We would like to request that you remove Standard 4: Sodium from the four nutritional standards proposed in regulation 8VAC20-740 for the reasons detailed below.

In the Purpose section of this reproposed regulation, you state “Section 22.1-207.4 requires the development and implementation of regulations regarding nutritional guidelines. In addition, the rising rate of obesity in children has become a major health concern, both because of its impact on childhood health and its potential effect on the development of chronic disease in adulthood.” However, there is no evidence to suggest that obesity is in any way caused by excessive ingestion of sodium. If anything the opposite is true.

In furtherance of its salt reduction program, dating back to the first set of Dietary Guidelines, Americans have been cautioned, then warned, about alleged dangers in high salt intakes (Americans’ salt intakes are exactly average in the world.).  Americans have been convinced that salt intake should be minimized. However, these recommendations should be viewed in the context of the landmark Institute of Medicine (IOM) publication (National Research Council: Institute of Medicine. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press, 2013), which stated that there was no consistent evidence to support an association between sodium intake and any adverse effects on health outcomes.  On the contrary, it indicated a negative association of reduced dietary sodium with cardiovascular disease outcomes and all-cause mortality. Notwithstanding this caveat, polls show that public education campaigns have been successful.  Food companies have developed thousands of reduced-sodium foods to cater to this demand and those foods are consumed today in amounts far greater than in 1980.  The “sodium density” of the American diet has been steadily decreasing resulting in less sodium intake per calorie. The result, however, has been an unchanged level of sodium intake and an increase in caloric intake leading to obesity.

Although certainly not a primary cause, the continued promotion of salt reduction found in the recommendations in the Dietary Guidelines and the anticipated call by the FDA for voluntary salt reductions in food products will likely worsen, not improve, the ongoing obesity crisis because people will consume more calories just to satisfy their innate salt appetite.  Decades of animal feeding experience serve as a foundation for this statement.  Specifically, the total calories consumed by animals in farm environments can be increased by decreasing the amount of salt (per calorie or per unit weight of feed) provided to the animals. In addition, the most recent UK Food Standards Agency (Salt intakes remain static in Scotland - June 22, 2011 accessible at: http://www.food.gov.uk/news/newsarchive/2011/june/salt) survey demonstrated that despite the food industry reducing salt significantly (10-25%) in their processed food formulations, people still consume the same amount of salt, indicating they are voluntarily adding more with the shaker or are simply eating more food (and calories) to satisfy their need for sodium.

Indeed, there is scientific evidence of a non-behavioral, neurally-mediated “salt appetite.” (J.C. Geerling, and A.D. Loewy, Central Regulation of Sodium Appetite, 93(2) Exp. Physiol. 177-209 (Feb 2008), Evans LC, Ivy JR, Wyrwoll C, et al. Conditional Deletion of Hsd11b2 in the Brain Causes Salt Appetite and Hypertension. Circulation. 2016 Apr 5;133(14):1360-70. doi: 10.1161/CIRCULATIONAHA.115.019341. Epub 2016 Mar 7). Other recent studies support findings that there is a non-behavioral, neurally-mediated “salt appetite,” including a recent study in The Clinical Journal of the American Society of Nephrology that indicates that physiology, not public policy, will determine a human’s daily sodium intake.  The study, Can Dietary Sodium Intake be Modified by Public Policy? (David A. McCarron, Joel C. Geerling, Alexandra G. Kazaks, and Judith S. Stern, Can Dietary Sodium Intake be Modified by Public Policy?, 4 Clinical J. of the Am. Soc of Nephrology  18788-82 (2009). Available at: http://cjasn.asnjournals.org/cgi/reprint/CJN.04660709v1.), analyzed existing research to determine whether sodium or salt intake follows a pattern consistent with a range set by the brain to protect normal functions of organs such as the heart and kidney. The analysis is based upon 19,151 subjects studies in 62 previously-published surveys and reflects the differing “food environments” of 33 countries. The data reported documents that humans have a habitual sodium intake in the range of 2800 to 4600 mg/day -- with an average intake of 3,600 mg/day. Currently, the U.S. citizens consume an average of about 3,400 mg/day of salt (This is consistent with the conclusion of renowned Swedish researcher, Björn Fokow, who described a “hygienic safety range” for sodium of 2,300 mg/day to 4,600 mg/day – recognizing that it could be as high as 5,750 mg/day.  See  Bjorn Folkow, News in Physiological Sciences (1990).).

