N A TIONAL INSTITUTES OF HEAL T H

N A TIONAL HEAR T , LUNG, AND BLOOD INSTITUTE

National High Blood Pressure Education Program

IMPLEMEN

RECOMME

FOR DIET

REDUCTIO

WHERE ARE 

WHERE ARE 

HO W D O W 

A S UMMAR

NHLBI WO
IMPLEME

RECOMM

FOR DIE

REDUCTI

WHERE AR

WHERE AR

HOW DO W

A S UMMA

NHLBI W

NIH PUBLI

NO. 55-728

NOVEMBER 

NATIONAL I

O F HEALTH

National H

and Blood I
Abstract...............................................................................................................................................

Introduction .......................................................................................................................................

Presentations—Where Are We?...........................................................................................................

Rationale for Sodium/Salt Reduction ...........................................................................................

Recommendations for Sodium Intake .........................................................................................

Salt and Sodium Intake...............................................................................................................

Sources of Sodium .......................................................................................................................

Nutrition Labeling .....................................................................................................................

Salt Taste.....................................................................................................................................

Food Industry .............................................................................................................................

Behavior Change.........................................................................................................................

Monitoring .................................................................................................................................

Working Group Recommendations—Where Are We Going? .............................................................

Closing Panel—How Do We Get There?.............................................................................................

Acknowledgments ...............................................................................................................................

References ...........................................................................................................................................

TABLE OF CONTENTS
iv

Table A: Percentage distribution of blood pressure levels in U.S. adult population ...............

Table B: Trends in mean 1-day dietary sodium intake (milligrams), by sex and age, from sel

national surveys: 1971 through 1991 ...................................................................

Table C: Reports of baseline urine sodium excretion in clinical trials of normotensive and 

hypertensive adults .................................................................................................

Table D: Percent of sodium contributed by food groups in adults .........................................

Table E: Definitions of sodium content claims on food labels ...............................................

Table F: Percent of respondents for whom various factors in food selection are very importan

Table G: Percent of consumers, by age, selecting foods in quick-service restaurants based on 

taste, convenience, cost, or health ...........................................................................

Table H: Percent of respondents who are very or somewhat concerned about specified 

nutrition content of food.........................................................................................

Table I: Percent of food store patrons changing dietary behavior .........................................

Table J: Percent of restaurant patrons consciously restricting foods .....................................

Table K: Modifiable challenges to salt/sodium reduction .......................................................

Table L: Monitoring change in sodium reduction behaviors and quantifying the change in 

sodium intake.........................................................................................................

TABLES
IMPLEMENTING RECOMMENDATIONS FOR

DIETARY SALT REDUCTION

WHERE ARE W E? WHERE ARE W E GOING? HO W D O W E GET THERE?

A SUMMARY O F A N NHLBI WORKSHOP

Marguerite Evans, M.S., R.D.

Division of Epidemiology and Clinical

Applications

National Heart, Lung, and Blood Institute

Jerome D. Cohen, M.D.

Preventive Cardiology

St. Louis University

Shiriki Kumanyika, Ph.D., R.D., M.P.H.

Department of Human Nutrition and Dietetics

University of Illinois at Chicago

Jeffrey A. Cutler, M.D., M.P.H.

Division of Epidemiology and Clinical

Applications

National Heart, Lung, and Blood Institut

Edward J. Roccella, Ph.D.

Office of Prevention, Education, and Cont

National Heart, Lung, and Blood Institut

For the Planning Committee and Participa

the Workshop
ABSTRACT

In 1993, the National High Blood Pressure

Education Program (NHBPEP) recommended

that the time is appropriate for a national campaign, the specific goal of which is the primary

prevention of high blood pressure. Various sets of

data clearly show that mean dietary salt/sodium

intake in our population is higher than optimal

and is one of the important mass exposures that

accounts for the generally unfavorable blood 

pressure distribution. In 1994, the National

Heart, Lung, and Blood Institute assembled representatives from a variety of disciplines (including researchers active in dietary aspects of blood

pressure reduction; representatives from the food

and restaurant industries; Federal, State, and local

public health professionals; and c

specialists) to discuss and recomm

tion strategies and materials, mo

ods, and research directions for d

um reduction. The recommenda

assembly, or workshop, are mean

to the foundation on which the N

developing a national campaign 

reduction as one step toward the 

vention of hypertension. This pa

the workshop presentations, the 

recommendations, and the closin

sion. It uniquely compiles differ

spectives on implementing publi

mendations for dietary salt reduc

vi
National dietary recommendations have consistently included qualitative recommendations for

salt/sodium since the 1970s, even as scientific

evidence has continued to accumulate. The

workshop summarized in this paper,

Implementing Recommendations for Dietary

Salt Reduction, was predicated on a scientific

perspective and proceeded with certain assumptions based on conclusions of the National

Heart, Lung, and Blood Institute (NHLBI)

Workshop on Salt and Blood Pressure.1

In August 1994, the NHLBI assembled representatives from a variety of disciplines (including

researchers active in dietary aspects of blood

pressure reduction; representatives from the food

and restaurant industries; Federal, State, and

local public health professionals; and communications specialists) to discuss and recommend

intervention strategies and materials, monitoring

methods, and research directions. The recommendations from this workshop are meant to

contribute to the foundation on which the

National High Blood Pressure Education

Program (NHBPEP) is developing a national

campaign for salt/sodium reduction as one step

toward the primary prevention of hypertension.

