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Mapping and Analysis of US State and Urban Local Sodium Reduction Laws

Sloan, Arielle A. JD, MPH; Keane, Thomas JD, MPA; Pettie, Jennifer Rutledge JD, MPH; Bhuiya, Aunima R. BSc; Taylor, Lauren N. MPH; Bates, Marlana MPH, RD; Bernard, Stephanie PhD, MPH; Akinleye, Fahruk MPH; Gilchrist, Siobhan JD, MPH

Author Information
Journal of Public Health Management and Practice: March/April 2020 - Volume 26 - Issue - p S62-S70
doi: 10.1097/PHH.0000000000001124

Abstract

The 2015-2020 Dietary Guidelines for Americans (“Dietary Guidelines”) recommend that adults consume fewer than 2300 mg of sodium per day, while the American Heart Association encourages an even lower daily maximum of 1500 mg for the majority of adults.1,2 However, the average US adult between the ages of 20 and 69 years consumes 3608 mg of sodium daily: 1.6 and 2.4 times as high, respectively, as each of these limits.3 The researchers estimate that if American adults met the Dietary Guidelines sodium intake recommendation, the number of American adults with hypertension would drop by 11 million and the amount of health care spending would decline by $18 billion annually.4

While sodium reduction may improve public health and save money, reaching this goal may prove difficult for consumers who lack access to or information about lower-sodium choices in their food environment. Even the most common foods in grocery stores, institutional facilities (such as nursing homes), vending machines, workplaces, and restaurants can include more than a third of a day's sodium limit, including some sandwiches, burgers, topping-heavy salads, and soups.5–8 While federal laws restrict sodium content and require menu labeling in certain food settings,9,10 many food facilities—especially those that cater to adults specifically—are not required by federal law to do so. This leaves the option of regulating sodium in food to state and local governments or to voluntary initiatives.

A publicly available early evidence assessment conducted by the Centers for Disease Control and Prevention (CDC), called the Quality and Impact of Component (QuIC) Evidence Assessment, identified 6 sodium reduction policy interventions (“interventions”) supported by varying degrees of early public health evidence.11 Some states and localities have implemented these interventions in the form of law. However, there is no current, publicly available listing of such laws across the United States.* The purpose of this legal epidemiology study is to compile and analyze sodium reduction laws in the 20 most populous cities and 20 most populous counties in the United States (“urban local” jurisdictions) and in the 50 states. The prevalence of sodium reduction laws is analyzed by policy intervention, geography, jurisdiction type (state vs urban local), and QuIC evidence classification. By determining how many laws are affiliated with each of these interventions, it is possible to identify where potential gaps in research or implementation of evidence-based interventions in law exist that warrant further exploration.

Methods

Based primarily on the 6 QuIC evidence interventions, the researchers collected laws authorizing, requiring, incentivizing, or preempting (1) vending machines to contain certain types or percentages of lower-sodium products (“vending laws”), (2) daily meal providers (eg, administrators of adult prisons or of residential living/congregate care services) to provide lower-sodium options to consumers (“meal services laws”), (3) workplaces to make lower-sodium options available to employees (“workplace laws”), (4) restaurants and other food service entities to provide consumers with sodium content information (“labeling laws”), (5) economic initiatives to help consumers purchase lower-sodium foods (“consumer incentives laws”), and (6) grocers, convenience store owners, or corner store owners to offer lower-sodium food (“grocery laws”). See Table 1 for more in-depth definitions of each category.

TABLE 1
TABLE 1:
Definition of the 6 Sodium Reduction Interventions Studied, With Law Example and Summary of All Laws Found per Category

Laws suitable for inclusion were statutes, regulations, ordinances, board policies, executive orders, and resolutions that fit into at least one of the 6 interventions (see definitions and examples of each intervention in Table 1). Laws also had to either expressly state the word “sodium” or “salt” or incorporate another policy that did so.

Only laws that targeted the general population or adults older than 18 years were included in this study due to high rates of hypertension in this population.12 Moreover, laws addressing therapeutic (prescribed) diets or that merely referenced the Dietary Guidelines for Americans or related standards (Dietary Reference Intakes etc) were too common to code comprehensively and were also excluded.

Pairs of legal researchers used Westlaw to identify relevant laws in the 50 states and Washington, District of Columbia, and used Municode, American Legal Publishing, Code Publishing, or local government Web sites to identify relevant laws in the remaining 19 most populous cities (excluding Washington, District of Columbia) and the 20 most populous counties in the United States.§ Each pair compared findings and discussed and resolved discrepancies for each law identified. Relevant laws were then categorized by policy intervention, with multiple categorizations allowed. One researcher also conducted an additional search of other food policy databases, including the Healthy Food Policy Project database,13 the Center for Science in the Public Interest's sodium policy database,14 the National Conference of State Legislatures' sodium policy listings,15 and Grassroots Change's state nutrition preemption law listings,16 to find and code additional relevant laws.

