CDC Update and Sodium CDC Update and Sodium Content of FoodsContent of Foods

Laurence M. Grummer-StrawnLaurence M. Grummer-Strawn, PhD, PhD

Division of Nutrition, Physical Activity and ObesityDivision of Nutrition, Physical Activity and Obesity

Association of State and Territorial Public Health Association of State and Territorial Public Health Nutrition DirectorsNutrition DirectorsJune 14, 2009June 14, 2009

Dr. Tom Frieden’s top 5 Dr. Tom Frieden’s top 5 prioritiespriorities

● Strengthen surveillance & Strengthen surveillance & epidemiologyepidemiology

● Strengthen state & local partnersStrengthen state & local partners

● Better address leading causes of Better address leading causes of illness/deathillness/death

● Improve global healthImprove global health

● Do more with less/be more efficient Do more with less/be more efficient (financial crisis)(financial crisis)

New day for nutritionNew day for nutrition

● White House gardenWhite House garden

● Asst White House chef working on Asst White House chef working on farmers marketfarmers market

● Prevention central to health care reformPrevention central to health care reform

● Frieden’s experienceFrieden’s experience Baby Friendly hospitalsBaby Friendly hospitals Trans fat bansTrans fat bans Menu labelingMenu labeling

DNPAO Organizational Structure

Physical Activity Branch

Team Structure:• Research Team• Surveillance Team• Guidelines

Development & Recommendations Team

Nutrition Branch

Team Structure:• Research & Surveillance

Team• Surveillance Systems

Team• Guidelines Development

& Recommendations Team

• International Unit (M/M)

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

Associate Director for Science

Associate Director for Policy, Planning & Communications

Team Structure• Policy Team• Communications Team

Program Resource ManagementOffice of the Director

FundingFunding

● Increasing funding to state Increasing funding to state cooperative agreement ($17.2 cooperative agreement ($17.2 →→ $18.3 million)$18.3 million) Two additional statesTwo additional states

● Stimulus funds expectedStimulus funds expected StatesStates CommunitiesCommunities

Weight of the Nation Weight of the Nation ConferenceConference

● July 27-29, 2009July 27-29, 2009

● Follows on Public Health Law & Follows on Public Health Law & Communities conferencesCommunities conferences

● ““Place Matters”Place Matters” Community success storiesCommunity success stories Environment influences outcomesEnvironment influences outcomes Obesity maps by countyObesity maps by county

IOM Pregnancy weight gain IOM Pregnancy weight gain recommendations, 2009recommendations, 2009

BMIBMI Recommended Recommended weight gainweight gain

<18.5<18.5 28-4028-40

18.5-24.918.5-24.9 25-3525-35

25-29.925-29.9 15-2515-25

30+30+ 11-2011-20

PNSS/PedNSS/WIC Participant PNSS/PedNSS/WIC Participant Characteristics ConsolidationCharacteristics Consolidation

PNSS/PedNSSPNSS/PedNSS

● HHS/CDCHHS/CDC● Ongoing data Ongoing data

collectioncollection● Reporting to Reporting to

states/communitistates/communitieses

● Health/nutrition Health/nutrition focusfocus

WIC Participant WIC Participant CharacteristicsCharacteristics

● USDA/FNSUSDA/FNS

● Biannual data Biannual data collectioncollection

● National report National report onlyonly

● Program operation Program operation focusfocus

Principal Target BehaviorsPrincipal Target Behaviors

Reduce sugar-sweetened beveragesReduce sugar-sweetened beverages

Decrease television timeDecrease television time

Decrease high energy-denseDecrease high energy-dense foodsfoods

Increase fruit and vegetable intakeIncrease fruit and vegetable intake

Increase breastfeeding initiation, Increase breastfeeding initiation, duration duration and exclusivityand exclusivity

Increase daily physical activityIncrease daily physical activity

CDC Guide to InterventionsCDC Guide to Interventions

● One per behavioral One per behavioral targettarget

● Includes description, Includes description, evidence of evidence of effectiveness, key effectiveness, key considerations, program considerations, program examples, online examples, online resourcesresources

● Ancillary products to be Ancillary products to be developeddeveloped

Reduce sugar-sweetened Reduce sugar-sweetened beveragesbeverages

● Key strategiesKey strategies Apply IOM standards for Apply IOM standards for

competitive foods in schoolscompetitive foods in schools Water availability in all venuesWater availability in all venues Competitive pricingCompetitive pricing Taxes on SSBsTaxes on SSBs

Decrease television timeDecrease television time

● Key strategyKey strategy Policy in child care and schoolsPolicy in child care and schools

Decrease high-energyDecrease high-energy dense foods dense foods

● Key strategiesKey strategies Healthy food retailHealthy food retail Apply IOM stds to competitive foods in Apply IOM stds to competitive foods in

schoolsschools Apply school standards to CACFP foodsApply school standards to CACFP foods Menu labelingMenu labeling Competitive pricingCompetitive pricing Food standards for meetings, cafeteria, Food standards for meetings, cafeteria,

and vending machinesand vending machines

Increase fruits and vegetable Increase fruits and vegetable intakeintake● Key strategiesKey strategies

