Food Preparation and Food Establishments (Article 81, Section 49) - Sodium Warning
Proposed Rules: Closed to Comments (View Public Comments Received:2)
Statement of Basis and Purpose
Section 558 of the New York City Charter (“the Charter”) authorizes the Board of Health (“the Board”) to amend the Health Code and to include in the Health Code all matters to which the authority of the New York City Department of Health and Mental Hygiene (“the Department”) extends. Section 556 of the Charter gives the Department jurisdiction to regulate all matters affecting health in the City of New York (“the City” or “NYC”) and makes the Department responsible for controlling disease and regulating the City’s food supply.
The regulation of food service establishments (“FSEs”), a category that includes both quick-service and sit-down restaurants, is a core public health function. The Department issues permits to and inspects FSEs in New York City to ensure safe and healthy dining options.
The Department proposes an amendment to the Health Code that would require FSEs that are part of chains with more than 15 locations across the nation to add a warning label to menus and menu boards, identifying food items that contain very high levels of sodium.
Sodium and Cardiovascular Disease
Cardiovascular disease is the leading cause of death in New York City, claiming nearly 17,000 lives in in 2012.[i] Hypertension, or high blood pressure, is a major risk factor for heart disease and stroke. A 2013 survey conducted by the Department revealed that 29.1% of adult New Yorkers had been told they had hypertension by a healthcare professional.[ii] Although hypertension is a complex vascular disease with many origins, a well-established connection between sodium intake and blood pressure has been documented in the scientific literature. Specifically, there is a continuous relationship between sodium and blood pressure – typically, the higher an individual’s sodium intake, the higher the individual’s blood pressure.[iii] In addition, disparities exist in terms of sodium intake, hypertension control, and related risk of disease – for example, premature stroke mortality is nearly three times as high among non-Hispanic Blacks in NYC compared to Whites and Asians.
New Yorkers Consume Too Much Sodium
Americans consume excessive amounts of sodium. Recent estimates indicate that the typical daily sodium intake of more than 95% of American adults exceeds the recommended daily limit of no more than 2,300mg.[iv],[v] On average, American adults consume approximately 3,400mg of sodium daily, well above the recommended limit.[vi] Sodium overconsumption is a reality in NYC as well. A 2010 study conducted found that more than 80% of adults in NYC exceeded recommended daily sodium limits (2,300mg/day), and average daily sodium consumption among New Yorkers was more than 3,200mg.[vii] The NYC study also revealed disparities in consumption with higher sodium intake among non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites.[viii]
Restaurant Food is a Primary Source of Sodium
The contemporary food retail environment is an important contributor to the epidemic of sodium overconsumption. Despite myriad efforts and initiatives to curb sodium consumption by public health and other organizations, the sodium content of fast food, in particular, appears to be on the rise. A 2013 study examining the change in the sodium content of menu offerings at 8 leading fast food chains found that the mean sodium content of menu items had increased more than 23% between 1997 and 2010.[ix] Heavily marketed and competitively priced, the food available in many restaurants contains very high levels of sodium. A 2014 study analyzing the nutritional profile of more than 2,500 items from chain restaurants in and near Philadelphia, Pennsylvania, found that adult meals contained an average of 3,512mg of sodium, more than 50% above the daily recommended intake limit.[x] A similar study using receipt data collected in 2007 from over 6,500 transactions occurring at fast food chain outlets in NYC demonstrated that the sodium content of 20% of meals exceeded the daily recommended sodium intake limit.[xi] Today, nearly one-third of the sodium consumed by Americans comes from restaurant food.[xii]
New Yorkers Need to be Warned about High Sodium Foods
An additional factor that contributes to sodium overconsumption is the lack of awareness regarding the risks related to excess sodium intake. Consumers typically underestimate the sodium content of restaurant food[xiii] and are generally unaware of both sodium intake recommendations and the major sources of dietary sodium.[xiv] In addition, menu items that are promoted as healthy options, like salads, can contain high levels of sodium (Applebee’s Grilled Shrimp ‘n Spinach Salad with regular dressing contains 2,990 mg of sodium, Baja Fresh Mexican Grill’s Shrimp Tostada Salad contains nearly 2,500mg of sodium), putting even the most health-conscious consumers at risk. Differences in formulation that result in similar foods containing highly variable amounts of sodium present another obstacle to consumers trying to comply with sodium intake recommendations. For example, Panera Bread offers a Smokehouse Turkey® Panini that contains 2,590 mg of sodium and a Roasted Turkey & Avocado BLT Sandwich that contains 960mg of sodium.