Results

Figure 1 shows the distribution of sodium reduction and preemption laws across all states and urban local jurisdictions studied. The researchers identified 48 laws meeting inclusion criteria, and 10 of these were preemption laws. Of the 38 remaining sodium reduction laws, 21 were established at the state level (representing 15 states), 5 at the county level (representing 5 counties), 10 at the city level (representing 6 cities), and 2 in Washington, District of Columbia (Figures 1 and 2). State sodium reduction laws were spread across the United States, and urban local sodium reduction laws were mainly found along the West Coast and in the Northeast (Figures 1 and 3).

FIGURE 1
FIGURE 1:
Map of State and Urban Local Sodium Reduction Laws in Effect January 1, 2019a aA larger circle indicates that more than 1 sodium reduction law is present in an urban local jurisdiction (city or county). For simplicity, states with sodium reduction laws were not shaded according to the number of sodium reduction laws present. Urban local jurisdictions are named in footnote “a” of Figure 3.
FIGURE 2
FIGURE 2:
Number of Sodium Reduction Laws per Jurisdiction Type, by Intervention, in Effect January 1, 2019a aWashington, District of Columbia, and San Francisco joint city-county laws are coded as “city” in this chart.
FIGURE 3
FIGURE 3:
Number of Sodium Reduction Laws per US Census Region, by Intervention, in Effect January 1, 2019a aRegions are based on US Census divisions (https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf): Northeast (9 states, 5 urban localities): Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York (including Kings County, Queens County, New York County, and New York City), and Pennsylvania (including Philadelphia). Midwest (12 states, 5 urban localities): Illinois (including Chicago and Cook County], Indiana (including Indianapolis), Michigan (including Wayne County), Ohio (including Columbus), Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota. South (16 states, 14 urban localities including District of Columbia): Delaware, Florida (including Jacksonville, Miami-Dade County, and Broward County), Georgia, Maryland, North Carolina (including Charlotte), South Carolina, Virginia, District of Columbia, West Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas (including Houston, San Antonio, Dallas, Austin, Fort Worth, Harris County, Dallas County, Tarrant County, and Bexar County). West (13 states, 16 urban localities): Arizona (Phoenix and Maricopa County), Colorado (Denver), Idaho, Montana, Nevada (Clark County), New Mexico, Utah, Wyoming, Alaska, California (Los Angeles, Los Angeles County, San Diego County, San Jose, San Diego, Orange County, Riverside County, San Bernardino County, San Francisco, and Santa Clara County), Hawaii, Oregon, and Washington (King County and Seattle).

As shown in Tables 1 and 2, laws that expressly authorized or required lower sodium offerings for meal services (n = 17) or workplaces (n = 12) were found in all 4 US regions. Both meal services and workplace provisions were found in jurisdiction-wide food procurement laws, and meal services provisions were also found in laws pertaining to residential care facilities and correctional facilities. The QuIC assessment classified both of these types of laws as supported by “best” (or the highest level of) early evidence (see the Supplementary Digital Content Table, available at http://links.lww.com/JPHMP/A633, for definitions of each QuIC category).

TABLE 2
TABLE 2:
Comparison of QuIC Ratings to Number of Laws per Sodium Reduction Category as of January 1, 2019

Vending machine (n = 13) and labeling (n = 11) laws were also common. Both were found in the context of jurisdiction-wide procurement laws, and labeling provisions were also found in laws pertaining to chain restaurants. Although vending machine laws were found in all 4 US regions, labeling laws were found in only 3 (Northeast, Midwest, and the West). Labeling was also most commonly preempted (in 9 state laws). The QuIC assessment classified vending machine interventions as having “promising impact” (an intermediate classification) and labeling interventions as supported by “best” early evidence.

The 2 least common sodium reduction laws were those that authorized or required grocers to carry or that incentivized consumers to purchase lower-sodium items. Consumer incentive provisions were found in jurisdiction-wide food procurement laws and laws implementing purchasing subsidy programs. Grocer initiatives were found in laws implementing government-supported healthy grocery store programs. Only 6 laws, 3 of which were local, targeted consumers, whereas only 2 laws (one state and one local) specifically targeted grocers. Both were present in only 2 regions each. The QuIC assessment categorized sodium-specific grocery store interventions as supported by “best” early evidence and sodium-specific consumer incentive interventions as supported by “emerging” early evidence (its lowest classification).

