CDC Update and Sodium Content of Foods

1. CDC Update and Sodium Content of Foods Laurence M. Grummer-Strawn, PhD Division of Nutrition, Physical Activity and Obesity Association of State and Territorial Public Health Nutrition Directors June 14, 2009

2. Dr. Tom Frieden’s top 5 priorities • Strengthen surveillance & epidemiology • Strengthen state & local partners • Better address leading causes of illness/death • Improve global health • Do more with less/be more efficient (financial crisis)

3. New day for nutrition • White House garden • Asst White House chef working on farmers market • Prevention central to health care reform • Frieden’s experience • Baby Friendly hospitals • Trans fat bans • Menu labeling

4. DNPAO Organizational Structure Office of the Director Program Resource Management Associate Director for Policy, Planning & Communications Team Structure • Policy Team • Communications Team Associate Director for Science Nutrition Branch Team Structure: • Research & Surveillance Team • Surveillance Systems Team • Guidelines Development & Recommendations Team • International Unit (M/M) Physical Activity Branch Team Structure: • Research Team • Surveillance Team • Guidelines Development & Recommendations Team Obesity Prevention & Control Branch Team Structure: • Research & Surveillance Team • Guidelines Development and Recommendations Team Program Development & Evaluation Branch Team Structure: • Program Advancement Team • Program Development and Translation Team • Evaluation Team

5. Funding • Increasing funding to state cooperative agreement ($17.2 → $18.3 million) • Two additional states • Stimulus funds expected • States • Communities

6. Weight of the Nation Conference • July 27-29, 2009 • Follows on Public Health Law & Communities conferences • “Place Matters” • Community success stories • Environment influences outcomes • Obesity maps by county

7. IOM Pregnancy weight gain recommendations, 2009 BMI Recommended weight gain <18.5 28-40 18.5-24.9 25-35 25-29.9 15-25 30+ 11-20

8. PNSS/PedNSS/WIC Participant Characteristics Consolidation PNSS/PedNSS • HHS/CDC • Ongoing data collection • Reporting to states/communities • Health/nutrition focus WIC Participant Characteristics • USDA/FNS • Biannual data collection • National report only • Program operation focus

9. Principal Target Behaviors Reduce sugar-sweetened beverages Decrease television time Decrease high energy-densefoods Increase fruit and vegetable intake Increase breastfeeding initiation, duration and exclusivity Increase daily physical activity

10. CDC Guide to Interventions • One per behavioral target • Includes description, evidence of effectiveness, key considerations, program examples, online resources • Ancillary products to be developed

11. Reduce sugar-sweetened beverages • Key strategies • Apply IOM standards for competitive foods in schools • Water availability in all venues • Competitive pricing • Taxes on SSBs

12. Decrease television time • Key strategy • Policy in child care and schools

13. Decrease high-energy dense foods • Key strategies • Healthy food retail • Apply IOM stds to competitive foods in schools • Apply school standards to CACFP foods • Menu labeling • Competitive pricing • Food standards for meetings, cafeteria, and vending machines

14. Increase fruits and vegetable intake • Key strategies • Farm to consumer • Farm to institution • Healthy food retail • Apply IOM standards for competitive foods • Competitive pricing

15. Environmental Surveillance Data Perceptions of physical access to healthy food retail MESA Study, HealthStyles 2009 Community checklists Farmer’s markets, grocery & food stores, restaurants (WI Tool) Consumer environment Nutrition Environment Measures Survey (NEMS) GIS, Spatial analysis Census Tract level data on grocery stores, produce markets, farmers’ markets Organizational survey School Health Policies and Programs Study (SHPPS)

16. States that introduced FV legislation 2001-2008 58 47

17. Fruit and Vegetable Report Card • Process Indicators • The DRAFT process indicators measure different types of support for F&V in 6 difference strategic areas: • Food Policy Council • Farmers Markets • Healthy Food Retail • Land Acreage • Farm to School • School Food Environment

18. Increase breastfeeding initiation, duration and exclusivity • Key strategies • Maternity Care Practices and Policies • Teaching mothers • Workplace Support • Peer Support • Educating Mothers • Professional Support • Media and Social Marketing

19. National Breastfeeding Trends and Related Federal Activities 2010 HHS Call to Action? 2006 1st Nat’l BF Coalitions Conference 2000 HHS Blueprint for Action on Breastfeeding 1984 Surgeon General’s Workshop on BF 1991 Second Follow-up Report on SG Workshop 2001 USBC Strategic Plan on Breastfeeding 1998 Nat’l BF Policy Conference US Breastfeeding Committee launched 1990 Breastfeeding Promotion Consortium formed Healthy People 2000 BF Goals established

20. CDC Survey on Maternity Practices in Infant Nutrition and Care (mPINC) • Biannual national census of facilities with registered maternity beds • August – December 2007 • Based on WHO/UNICEF Ten Steps • Anonymous • Benchmark reports • MMWR, state reports www.cdc.gov/mPINC

21. Increase physical activity • Key strategies • PE in schools • Physical activity regulations in child care • Safe Routes to School • Incentives • Access to places for pa with informational outreach • Social supports for change • Comprehensive community campaigns

22. Healthy People 2010Physical Activity Objective 22-2 • Increase the proportion of adults who engage in: • Moderate physical activity for at least 30 minutes per day 5 or more days per week; or • Vigorous physical activity for at least 20 minutes per day 3 or more days per week http://www.healthypeople.gov/