It is imperative that consumers are readily able to identify menu items containing the recommended daily limit of 2,300mg or more of sodium, because these items are clearly incompatible with recommendations regarding sodium consumption. The proposed consumer warning label will provide consumers with information about food items that contain exceedingly high sodium levels and will empower them to make well-informed decisions when making choices for themselves and their family members in the food retail environment.
The Department proposes amending Health Code Article 81 to add a new section 81.49 requiring chain FSEs (those with 15 or more locations nationally) to warn consumers about any menu items containing 2,300mg of sodium or more.[xv]
This policy would impact FSEs with 15 or more locations nationally, capturing leading fast-food and fast-casual restaurants, which can easily make sodium information available.
[i] Zimmerman R, Li W, Gambatese M, Madsen A, Lasner-Frater L, Van Wye G, Kelley D, Kennedy J, Maduro G, SunY. Summary of Vital Statistics, 2012: Mortality. New York, NY: New York City Department of Health and Mental Hygiene, Office of Vital Statistics, 2014.
[ii] NYC DOHMH Community Health Survey, 2013
[iii] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
[iv] Centers for Disease Control and Prevention. Trends in the Prevalence of Excess Dietary Sodium Intake – United States 2003-2010. MMWR 2013;62:1021-1025.
[v] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
[vi] Centers for Disease Control and Prevention. Trends in the Prevalence of Excess Dietary Sodium Intake – United States 2003-2010. MMWR 2013;62:1021-1025.
[vii] Angell SY, Yi S, Eisenhower D, Kerker BD, Curtis CJ, Bartley K, Silver LD, Farley TA. Sodium Intake in a Cross-Sectional, Representative Sample of New York City Adults. American Journal of Public Health. 2014;104(12):2409-16.
[viii] Angell SY, Yi S, Eisenhower D, Kerker BD, Curtis CJ, Bartley K, Silver LD, Farley TA. Sodium Intake in a Cross-Sectional, Representative Sample of New York City Adults. American Journal of Public Health. 2014;104(12):2409-16.
[ix] Rudelt A, French A, Harnack L. Fourteen-year trends in sodium content of menu offerings at eight leading fast-food restaurants in the USA. Public Health Nutrition. 2013;17(8):1682-88.
[x] Auchincloss AH, Leonberg BL, Glanz K, Bellitz S, Ricchezza A, Jervis A. Nutritional Value of Meals at Full-service Restaurant Chains. J Nutr Educ Behav. 2014;46:75-81.
[xi] Johnson CM, Angell SA, Lederer A, Dumanovsky T, Huang C, Bassett MT, Silver LD. JAMA Internal Medicine. 2010;170(8):732-34.
[xii] Drewnowski A, Rehm CD. Sodium Intakes of US Children and Adults from Foods and Beverages by Location of Origin and by Specific Food Source. Nutritients. 2013;5:1840-55.
[xiii] Burton S, Creyer E, Kees J, Huggins K. Attacking the obesity epidemic: The potential health benefits of providing nutrition information in restaurants. American Journal of Public Health. 2006;96:1669–1675.
[xiv] Sarmugan R, Worsley A. Current Levels of Salt Knowledge: A Review of the Literature. Nutrients. 2014;6:5534-559.
[xv] Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments. Final Rule, 79 (230) Fed Reg 71156-71259. (December 1, 2014) (to be codified 21 CFR pt 11 and 101).