Ten state laws preempted local governments from enacting certain types of sodium reduction laws, including 2 in states that also had sodium reduction laws (Maine and Georgia). The majority of preemption laws were found in the Midwest and in the Southeastern United States and most often preempted labeling at the local level.

Discussion

Only 27 of the 90 jurisdictions studied had at least 1 sodium reduction law targeting adults or the general population. This was expected, as sodium reduction policy is a developing field of policy and public health interest.11 Law counts also varied notably by QuIC evidence classification rating, intervention, jurisdiction type, and geography. This discussion describes possible reasons for these variations and suggests opportunities for continued research.

The most common sodium reduction law interventions (workplaces, meal services, vending, and labeling) were supported by either best or promising early public health evidence, whereas consumer incentives laws were less common and supported by weaker (“emerging”) evidence. This suggests that the state of sodium reduction law and the state of corresponding public health evidence are generally aligned. The one exception to this finding was that grocery interventions with specific sodium components were supported by best evidence but were least common in law. However, healthy corner store programs have been relatively popular throughout the country in recent years and have emerged in large cities such as Baltimore, Philadelphia, and New York City.17 It may be the case, therefore, that governments recognize the public health value of grocer initiatives but that programs provide more freedom to experiment with locally tailored approaches at this time.18 Continued research is warranted to determine how grocery-focused sodium reduction programs and laws evolve in the future.

It should be noted that although workplace and meal services laws had similar levels of evidentiary support as menu labeling laws, they were less commonly preempted. This may be because workplace and meal services laws in this data set applied to government-owned or -regulated entities. Such laws show that policy makers are willing to “walk-the-walk” of nutrition reform, protect the health of government employees and vulnerable residents, and promote long-term government health care savings.19–21 Labeling laws, however, are often public-facing and impact private entities, and it is perhaps more difficult to find public support for these kinds of laws. Regulating sodium content information in restaurants might be viewed as hindrances to business development and freedom of speech, for example.22 Again, however, ongoing surveillance of the state of evidence and law among these 3 interventions is warranted to determine whether this finding changes in the future.

Often, sodium reduction laws were either more common in the studied urban localities than in states or, at a minimum, just as common as in states. Many of these laws impact businesses and the eating behaviors of noninstitutionalized adults, so they understandably need strong public support to implement successfully.18 Broad Leib explains that localities are better equipped than states to pass such laws because every local food system is different, and local governments can more easily “work with local constituents to craft targeted responses” to local problems.18(p323) Stahl adds that “[u]rbanites generally have a greater tolerance ... for government regulation because aggressive ... intervention is often required to coordinate activity among large groups of strangers in a densely populated area.”23 It would therefore make sense that urban localities would have more sodium reduction laws than states. Indeed, the only sodium reduction law in this study that was more common in states than in urban localities targeted meal services providers and that may only have been because most of those meal services providers were already being licensed or regulated at the state level.

Sodium reduction and preemption laws also varied by region. About a quarter of all sodium reduction laws were in California (despite representing only 11 of 90 jurisdictions in the data set), half of preemption laws were in the South (despite representing 16 of 50 states in the data set), and the fewest (n = 4) sodium reduction laws were found in the Midwest (despite representing 17 of 90 jurisdictions in the data set), for example. These regional differences may be rooted in cultural, economic, or governmental factors.24 Regardless of these differences, however, all 4 US regions had sodium reduction laws. Further research on regional involvement in sodium reduction programs or related initiatives might provide a more comprehensive understanding of sodium reduction efforts across the country.25

Evidentiary, jurisdictional, and regional factors all appear to be interrelated with the small but varied constellation of sodium laws in 2019. However, the respective weights of each of these factors on sodium law have yet to be fully teased out. Continued national surveillance and jurisdiction-specific research may be warranted to better understand these influences.

Limitations

This study does not include state or local contracts, programs, requests for proposals, administrative policies, or corporate policies. This study also does not include laws or policies targeted toward children 18 years or younger, laws in cities or counties not in the top 20 by population, or laws that are indirectly related to sodium reduction (such as laws that promote nonprocessed or plant-based foods generally). These restrictions were decided upon in an effort to narrow the scope of research to laws or policies with the strongest (and often most binding) applicability to adult sodium consumers. However, research into each of these areas could shed additional light on the national sodium policy landscape.

The authors used multiple methods, including redundant searches, multiple search strategies, and several databases, in an attempt to identify all current laws meeting inclusion criteria. However, the authors acknowledge that some laws may be missing, because they were unavailable, difficult to search for online, used language unanticipated by search strings, or were subjectively classified. The data set provided here is therefore considered noncomprehensive and subject to change.

