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Trends in the Prevalence of Excess Dietary Sodium Intake — United States, 2003–2010

Excess sodium intake can lead to hypertension, the primary risk factor for cardiovascular disease, which is the leading cause of U.S. deaths (1). Monitoring the prevalence of excess sodium intake is essential to provide the evidence for public health interventions and to track reductions in sodium intake, yet few reports exist. Reducing population sodium intake is a national priority, and monitoring the amount of sodium consumed adjusted for energy intake (sodium density or sodium in milligrams divided by calories) has been recommended because a higher sodium intake is generally accompanied by a higher calorie intake from food (2). To describe the most recent estimates and trends in excess sodium intake, CDC analyzed 2003–2010 data from the National Health and Nutrition Examination Survey (NHANES) of 34,916 participants aged ≥1 year. During 2007–2010, the prevalence of excess sodium intake, defined as intake above the Institute of Medicine tolerable upper intake levels (1,500 mg/day at ages 1–3 years; 1,900 mg at 4–8 years; 2,200 mg at 9–13 years; and 2,300 mg at ≥14 years) (3), ranged by age group from 79.1% to 95.4%. Small declines in the prevalence of excess sodium intake occurred during 2003–2010 in children aged 1–13 years, but not in adolescents or adults. Mean sodium intake declined slightly among persons aged ≥1 year, whereas sodium density did not. Despite slight declines in some groups, the majority of the U.S. population aged ≥1 year consumes excess sodium.

NHANES is a nationally representative, multistage survey of the noninstitutionalized U.S. civilian population. Certain populations are oversampled to allow for reliable estimates within subgroups.* During NHANES 2003–2010, a total of 49,731 participants aged ≥1 year (including those currently breastfed) were screened. Participants who completed an initial in-person dietary recall in a mobile examination center were asked to complete a second 24-hour dietary recall by telephone 3–10 days later. After those with missing or incomplete dietary recall data were excluded, the final analytic sample was 34,916, for a response rate of 70.3% among those screened. The 24-hour dietary recall was collected by trained interviewers using the U.S. Department of Agriculture (USDA) automated multiple-pass method by proxy for those aged 1–5 years, by participants with proxy assistance for those aged 6–11 years, and directly by participants aged ≥12 years. The nutrient values of sodium were assigned to foods and beverages using the USDA Food and Nutrient Database for Dietary Studies corresponding with each NHANES 2-year cycle.§ Sodium intake for each respondent on each recall day was estimated by summing the sodium consumed from each food and beverage during the previous 24 hours (excluding supplements, antacids, and salt added at the table). To evaluate trends, from 2003–2010, estimates of sodium in foods did not include salt adjustments for participants whose household used salt in cooking occasionally or less often. For children consuming human milk, the sodium content was estimated and added to sodium from other foods and beverages.**

Up to two 24-hour dietary recalls were used. Data were analyzed with statistical software that fits a measurement error model.†† All estimates were based on usual sodium intake, adjusting for within person, day-to-day variability. After adjusting for the day of the week of the recall, age (years), sex, and race/ethnicity, estimates were calculated for mean usual sodium intake, sodium density, and prevalence of excess sodium intake. Jackknife replicate weights based on survey weights were used to estimate standard errors and account for the complex survey design. The differences in the prevalence of excess sodium intake were examined by z test. Using linear regression models with the usual mean intake for each 2-year phase weighted by the inverse of the variance, trends in sodium intake and sodium intake density were examined using a z test. A p-value of <0.05 was considered statistically significant. No adjustment was made for multiple testing.

During 2007–2010, the prevalence of excess usual sodium intake ranged from 79.1% for U.S. children aged 1–3 years to 95.4% for U.S. adults aged 19–50 years (Table 1). A statistically significant 2.7–4.9 percentage point decline in excess usual sodium intake occurred from 2003–2006 to 2007–2010 among children aged 1–3, 4–8, and 9–13 years, but not among adolescents or adults. Among children aged 4–8 years, statistically significant declines occurred across all sex and race/ethnicity subgroups.