23. 2008 Physical Activity Guidelines for Americans – Adult Guidelines Aerobic Physical Activity Guidelines ≥ 150 minutes of moderate-intensity aerobic activity per week; or ≥ 75 minutes of vigorous-intensity aerobic activity per week; or Equivalent combination of moderate- and vigorous-intensity physical activity http://www.health.gov/paguidelines

24. Comparison of age-adjusted prevalence estimates from the 2008 Physical Activity Guidelines and the Healthy People 2010 objectives, BRFSS - 2007 15.7%

25. Difference in Estimates • Reasons for shift • Removal of frequency or duration requirement • Combination of minutes • Breakdown of shifts • 15.7% difference in prevalence estimates ► 5.4% - removal of frequency or duration requirement ► 4.3% - combination of moderate- and vigorous-intensity minutes ► 6.0% - for either reason

26. Trends: 2008 Guidelines and Healthy People 2010 Criteria 17.2% 16.7% 15.7%

27. Sodium and Hypertension

28. Burden of Heart Disease and Stroke • Heart disease is the leading cause of death in the United States • Stroke is the third leading cause of death in the United States • In 2009, • ~ 785,000 people will have a new coronary attack • ~ 610,000 people will have a new stroke • Marked disparities persist Source: Lloyd-Jones D, et al. Heart Disease and Stroke Statistics—2009 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21-e181.

29. Salt and High Blood Pressure • Generally, higher consumption of salt means higher blood pressure • Sodium intake is related to levels of blood pressure and the prevalence of hypertension across populations • Within the span of a few weeks, most people experience a reduction in blood pressure when salt intake is reduced

30. Salt and High Blood Pressure • The lower your blood pressure, the lower your risk of heart disease even if you do not have hypertension. • Decreasing sodium intake from 3,500 mg/day to 1,500 mg/day could lead to a 30% decrease in hypertension prevalence.* *Source: Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol 2007 May 1;23(6):437-43.

31. Lower Pressure = Lower Risk Lower BP, Lower Risk Higher BP, Higher Risk Risk of ISD Death Systolic Blood Pressure Data Source: Lewington, Lancet 2002;360:1903-13, Using population risk estimates for ages 50-59 years old.

32. Sodium Recommendation • 2005 Dietary Guideline recommendation: <2,300 mg/day • “Specific Populations” recommended to consume ≤1,500 mg/day • Hypertensive • Black • Middle or Older American • Average intake: 3,466 mg/day

33. Too much sodium • The Loop. Crispy Chicken Salad w/ Lite Ranch • 722 kcal/ 1,527 mg of sodium • Panera Low-fat Chicken Noodle Soup • 160 kcal/ 1,670 mg of sodium • Little Caesars Slice of Pepperoni Pizza • 280 kcal/ 520 mg of sodium • Progresso Microwave Bowl of Minestrone Soup - 180 kcal/ 1,860 mg of sodium

34. Is it Salt or Sodium? • Sodium Chloride is the chemical name for salt • 90% of the sodium we consume is in the form of salt • Other food additives contain sodium • Some amount of sodium is naturally occurring in foods

35. Relative Amounts of Dietary Sodium in the American Diet Source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.

36. International Perspective • Elevated blood pressure and high sodium intake are global issues • Sodium content of foods differ by country • Several countries have implemented strategies to reduce sodium intake

37. Similar Foods Have Less Sodium in U.K. U.S. sodium/serving = 210mg U.K. sodium/serving = 160mg Slide borrowed from Dr. Angell, NYC U.S. sodium/serving = 220mg U.K. sodium/serving = 120mg

38. Sodium Content Varies Widely Internationally U.K. U.S. Chicken Sandwich 830mg sodium (143g) Chicken Sandwich 640mg sodium (178g) 190mg more sodium per serving *Slide borrowed from Dr. Angell, NYC

39. World Health Organization, 2007 Interventions should focus on three main pillars: • product reformulation(the main focus should be on the highest reduction possible in the salt content of commercialized foods and meals) • consumer(including improving nutritional education about the deleterious effects of excessive salt consumption on how to read the labels and choose healthier foods) • theenvironment(by building an environment where choosing the healthiest foods is the easiest and most affordable option to population groups at all socioeconomic levels).

40. AMA Policy Recommendations • Minimum of 50% reduction of sodium in processed and restaurant foods over the next decade • Removal by the FDA of the GRAS status of sodium • Better sodium product labeling; warnings for foods high in sodium • Exploration by FDA of all options to reduce sodium • National consumer education initiative on sodium Source: Report 10 of the Council on Science and Public Health (A-06) Promotion of Healthy Lifestyles I: Reducing the Population Burden of Cardiovascular Disease by Reducing Sodium Intake

41. Industry Response • Industry has voluntarily taken some action to reduce sodium • Several companies have salt workgroups • Increase in introduction of lower sodium foods • Some companies, such as Burger King, have made commitments

42. CDC Activities to Lower Sodium Consumption • Ongoing Sodium Workgroup • IOM study • Aug 2008-May 2010 • Focus on means to reduce intake (regulation, labeling, education, incentives, health professional role, industry codes of conduct) • Tactics to address manufacturers, restaurants, grocers, schools, institutions) • Include implications for iodine deficiency • Comment/testimony on sodium as GRAS, labeling • Guidance to state DHDSP programs • Consultation with WHO and others

43. Thank you! Acknowledgments: William Dietz Janelle Peralez Heidi Blanck Janet Fulton Rosanne Farris www.cdc.gov/nccd/dnpa