Taken in combination, these two studies strongly suggest that salt/sodium intake is a neurally-determined salt appetite signaled unconsciously from the brain and not the product of taste, labeling, consumer education, nor of the availability of low-sodium alternative products. A needs-based salt appetite suggests that whatever the School Nutrition Program Regulations may say about salt intake, physiology will prevail over the opinions of policy makers. Put another way, if the amount of sodium per calorie is reduced in the food made available to students, the students will eat more calories (and thus increase their risks for obesity) to get the sodium they need.

The nutrition standards in the regulation in question are based on the Dietary Guidelines for Americans, yet the provisions of the 2010 Dietary Guidelines for Americans and the 2015-2020 Dietary Guidelines for Americans related to sodium (“sodium provisions”) both violate the National Nutrition Monitoring and Related Research Act, 7 U.S.C. §5301, et seq.

The sodium provisions, jointly issued as part of the Dietary Guidelines on January 31, 2011, by the U.S. Department of Agriculture (“USDA”) and the Department of Health and Human Services (“HHS”), were based on inadequate medical and scientific evidence, as admitted by their original author, the Institute of Medicine (“IOM”). IOM published “Dietary Recommended Intakes (“DRIs”) in 2004, that were adopted as the 2010 Dietary Guidelines, regardless of the IOM conclusion that: “...because of insufficient data from dose-response trials, an Estimated Average Requirement could not be established and thus a Recommended Dietary Allowance could not be derived.” (Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, 269-423 (2004).)

Regardless of this scientific conclusion, IOM’s arbitrary, outdated, non-governmental guidelines, issued without adequate protections against bias and conflicts of interest, and without the protections of transparent rulemaking under the Administrative Procedures Act, were adopted by the 2010 Dietary Guidelines, (Both the Dietary Guidelines and the 2005 Dietary Guidelines contain the same sodium limit range of 1500-2300 mg/day.  Because a Recommended Daily Allowance could not be determined, the IOM set DRIs that are the basis for the sodium limits in both the 2010 Dietary Guidelines and the 2005 Dietary Guidelines.  See IOM, Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate (2004).) improperly delegating the statutory role of the Departments and the Executive Branch, to an outside party, without regard to the statutory duties imposed on the Departments.

The latest evidence persistently published during the last five years demonstrate that there is a safe “range” of salt consumption that results in a lower risk to the overall population. According to this research, the lower end of this safe range begins at 2,800 mg and extends up to about 5000 mg sodium. (Asayama K, Stolarz-Skrzypek K, Persu A, Staessen JA. Systematic review of health outcomes in relation to salt intake highlights the widening divide between guidelines and the evidence. Am J Hypertens. 2014 Sep;27(9):1138-42. O'Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium and potassium excretion and risk of cardiovascular even JAMA. 2011 Nov 23;306(20):2229-38. Graudal N, Jürgens G, Baslund B, Alderman MH. Compared with usual sodium intake, low- and excessive-sodium diets are associated with increased mortality: a meta-analysis. Am J Hypertens. 2014 Sep;27(9):1129-37. O'Donnell MJ, Mente A, Smyth A, Yusuf S. Salt intake and cardiovascular disease: why are the data inconsistent? Eur Heart J. 2013 Apr;34(14):1034-40.) Americans consume about 3,400 mg sodium on average – at the lower end of this safe range.  Notwithstanding this most recent evidence, the new 2015-2020 Dietary Guidelines stubbornly clings to the invalid recommendation of 2,300 mg sodium – a figure outside the safe range because of obsolete “…evidence on blood pressure, a surrogate indicator of CVD risk.”  Most physicians agree that surrogate measures have no place in effective public policy making (Furberg CD. Public health policies: no place for surrogates. Am J Hypertens. 2012 Jan;25(1):21.).

In conclusion, the scientific evidence is clear that sodium intake in the US is toward the low end of the safe range, and thus attempts to restrict sodium intake are unnecessary. Further, there is evidence that there is a “salt appetite” that needs to be satisfied by humans, and so reducing the levels of sodium in foods would only result in students in the schools eating more food, thus perhaps contributing to the very issue of obesity which these regulations purport to address. We would therefore again urge most strongly that you remove Standard 4: Sodium from the four nutritional standards proposed in regulation 8VAC20-740

Wilfrid A. Nixon, Ph.D., P.E., Vice President for Science and the Environment, Salt Institute.