Mean usual sodium intake among the U.S. population aged ≥1 year decreased slightly from 2003–2004 to 2009–2010 (3,518 mg versus 3,424 mg; p-value for trend = 0.037). The U.S. population aged ≥1 year consumed, on average, approximately 1,700 mg sodium per 1,000 kcal during 2009–2010, with no significant trend over time compared with previous investigation years (Table 2). Across age groups, mean usual sodium density did not change significantly over time, with the exception of youths aged 14–18 years, for whom sodium density increased slightly. Within age groups, mean usual sodium density slightly increased among males aged 4–8 years and females aged 14–18 years and slightly declined among non-Hispanic whites aged ≥51 years.

Reported by

Alicia Carriquiry, PhD, Iowa State Univ. Alanna J. Moshfegh, MS, Lois C. Steinfeldt, MPH, Food Surveys Research Group, Beltsville Human Nutrition Research Center, Agricultural Research Svc, US Dept of Agriculture. Mary E. Cogswell, DrPH, Fleetwood Loustalot, PhD, Zefeng Zhang, MD, PhD, Quanhe Yang, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion; Niu Tian, MD, PhD, EIS Officer, CDC. Corresponding contributor: Niu Tian, vii9@cdc.gov, 770-488-5679.

Editorial Note

The findings in this report indicate that during 2007–2010, approximately eight out of 10 U.S. children aged 1–3 years and nine out of 10 U.S. residents aged ≥4 years were at potential risk for high blood pressure attributable to excess sodium intake. Although a slight decrease in the prevalence of excess usual sodium intake occurred after 2003–2006 among children aged 1–13 years, excess intake did not decrease among adolescents and adults. During 2003–2010, a slight decrease occurred in average population sodium intake, but not sodium intake per calorie. Although some variation in trends occurred among population subgroups in usual mean sodium intake and sodium density, the lack of a change in sodium consumed per calorie (approximately 1,700 mg/1,000 kcal) suggests that the small reduction in usual sodium intake might be related to declines in calorie consumption, rather than to changes in sodium density of foods.

Previous reports (4,5) included data on trends in U.S. sodium intake from the 1970s to 2003. The findings in this report update these trends, and include new data on usual excess sodium intake and sodium density. The slight declines in excess usual sodium intake among children aged 1–13 years might be partially explained by declines in energy intake among children over the same period.§§ Given an average sodium consumption of 1,700 mg/1,000 kcal/day, reducing 100 calories per day could result in a mean reduction of 170 mg of sodium per day, slightly shifting the distribution of sodium intake and lowering the percentage of those with excess intake. Among adults, the pattern of trends in sodium intake also might be explained by changes in energy intake over time. Although average energy intake declined slightly during 1999–2010 among adults aged 20–39 years, it did not change among older adults (6).

The findings in this report are subject to at least four limitations. First, NHANES data exclude military personnel and institutionalized populations such as persons who reside in long-term care or correctional facilities. Second, the response rate was 70.3%; lower response rates can result in response bias. Third, the 24-hour dietary recall underestimates mean caloric intake by an estimated 11% and sodium intake by 9%, and sodium intake excluded use of salt at the table, which accounts for nearly 5% of U.S. sodium intake (7). Finally, no adjustments for multiple comparisons were performed to determine whether differences between any pair of estimates were statistically significant.

Despite slight declines in sodium intake among some population groups, most U.S. residents aged ≥1 year consume excess sodium. Given consumption of approximately 1,700 mg of sodium per 1,000 kilocalories/day, a mean energy reduction of approximately 600 kcal/day would be required to reduce mean sodium intake by approximately 1,000 mg, to approximately 2,300 mg/day. A sodium density target of 1,000 mg/1,000 kcal was recently proposed to lower sodium intake to <2,300 mg per day (2). Given that average energy and sodium intakes have changed little over time, coupling efforts to reduce obesity with efforts to reduce the sodium content per calorie in foods might accelerate progress. Considering that 8.1% of sodium intake among U.S. children comes from school meals (8), new school food guidelines might promote progress toward achieving goals for reducing sodium consumption among children who obtain meals at school.¶¶ Other ongoing public health efforts include working with industry to gradually reduce sodium in commercially processed packaged and restaurant foods.*** Even a 400 mg reduction in mean U.S. sodium intake might save billions of health-care dollars (9).

