2009. This initially helped build support for sodium reduction efforts, although awareness of the issue has gradually fallen over the years, demonstrating the transient nature of such campaigns.

Mandatory Versus Voluntary Sodium Reduction

Above all, the FDA must be willing to introduce mandatory targets if progress towards voluntary policies is poor. South Africa has already implemented mandatory targets across a range of products. These were announced in 2013 and implemented in 2016, and by that time, around had already been reformulated to reduce sodium content and comply with the targets. shows that average population sodium intake in South Africa has fallen by 460 mg/day, which is a huge success in the world of sodium reduction.

Given that the U.S. food industry is larger and more diverse than in the U.K., a mandatory programme may be necessary in the long term to create a level-playing field, ensuring that all companies are held to and progress toward the same standard.

Global Sodium Reduction

In 2013, the WHO highlighted sodium reduction as a key goal to prevent CVD, and to reduce population sodium intake by 30% by 2025. To help spur progress towards this goal, the WHO released earlier this year to give a reference to all countries that have yet to set sodium reduction targets and to provide more specific guidance for those countries with targets in place. However, to date, no country is on track to achieve the kind of reductions in population sodium intake needed to make enough of an impact.

Reducing sodium intake to the recommended level could prevent millions of deaths globally and save many thousands of dollars in healthcare costs. We must move faster, with strong and ambitious sodium reduction policies. Let's hope the FDA is up to the challenge.

is a registered nutritionist and programme manager for World Action on Salt, Sugar and Health (WASSH), an expert research and advocacy group based at Queen Mary University of London. is professor of global health research at Queen Mary University of London. is professor of cardiovascular medicine at Queen Mary University of London and chair of WASSH.

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