Farm to consumerFarm to consumer Farm to institution Farm to institution Healthy food retailHealthy food retail Apply IOM standards for Apply IOM standards for

competitive foodscompetitive foods Competitive pricingCompetitive pricing

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)

States that introduced FV legislation 2001-2008

47

58

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

Increase breastfeeding initiation, Increase breastfeeding initiation, duration and exclusivityduration and exclusivity

● Key strategiesKey strategies Maternity Care Practices and PoliciesMaternity Care Practices and Policies Teaching mothersTeaching mothers Workplace SupportWorkplace Support Peer SupportPeer Support Educating MothersEducating Mothers Professional SupportProfessional Support Media and Social Media and Social

MarketingMarketing

0

10

20

30

40

50

60

1970 1975 1980 1985 1990 1995 2000 2005 2010Year

Percent Breastfeeding

National Breastfeeding Trends and Related Federal Activities

1984Surgeon General’s

Workshop on BF

2001USBC Strategic Plan on Breastfeeding

1998Nat’l BF Policy Conference

US Breastfeeding Committee launched

1990Breastfeeding Promotion

Consortium formed

Healthy People 2000 BF Goals established

2000HHS

Blueprint for Action on

Breastfeeding

2010HHS Call to

Action?2006

1st Nat’l BF Coalitions

Conference

1991Second

Follow-up Report on SG

Workshop

CDC Survey on Maternity Practices in Infant Nutrition and Care (mPINC)

Biannual national census of Biannual national census of facilities with registered maternity facilities with registered maternity bedsbeds

August – December 2007August – December 2007

Based on WHO/UNICEF Ten Based on WHO/UNICEF Ten StepsSteps

AnonymousAnonymous

Benchmark reportsBenchmark reports

MMWR, state reportsMMWR, state reports

www.cdc.gov/mPINCwww.cdc.gov/mPINC

Increase physical activityIncrease physical activity

● Key strategiesKey strategies PE in schoolsPE in schools Physical activity regulations Physical activity regulations

in child carein child care Safe Routes to SchoolSafe Routes to School IncentivesIncentives Access to places for pa with Access to places for pa with

informational outreach informational outreach Social supports for change Social supports for change Comprehensive community campaignsComprehensive community campaigns

Healthy People 2010 Physical Activity Objective 22-2

Healthy People 2010 Physical 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

• 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/

2008 Physical Activity Guidelines for Americans – Adult Guidelines

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

• 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

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

48.8%

37.7%

13.5%22.0%

64.5%

0

20

40

60

80

100

Active Insufficiently Active Inactive

Pre

vale

nce

Healthy People 2010 2008 Physical Activity Guidelines

15.7%

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

Trends: 2008 Guidelines and Healthy People 2010 Criteria

64.5%63.8%62.6%62.5%

48.8%48.1%45.9%45.3%

0

20

40

60

80

100

2001 2003 2005 2007

Pre

vale

nce

2008 Physical Activity Guidelines Healthy People 2010 Criteria

17.2% 16.7% 15.7%

Sodium and HypertensionSodium and Hypertension

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.

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

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.

0

5

10

15

20

25

30

110-119

120-129

130-139

140-149

150-159

160-169

170-179

Lower Pressure = Lower Risk

Data Source: Lewington, Lancet 2002;360:1903-13, Using population risk estimates for ages 50-59 years old.

Lower BP,Lower Risk

Higher BP,Higher Risk

Ris

k of

IS

D D

eath

Systolic Blood Pressure

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

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

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

Relative Amounts of Dietary Sodium in the American Diet

During Cooking5%

At the table6%

Naturally Occurring12%

Food Processing77%

Source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.

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

U.K. sodium/serving = 160mgU.S. sodium/serving = 210mg

U.K. sodium/serving = 120mgU.S. sodium/serving = 220mg

Similar Foods Have Less Sodium in U.K.

Slide borrowed from Dr. Angell, NYC

*Slide borrowed from Dr. Angell, NYC

Chicken Sandwich830mg sodium

(143g)

Chicken Sandwich640mg sodium

(178g)

U.S.U.K.

190mg more sodium per

serving

Sodium Content Varies Widely Internationally

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)

• the environment (by building an environment where choosing the healthiest foods is the easiest and most affordable option to population groups at all socioeconomic levels).

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

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

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

Thank you!Thank you!

Acknowledgments:Acknowledgments:

William DietzWilliam Dietz

Janelle PeralezJanelle Peralez

Heidi BlanckHeidi Blanck

Janet FultonJanet Fulton

Rosanne Farris Rosanne Farris

www.cdc.gov/nccd/dnpawww.cdc.gov/nccd/dnpa