References

  1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012;125:e2–220.
  2. Guenther PM, Lyon JM, Appel LJ. Modeling dietary patterns to assess sodium recommendations for nutrient adequacy. Am J Clin Nutr 2013;97:842–7.
  3. Institute of Medicine. Dietary reference intake for water, potassium, sodium, chloride, and sulfate. Washington, DC: The National Academies Press; 2005. Available at http://www.nal.usda.gov/fnic/DRI/DRI_Water/water_full_report.pdf.
  4. Bernstein AM, Willett WC. Trends in 24-h urinary sodium excretion in the United States, 1957–2003: a systematic review. Am J Clin Nutr 2010;92:1172–80.
  5. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr 2004;24:401–31.
  6. Ford ES, Dietz WH. Trends in energy intake among adults in the United States: findings from NHANES. Am J Clin Nutr 2013;97:848–53.
  7. Rhodes DG, Murayi T, Clemens JC, et al. The USDA automated multiple-pass method accurately assesses population sodium intakes. Am J Clin Nutr 2013;97:958–64.
  8. CDC. Vital signs: food categories contributing the most to sodium consumption—United States, 2007–2008. MMWR 2012;61:92–8.
  9. Coxson PG, Cook NR, Joffres M, et al. Mortality benefits from US population-wide reduction in sodium consumption: projections from 3 modeling approaches. Hypertension 2013;61:564–70.

* Additional information available at http://www.cdc.gov/nchs/nhanes.htm.

Additional information available at http://www.ars.usda.gov/ba/bhnrc/fsrg.

§ Additional information available at http://www.ars.usda.gov/services/docs.htm?docid=12089.

Additional information available at http://www.ncbi.nlm.nih.gov/pubmed/23567248.

** The volume of human milk was assumed to be 600 mL per day for children aged 7–11 months fed only human milk; 600 mL per day minus the volume of infant formula plus other milk for other children aged 7–11 months, 89 mL per human milk feeding for children aged 12–18 months, and 59 mL per feeding for children aged 19–36 months. Sodium, potassium, and energy concentrations in human milk were assumed to be 177 mg/L, 531 mg/L, and 75 kcal/L, respectively, based on the USDA National Nutrient Database for Standard Reference values for mature, human milk, 33.8 fluid ounces per liter.

†† PC-SIDE (Software for Intake Distribution Estimation for the Windows operating system), Center for Agriculture and Rural Development, Iowa State University. Additional information available at http://www.side.stat.iastate.edu/pc-side.php and http://www.card.iastate.edu/publications/synopsis.aspx?id=168.

§§ Additional information available at http://www.cdc.gov/nchs/data/databriefs/db113.htm.

¶¶ Additional information available at http://www.gpo.gov/fdsys/pkg/FR-2012-01-26/html/2012-1010.htm.

*** Additional information available at http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892012001000009&lng=en&nrm=iso&tlng=en.


What is already known on this topic?

Excess sodium intake can lead to hypertension and consequent cardiovascular disease. Sodium consumption in the United States is well above national recommendations. Reports of national data on sodium consumption trends are limited.

What is added by this report?

As of 2010, >90% of U.S. adolescents and adults consume sodium in excess of recommendations, and little has changed since 2003. U.S. children have seen a slight decline in excess sodium consumption during the same period, but 80%–90% of children continue to consume excess sodium. From 2003 to 2010, a slight decrease occurred in average sodium intake, but not sodium intake per calorie.

