Sodium Reduction: State Policy Interventions by Evidence Level

Meal service providers offer items that are consistent with nutrition guidance, along with corresponding nutrition education encouraging participants to adopt dietary patterns that promote nutritional health and reduce the risk of diet-related chronic disease.¹ The available evidence mentioned sodium limits on items (i.e., prepared foods, packaged snacks, and/or beverages) delivered by daily meal providers, such as:

• No more than 720 mg of sodium per serving of combo meal items, 600 mg of sodium per serving for entrée items, 200 mg of sodium per serving for side items, and 200 mg per serving of sodium per package for snack items (Morrison’s new Great Living patient menu).²
• No more than 700 mg sodium per serving (LiVe Well Plate health initiative).³

State law example: “Agencies providing congregate nutrition or home delivered meal services must comply with the following menu planning requirements: … The sodium content shall not exceed 1,300 mg per meal.” 10A N.C. Admin. Code 6K.0203(a) (2019) [PDF – 13.8 KB].

Local law example: “All City agencies shall follow the Food Standards [New York City Food Standards, here [PDF – 133 KB], which set several limits on sodium content] for all meals that are purchased, prepared or served by the agency.” N.Y.C. Executive Order No. 122 (Sept. 19, 2008) [PDF – 18.4 KB].

Limiting sodium in prepared foods, packaged snacks, and beverages served or purchased in workplaces or worksites may be achieved by setting nutrition standards, increasing the availability and access of lower sodium options in locations serving employees, and restricting the sodium content in foods or beverages served at work events or meetings.

This strategy is linked to reductions in sodium intake over time and improved health outcomes and workforce productivity.^4,5,6 The available evidence included sodium limits on items served or purchased in workplaces, such as:

• No more than 800 mg of sodium per serving for sandwiches, salads, and entrees; 480 mg of sodium per serving for soups; 200 mg of sodium per serving for steamed, baked, or grilled vegetables; 200 mg of sodium per serving for prepackaged snacks; and 800 mg of sodium per serving for a value meal (New York City Healthy Hospital Food Initiative).⁷

NOTE: Hospital cafeterias were included for this policy intervention, as hospital employees, staff, patients, and visitors dine in this setting.

State law example: “The Commissioner of Health shall establish and post on the Department’s website nutrition procurement standards that…consider both positive and negative contributions of nutrients, ingredients, and food groups to diets, including calories, portion size, saturated fat, trans fat, sodium, sugar, and the presence of fruits, vegetables, whole grains, and other nutrients of concern in Americans’ diets; and…[a]ll foods and beverages purchased, sold, served, or otherwise provided by the State or any entity, subdivision, or employee on behalf of the State shall meet the minimum nutrition procurement standards established by the Commissioner of Health.” Vt. Stat. Ann. tit. 29, § 160c (West 2018).

Local law example: “City departments shall use their best efforts to adhere to the following recommended nutritional guidelines for food and/or beverages that are (A) served at City Meetings or City-Sponsored Events and (B) purchased using City funds…. Healthy food items should be served, such as the following: …Minimally processed foods that are made or produced without added sugar and are ‘low sodium’….” San Francisco Admin. Code § 4.9-1 (2019).

Manufacturers providing nutrition content on the front of packages and on menus can influence purchasing habits and sodium consumption. When required to display numeric or symbolic indicators of the sodium content in items (i.e., prepared foods, packaged snacks, and/or beverages), manufacturers are likely to reduce sodium in their items and positively affect consumer health. Labels can come in the form of traffic lights, text labels with sodium amounts, or scores based on nutrient content.

NOTE: Literature related to Nutrition Facts labels was excluded, as these labels are covered within federal law through The Nutrition Labeling and Education Act.

State law example: Each chain restaurant shall accurately ascertain and make available on site, and in written format, the typical nutrient values for each menu item and combination meal menu item, as the item is usually prepared and offered for sale on menus, menu boards and food tags, including condiments routinely added to a menu item as part of a standard recipe: …Total milligrams of sodium.” Or. Admin. R. 333-015-0110 (2019).

Local law example: “A covered establishment that offers for sale any food item with a high sodium content must provide the following warning: …An icon must appear on a menu or menu board next to any food item with a high sodium content, or on a tag next to any food on display that is a food item with a high sodium content…. The icon must be a black and white equilateral triangle as wide as it is tall and equal in height to the largest letter in the food item’s name, as displayed on the menu, menu board, or tag next to any food on display; and [t]he following statement must be posted conspicuously at the point of purchase: ‘Warning: [symbol] indicates that the sodium (salt) content of this item is higher than the total daily recommended limit (2300 mg). High sodium intake can increase blood pressure and risk of heart disease and stroke.’” N.Y.C. Health Code § 81.49(b) (2019). [PDF – 488 KB]

Incentivizing or requiring stores (including chain grocery stores, convenience stores, corner stores, bodegas, gas stations, retailers, and markets) to limit sodium in the foods (i.e., prepared foods, packaged snacks, and/or beverages) they are selling may reduce consumer sodium intake by increasing the availability of lower sodium products,⁸ encouraging consumers to purchase food with lower sodium content,^9,10 influencing consumer ordering decisions and intentions,¹¹ and supporting community programs that promote access to healthy foods and the reduction of sodium intake.¹² When available, the evidence base included sodium limits such as:

• No more than 2,300 mg of sodium per day (2010 Dietary Guidelines for Americans).¹³

State law example: “[A] healthy corner store shall meet the following requirements to be certified by the Department: …(3) Actively promote healthy foods through signage and premium shelf space. (4) Stock items that include…a minimum of six (6) types of fresh produce…low-sodium or unsweetened canned fruits and vegetables….” Okla. Admin. Code § 35:40-13-2 (2019).