The appropriateness of adopting any law, policy, or program is a question best suited for the residents and policy makers of a jurisdiction but should be based on the best evidence available. Moreover, public health evidence evolves over time. This study broadly notes the early evidence bases supporting 6 types of policy interventions. However, readers are encouraged to read Table 1, the CDC Sodium QuIC assessment,11 and accompanying QuIC documentation26 to learn about limitations specific to the QuIC analysis and the extent to which it can be compared with this legal analysis.

Conclusion

State and urban local sodium reduction laws that target food or beverages consumed or purchased by adults or the general population are relatively uncommon in the United States. However, the number of sodium reduction laws overall and by intervention varies by QuIC evidence classification, region, and jurisdiction type (state vs urban local). Future research should continue to track evolutions in evidence and law and seek to better understand scientific, cultural, economic, and other influences on sodium reduction policy.

Implications for Policy & Practice

  • State and urban local sodium reduction laws are not common, and the number of sodium reduction laws varies by intervention type, region, and jurisdiction type (state or urban local).
  • Early evidence generally supports more common types of sodium reduction laws, including those that affect offerings in workplaces, institutional meal settings, and vending machines, as well as those that target provision of sodium information in restaurants or at point of purchase (labeling).
  • Continued policy surveillance and additional research are warranted to track the degree to which developments in public health evidence over time correspond to changes in state and local sodium reduction laws.

References

1. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans 2015-2020. https://health.gov/dietaryguidelines/2015/guidelines/executive-summary. Published December 2015. Accessed August 12, 2019.
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3. Cogswell ME, Loria CM, Terry AL, et al Estimated 24-hour urinary sodium and potassium excretion in US adults. JAMA. 2018;319(12):1209–1220. https://reference.medscape.com/medline/abstract/29516104. Accessed August 13, 2019.
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11. Centers for Disease Control and Prevention. What Is the Evidence for State and Local Laws Addressing Sodium Reduction Interventions Among the US Adult Population? A Policy Evidence Assessment Report. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2019.
12. High blood pressure. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/bloodpressure/index.htm. Last reviewed May 13, 2019. Accessed August 6, 2019.
13. Policy Database. Healthy Food Policy Project Web site. https://healthyfoodpolicyproject.org/policy-database. Accessed January 15, 2019.
14. Examples of policies to increase access to healthier food choices for public places: national, state, and local food and nutrition guidelines. Center for Science in the Public Interest Web site. https://cspinet.org/sites/default/files/attachment/examples2_0.pdf. Published October 19, 2017. Accessed August 7, 2019.
15. State laws related to dietary sodium. National Conference of State Legislatures Web site. http://www.ncsl.org/research/health/analysis-of-state-laws-related-to-dietary-sodium.aspx. Accessed January 15, 2019.
16. Preemption map. Grassroots Change Web site. https://grassrootschange.net/preemption-watch/#/category/nutrition. Accessed January 15, 2019.
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22. Hodge JG, Barraza LF. Legal regulation of sodium consumption to reduce chronic conditions. Prev Chronic Dis. 2016;13:E26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758800. Accessed August 12, 2019.
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* Several related databases exist, such as the National Conference of State Legislature's state sodium policy listings, the Healthy Food Policy Project, and Preemption Watch. However, the authors were not able to identify any databases that included both state and local laws, treated the topic of sodium reduction law comprehensively, and were fewer than several years old. These databases were used to inform this surveillance project.
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† Based on 2017 US Census estimates.
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‡ One representative administrative policy was also included in this study that was listed in a Board Policy Manual. The authors used best judgment to determine which policies or standards were either legally binding (as ordinances, regulations, and statutes generally are) or had equivalent standing to a resolution focused on specific sodium reduction standards.
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§ Each legal researcher used different search strings to identify laws of interest depending on the quantity of laws in each jurisdiction. In cities, for example, researchers often searched using the string “salt” or “sodium,” while this string produced too many results in Westlaw to code comprehensively. After state coding was complete, the lead researcher conducted one final search in Westlaw using the search string adv: (salt or sodium)/10 (diet or meal or sugar or fat or food or calorie or beverage or drink or nutri! or intake or consum! or reduc!).
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¶ Two of these 38 laws granted broad jurisdictional authority to regulate nutrition, including sodium, but due to lack of specificity in the laws regarding the specific interventions that would likely be targeted, they were included in overall analysis and excluded from intervention analysis. Only 36 laws have been categorized by intervention.
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Keywords:

food; law; salt; sodium; surveillance

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