What are the implications for public health practice?

Small reductions in sodium intake might be related to declines in average energy consumption, rather than changes in the amount of sodium per calorie in foods consumed. Given that average energy and sodium intakes have changed little over time, coupling efforts to reduce obesity with efforts to reduce the sodium content per calorie in foods might accelerate reductions in sodium consumed.


TABLE 1. Proportion of usual sodium intake exceeding the Institute of Medicine tolerable upper intake level,* by age group, sex, and race/ethnicity— National Health and Nutrition Examination Survey (NHANES), United States, 2003–2010

Characteristic

Upper limit

(mg/day)

2003–2006

2007–2010

Percentage point change

p-value

No.§

Proportion
over upper intake level
(%)

Standard
error

No.

Proportion
over upper intake level
(%)

Standard
error

Age 1–3 yrs

1,500

1,560

(84.0)

1.4

1,558

(79.1)

1.9

(-4.9)

0.019

Male

784

(84.1)

2.0

809

(79.4)

2.7

(-4.7)

0.081

Female

776

(84.3)

2.2

749

(79.7)

2.2

(-4.6)

0.071

White, non-Hispanic

470

(84.0)

2.9

525

(80.3)

3.7

(-3.7)

0.215

Black, non-Hispanic

407

(87.6)

3.3

297

(86.3)

3.0

(-1.3)

0.385

Mexican-American

519

(75.7)

3.2

437

(71.2)

4.9

(-4.5)

0.222

Age 4–8 yrs

1,900

1,682

(97.3)

0.4

1,890

(92.6)

0.8

(-4.6)

<0.001

Male

815

(97.7)

0.5

995

(94.3)

1.0

(-3.4)

0.008

Female

867

(96.9)

0.8

895

(90.5)

1.4

(-6.3)

<0.001

White, non-Hispanic

479

(96.3)

0.8

621

(90.3)

1.5

(-5.9)

<0.001

Black, non-Hispanic

519

(98.9)

0.7

402

(95.6)

1.3

(-3.3)

0.012

Mexican-American

517

(94.2)

1.4

529

(89.3)

2.6

(-4.9)

0.045

Age 9–13 yrs

2,200

2,040

(96.9)

0.7

1,717

(94.2)

0.9

(-2.7)

0.008

Male

999

—**

—**

850

(96.8)

0.7

††

††

Female

1,041

(91.4)

1.6

867

(90.1)

1.7

(-1.4)

0.279

White, non-Hispanic

516

(97.0)

0.8

544

—**

—**

††

††

Black, non-Hispanic

691

—**

—**

406

—**

—**

††

††

Mexican-American

669

(95.4)

1.3

456

(84.8)

3.1

(-10.5)

0.001

Age 14–18 yrs

2,300

2,673

(94.2)

1.0

1,552

(92.3)

1.5

(-1.9)

0.145

Male

1,353

(97.8)

0.7

818

—**

—**

††

††

Female

1,320

(84.2)

2.3

734

(80.2)

3.1

(-4.0)

0.938

White, non-Hispanic

731

(95.7)

1.0

517

(93.4)

1.7

(-2.3)

0.123

Black, non-Hispanic

938

(90.7)

1.8

369

—**

—**

††

††

Mexican-American

820

(94.3)

1.3

385

(90.0)

2.2

(-4.3)

0.047

Age 19–50 yrs

2,300

5,428

(95.9)

0.4

6,086

(95.4)

0.5

(-0.5)

0.200

Male

2,528

(99.2)

0.1

2,936

(99.1)

0.2

(-0.1)

0.242

Female

2,900

(86.6)

1.2

3,150

(84.8)

1.4

(-1.9)

0.152

White, non-Hispanic

2,384

(97.1)

0.4

2,598

(96.4)

0.6

(-0.7)

0.170

Black, non-Hispanic

1,310

(92.5)

1.4

1,190

(93.4)

0.8

(0.9)