Local law example: “There is hereby created a Healthy Food Retailer Incentives Program for the City and County of San Francisco to be administered by the Department…. The purpose of the Program shall be to increase access to healthy food; reduce unhealthy influences such as tobacco, alcohol, and processed foods high in salt, fat, and sugar in underserved parts of the City; and stimulate economic development and job creation by creating incentives for Healthy Food Retailers to open or expand in those underserved areas.” San Francisco Admin. Code § 59.4 (“Healthy Food Retailer Incentives Program”) (2018).

Items in vending machines meeting sodium limits are part of a larger strategy to increase the availability of and access to healthy foods.¹⁴ From the available evidence, sodium limits on items (i.e., packaged snacks and/or beverages) sold in vending machines included:

• No more than 200 mg of sodium per serving (Massachusetts School Nutrition Standards for Competitive Foods and Beverages¹⁵ and Food Services Guidelines for Federal Facilities).¹⁶
• No more than 230 mg of sodium per serving for “green foods” and no more than 400 mg of sodium per serving for “yellow foods” in a stoplight-categorized system (Eskenazi Health, loosely modeled on the Health and Sustainability Guidelines for Federal Concessions and Vending Operations).¹⁷
• No more than 360 mg of sodium per serving (Los Angeles Healthy Vending Machine Policy).¹⁴
• No more than 400 mg of sodium per serving (Alliance for a Healthier Generation and American Heart Association).¹⁸

State law example: “By July 1, 2014, all state executive agencies shall adopt and begin to implement a food and beverage service policy for employees…. These policies shall ensure for the provision of healthful food and beverages in…vending machines…. These policies shall meet the standard of the Washington State Healthy Nutrition Guidelines [PDF – 6.46 MB]….” Washington Executive Order No. 13-06 (October 30, 2013) [PDF – 63.6 KB].

Local law example: “On all County property, at least 75 percent of the packaged food and beverage options offered in vending machines shall be healthy food or beverage options…[and h]ealthy food options shall…[c]ontain no more than 200 mg of sodium per package.” Howard Cty., Md., Code §§ 12.1801(d)(6), 12.1802 (2019).

Economic incentives (such as subsidies and reduced licensing fees for restaurants) can potentially lower the cost of low sodium items such as prepared foods, packaged snacks, and beverages. The intervention is briefly mentioned in five items of evidence.^19-23 A health impact assessment with a mathematical simulation found that food procurement policies, including incentives, could achieve positive health and economic outcomes.²⁰ While there is limited evidence related to sodium reduction, the concept of economic incentives is considered an evidence-based strategy to improve overall population dietary habits.²³

State law example: “The Department of Human Services shall establish a Healthy Local Food Incentives Program to double the purchasing power of Illinois residents with limited access to fresh fruits and vegetables…[to purchase] any variety of fresh, canned, dried, or frozen whole or cut fruits and vegetables without added sugars, fats, or oils, and salt (i.e. sodium)….” 305 Ill. Comp. Stat. Ann. 5/12-4.50 (West 2019).

Local law example: “A Restaurant may not provide an incentive item linked to the purchase of a single food item or meal if it includes any of the following: …More than 480 mg of sodium for a single food item, or more than 600 mg of sodium for a meal….” Santa Clara Cty., Cal., Code § A18-352 (2019).*

*Although the law highlighted here has often been discussed in the context of children’s meals, the text of this subsection of the law appears to have a general population focus.