0.709

Mexican-American

1,276

(93.5)

1.0

1,270

(90.8)

1.3

(-2.8)

0.050

Age ≥51 yrs

2,300

4,062

(88.9)

1.0

4,668

(90.1)

0.8

(1.2)

0.839

Male

2,028

(95.9)

0.6

2,341

(96.5)

0.5

(0.6)

0.782

Female

2,034

(77.1)

1.4

2,327

(77.9)

1.4

(0.9)

0.668

White, non-Hispanic

2,416

(91.4)

0.9

2,273

(92.8)

0.8

(1.4)

0.876

Black, non-Hispanic

762

(79.0)

2.4

975

(82.2)

2.0

(3.2)

0.842

Mexican-American

674

(67.7)

3.9

757

(76.3)

3.1

(8.6)

0.959

* The upper intake level is the age-specific, tolerable upper intake level, as defined by the Institute of Medicine (2005). The proportion of usual sodium intake over the upper intake level was estimated using PC-SIDE software (Department of Statistics, Iowa State University) with jackknife replicate weights and adjusted for the day of the week of the recall, age (years), sex, and race/ethnicity. Persons missing data on incomplete first-day recall were excluded from the analysis.

Other racial/ethnic groups were not included. The sum of the sample size of non-Hispanic white, non-Hispanic black, and Mexican-American is not equal to the total sample size.

§ Sample sizes unweighted.

p<0.05, when trends of proportion of usual sodium intake over the upper intake level were examined using the z test.

** Data statistically unreliable; relative standard error ≥0.3.

†† Not applicable.


TABLE 2. Mean usual sodium density* (mg/1,000 kcal), by age group, sex, and race/ethnicity — National Health and Nutrition Examination Survey (NHANES), United States, 2003–2010

Characteristic

2003–2004

2005–2006

2007–2008

2009–2010

Changes
per
cycle

p-value
for
trend

No.§

Mean

Standard error

No.

Mean

Standard error

No.

Mean

Standard error

No.