1. Lederer A, Toner C, Krepp EM, Curtis CJ. Understanding hospital cafeterias: results from cafeteria manager interviews. J Public Health Manag Pract. 2014;20(1 Suppl 1):S50-S53. doi:10.1097/PHH.0b013e31829f7378
2. Centers for Disease Control and Prevention. Reducing Sodium Makes Cents: How Morrison Healthcare Is Moving the Marketplace Toward Healthful, Lower Sodium Foods for Smaller Purchasers. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
3. Derrick JW, Bellini SG, Spelman J. Using the Hospital Nutrition Environment Scan to evaluate health initiative in hospital cafeterias. J Acad Nutr Diet. 2015;115(11):1855-1860. doi:10.1016/j.jand.2015.06.378
4. Millen BE, Abrams S, Adams-Campbell L, et al. The 2015 Dietary Guidelines Advisory Committee scientific report: development and major conclusions. Adv Nutr. 2016;7(3):438-444. doi:10.3945/an.116.012120
5. Doran K, Resnick B, Alghzawi H, Zhu S. The worksite heart health improvement project’s impact on behavioral risk factors for cardiovascular disease in long-term care: a randomized control trial. Int J Nurs Stud. 2018;86:107-114. doi:10.1016/j.ijnurstu.2018.06.011
6. Flannery K, Resnick B, McMullen TL. The impact of the Worksite Heart Health Improvement Project on work ability: a pilot study. J Occup Environ Med. 2012;54(11):1406-1412. doi:10.1097/JOM.0b013e3182619053
7. Centers for Disease Control and Prevention. NYC Healthy Hospital Food Initiative. Atlanta, GA: Centers for Disease Control and Prevention; 2014.
8. Gittelsohn J, Suratkar S, Song H-J, et al. Process evaluation of Baltimore Healthy Stores: a pilot health intervention program with supermarkets and corner stores in Baltimore City. Health Promot Pract. 2010;11(5):723-732. doi:10.1177/1524839908329118
9. Zenk SN, Odoms-Young A, Powell LM, et al. Fruit and vegetable availability and selection: federal food package revisions, 2009. Am J Prev Med. 2012;43(4):423-428.
10. Dannefer R, Williams DA, Baronberg S, Silver L. Healthy bodegas: increasing and promoting healthy foods at corner stores in New York City. Am J Public Health. 2012;102(10):e27-e31. doi:10.2105/AJPH.2011.300615
11. Centers for Disease Control and Prevention. Reducing Sodium—A Johnson County Heart Health Initiative. Atlanta, GA: Centers for Disease Control and Prevention; 2013.
12. Aoki JR, Dawkins SA, Bishop SK. Implementing the IOM’s recommendations for reducing sodium in the U.S. food supply: considerations and approaches. Food Drug Law J. 2014;69(1):53-85, ii.
13. Greer S, Schieb L, Schwartz G, Onufrak S, Park S. Association of the neighborhood retail food environment with sodium and potassium intake among U.S. adults. Prev Chronic Dis. 2014;11:E70. doi:10.5888/pcd11.130340^a
14. Wickramasekaran RN, Robles B, Dewey G, Kuo T. Evaluating the potential health and revenue outcomes of a 100% healthy vending machine nutrition policy at a large agency in Los Angeles County, 2013–2015. J Public Health Manag Pract. 2018;24(3):215-224. doi:10.1097/PHH.0000000000000702^b
15. Brooks CJ, Barrett J, Daly J, et al. A community-level sodium reduction intervention, Boston, 2013–2015. Am J Public Health. 2017;107(12):1951-1957. doi:10.2105/AJPH.2017.304070^c
16. Centers for Disease Control and Prevention. Food Services Guidelines: Case Studies from States and Communities. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
17. Centers for Disease Control and Prevention. Eskenazi Health Food and Nutrition Services, Indianapolis, Indiana: Sodium Reduction in Vending Machines. Atlanta, GA: Centers for Disease Control and Prevention; 2016.
18. Mason M, Zaganjor H, Bozlak CT, Lammel-Harmon C, Gomez-Feliciano L, Becker AB. Working with community partners to implement and evaluate the Chicago Park District’s 100% Healthier Snack Vending Initiative. Prev Chronic Dis. 2014;11:E135. doi:10.5888/pcd11.140141^d
19. Cummings PL, Kuo T, Gase LN, Mugavero K. Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010–2012. J Public Health Manag Pract. 2014;20(1 Suppl 1):S16-S22. doi:10.1097/PHH.0b013e31829d7f63
20. Gase LN, Kuo T, Dunet D, Schmidt SM, Simon PA, Fielding JE. Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the county of Los Angeles. Am J Public Health. 2011;101(8):1501-1507. doi:10.2105/AJPH.2011.300138
21. Gase LN, Kuo T, Dunet DO, Simon PA. Facilitators and barriers to implementing a local policy to reduce sodium consumption in the County of Los Angeles government, California, 2009. Prev Chronic Dis. 2011;8(2):A33.
22. Levings JL, Gunn JP. From menu to mouth: opportunities for sodium reduction in restaurants. Prev Chronic Dis. 2014;11:130237. doi:10.5888/pcd11.130237
23. Mozaffarian D. Dietary and policy priorities for cardiovascular disease, diabetes, and obesity: a comprehensive review. Circulation. 2016;133(2):187-225. doi:10.1161/CIRCULATIONAHA.115.018585

^aMixed outcome—Results showed no significant relationship between sodium intake and food environment. The presence or absence of stores selling more healthy foods does not influence levels of sodium consumption. Interventions may be more effective at the national level versus the local level.

^bNegative outcome—The authors reported a decrease in revenue related to snacks and beverages purchased in vending machines.

^cMixed outcome—The authors indicated that there was no overall significant change in percentage of prepackaged foods with more than 200 mg per serving of sodium across vending machines. However, there was statistically significant decrease in the percentage of products with more than 200 mg per serving of sodium in the YMCA, community health centers, and organizations serving homeless populations.

^dMixed outcome—The authors reported that individuals had positive remarks on the healthful snack vending items (including low sodium options), but noncompliance was an issue and may have stemmed from mislabeling of items and restocking issues within vending machines.