Mean

Standard error

Overall

8,579

1,661

10

8,866

1,693

14

8,473

1,697

12

8,998

1,689

10

9

0.248

Male

4,192

1,653

9

4,315

1,666

14

4,266

1,695

15

4,483

1,690

14

14

0.054

Female

4,387

1,669

17

4,551

1,719

17

4,207

1,698

16

4,515

1,688

13

2

0.879

White, non-Hispanic

3,541

1,679

10

3,455

1,710

14

3,367

1,698

11

3,711

1,692

10

4

0.560

Black, non-Hispanic

2,284

1,617

26

2,343

1,637

14

1,939

1,664

21

1,700

1,632

17

5

0.652

Mexican-American

2,123

1,548

15

2,352

1,569

16

1,773

1,582

16

2,061

1,581

28

13

0.063

Age 1–3 yrs

740

1,431

21

820

1,458

34

765

1,429

23

793

1,427

15

-3

0.589

Male

363

1,404

32

421

1,472

46

399

1,392

34

410

1,419

25

0

0.993

Female

377

1,457

31

399

1,433

20

366

1,463

27

383

1,433

22

-3

0.727

White, non-Hispanic

226

1,435

25

244

1,472

36

246

1,399

36

279

1,434

34

-5

0.729

Black, non-Hispanic

218

1,500

30

189

1,464

34

163

1,497

29

134

1,479

75

-3

0.840

Mexican-American

228

1,364

49

291

1,343

31

207

1,368

46

230

1,360

47

3

0.695

Age 4–8 yrs

783

1,541

19

899

1,550

19

934

1,530

20

956

1,556

23

2

0.822

Male

382

1,491

20

433

1,531

21

500

1,544

31

495

1,573

41

27

0.028**

Female

401

1,594

29

466

1,567

28

434

1,518

24

461

1,541

21

-18

0.252

White, non-Hispanic

220

1,545

31

259

1,522

28

300

1,480

26

321

1,546

37

-7

0.747

Black, non-Hispanic

261

1,574

42

258

1,614

40

230

1,620

32

172

1,568

32

-3

0.840

Mexican-American

224

1,434

34

293

1,491

23

250

1,524

31

279

1,487

31

3

0.695

Age 9–13 yrs

995

1,601

23

1,045

1,633

16

832

1,637

32

885

1,636

19

9

0.292

Male

482

1,580

35

517

1,640

29

411

1,647

40

439

1,665

30

25

0.102

Female

513

1,622

34

528

1,627

39

421

1,625

45

446

1,613

27

-3

0.269

White, non-Hispanic

266

1,568

28

250

1,648

25

252

1,638

45

292

1,635

23

17

0.370

Black, non-Hispanic

350

1,750

58

341

1,685

39

224

1,722

48

182

1,599

30

-44

0.140

Mexican-American

301

1,520

45

368

1,613

27

206

1,514

64

250

1,598

38

12

0.700

Age 14–18 yrs

1,343

1,567

26

1,330

1,636

39

738

1,683

36

814

1,689

30

43

0.036**

Male

697

1,594

33

656

1,638

50

385

1,721

38

433

1,678

37

35

0.143

Female

646

1,535

31

674

1,625

36

353

1,644

36

381

1,698

37

54

0.036**

White, non-Hispanic

360

1,586

33

371

1,639

48

247

1,717

47

270

1,675

38

34

0.137

Black, non-Hispanic

488

1,542

42

450

1,531

27

195

1,594

50

174

1,609

25

27

0.137

Mexican-American

411

1,551

31

409

1,607

28

165

1,656

70

220

1,631

58

36

0.104

Age 19–50 yrs

2,583

1,657

17

2,845

1,717

20

2,865

1,718

14

3221

1,708

11

12

0.345

Male

1,226

1,651

21

1,302

1,687

22

1,404

1,712

15

1532

1,703

20

18

0.163

Female

1,357

1,660

25

1,543

1,742

29

1,461

1,723

22

1689

1,712

17

10

0.527

White, non-Hispanic

1,189

1,663

21

1,195

1,729

25

1,188

1,720

18

1410

1,709

15

11

0.432

Black, non-Hispanic

633

1,603

50

677

1,641

30

623

1,664

31

567

1,636

22

5

0.697

Mexican-American

560

1,578

17

716

1,598

25

598

1,602

15

672

1,601

30

9

0.113

Age ≥51 yrs

2,135

1,778

17

1,927

1,759

16

2,339

1,768

23

2,329

1,748

20

-8

0.159

Male

1,042

1,784

25

986

1,712

24

1,167

1,768

25

1,174

1,760

36

-3

0.904

Female

1,093

1,775

20

941

1,799

19

1,172

1,767

27

1,155

1,736

24

-15

0.290

White, non-Hispanic

1,280

1,799

18

1,136

1,771

17

1,134

1,752

17

1,139

1,738

25

-21

0.012**

Black, non-Hispanic

334

1,671

29

428

1,689

30

504

1,726

32

471

1,697

34

12

0.354

Mexican-American

399

1,637

45

275

1,567

47

347

1,657

42

410

1,631

31

4

0.809

* Sodium intake density was calculated as sodium intake divided by daily calories. Mean usual sodium intake density was estimated using PC-SIDE software (Department of Statistics, Iowa State University) with jackknife replicate weights and adjusted for the day of the week of the recall, age (years), sex, and race/ethnicity. Persons missing first-day recall data were excluded.

Other racial/ethnic groups were not included. The sum of the sample size of non-Hispanic white, non-Hispanic black, and Mexican-American is not equal to the total sample size.

§ Sample sizes are unweighted.

Mean change in sodium density per 2-year cycle (mg/1,000 kcal) estimated from a linear regression model with the usual mean sodium density for each 2-year phase weighted by the inverse of the variance.

** p<0.05, when mean usual sodium intake density was examined by using linear regression model.


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