This paper summarizes the workshop presentations that provided the background on “where

are we,” the working group recommendations on

“where are we going,” and the closing panel discussion of “how do we get there.” This paper

compiles different current perspectives on implementing public health recommendations for

dietary salt/sodium* reduction.

The initiation of the NHLBI’s National H

Blood Pressure Education Program in 197

resulted in the development of a series of r

by the NHBPEP’s Joint National Commit

Detection, Evaluation, and Treatment of H

Blood Pressure (JNC) that provided guide

for screening, diagnosis, and management 

hypertension. Over the past years, activit

the NHBPEP focused primarily on the ph

cologic treatment of high blood pressure a

only relatively recently on nonpharmacolo

treatment, including dietary salt/sodium r

tion and its role in hypertension preventio

parallel with these efforts, recent years hav

the introduction and promotion of sodium 

ing on food products, national dietary guid

and the development of a variety of lower

salt/sodium food products by the food ma

turing industry. Despite these accomplish

sodium intake remains considerably highe

generally recommended.

In 1993, the NHBPEP recommended in i

Working Group Report on Primary Prevention 

Hypertension2 that the time is appropriate f

NHBPEP to initiate a national campaign, 

specific goal of which is the primary preve

of high blood pressure. “The campaign sh

inform the public and health care provider

the lifestyles and specific factors that incre

risk of developing high blood pressure and 

foster the adoption of population-based an

geted intervention strategies aimed at the 

vention of hypertension.”

INTRODUCTION

* The term “salt/sodium” is used in this paper when the statement is true for both salt and sodium. However, when the statement is true only for one, t

only that one is stated. Terminology has been a source of confusion for the lay public.
viii

The importance of a populationwide and primary

prevention approach cannot be fully understood

without knowledge of the nature of the blood

pressure (BP) problem in the United States.

Various sets of data clearly show that mean

dietary salt/sodium intake in our population is

higher than optimal and is one of the important

mass exposures that accounts for 

unfavorable blood pressure distri

goal of lowering habitual salt/sod

the U.S. population is driven by 

wide distribution of adverse BP l

causal relationship to high salt/so
RATIONALE FOR SODIUM/SALT REDUCTION

In the United States and most other countries

(both industrialized and economically developing), BP rises with age for most people during

the decades from youth through middle age. As

a consequence, by middle age, population average systolic (SBP) and diastolic (DBP) blood

pressures are above optimal levels (below 120/80

mmHg).3 Only a small minority have optimal

BP levels, and an absolute majority have highnormal and high BP levels (table A), with resultant increased risk of major cardiovascular diseases. These adverse BP patterns prevail in all

geographic, ethnic, and socioeconomic strata

(SES) of the U.S. middle-aged and older population and in particular among African Americans

and lower SES groups.3,4

The basal sodium requirement for growing and

adult humans is no greater than 8 to 10mmol/day

(equivalent to about 500 mg of salt)5-7 and may

be lower.

6 Exposure to a high-sodium diet

greater than the physiologic need is an exposure

to which the human species has had no opportunity for evolutionary adaptation by natural selection.8 To arrive at sound judgment on the role of

salt/sodium as one of the key exposures causing

elevated BP, consideration must be given — in

accordance with established scientific practice —

to all the evidence, from all research methods.

This evidence is extensive1 — from clinical therapeutics, animal experimentation, physiology and

pathophysiology, cross-population and withinpopulation epidemiologic research, anthropology,

and randomized controlled trials.

From mid-century on, feeding experimental animals high-salt/sodium diets was repeatedly

shown to raise BP9 and data from observa

studies in humans10-12 indicated a relation

between population average sodium intak

average BP and/or prevalence of hyperten

Low sodium intake in isolated populations

around the world was found to be associat

low-normal average BP, little or no rise in 

during adulthood, and low or zero prevale

rates of hypertension. In addition, the IN

SALT study, a cross-sectional epidemiolog

showed a significant graded relation of 24

urinary sodium excretion to SBP independ

age, sex, alcohol intake, body mass, and u

potassium, calcium, and magnesium. A d

ence in population median sodium intake 

mmol/day (e.g., 70 versus 170 mmol/day 

1,610 versus 3,910 mg/day) was associate

a gradient in SBP/DBP of 10/6 mmHg fr

22 to age 55.13-16 This relationship, of al

equal magnitude, was also found for nonh

tensive INTERSALT participants, suggest

that BP response to changes in sodium in

not confined to the hypertensive populatio

Consistent with results of observational ep

ologic studies, meta-analyses of recent ran

ized controlled trials indicated that a 65

mmol/day (1,500 mg/day) sodium reducti

about 104 mmol/day (2,300 mg/day) lead

population average SBP reduction of abou

mmHg and DBP reduction of about 2 mm

The BP reduction was about 5/3 mmHg i

hypertensive subjects and about 2/1 mmH

normotensive subjects.17 The estimated p

tive impact on cardiovascular disease risk 

cause mortality of downward shifts in BP 

ution resulting from habitual lower salt/so

intake is substantial.4

PRESENTATIONS — WHERE ARE WE?
2

P ERCENT AGE DISTRIBUTION O F BLOOD PRESSURE LE

U.S. ADUL T POPULA TION 3

High 

Optimal Normal Normal Stage 1 Stage 

SBP <120 120-129 130-139 140-159 160-17

DBP <80 80-84 85-89 90-99 100-10

Overall 47 21 13 14 

Non-Hispanic Black 43 21 13 16 

Men 30 27 17 18 

18-49 41 30 14 11 

50-69 10 22 23 33 

70+ 10 18 23 30 1

Women 54 15 10 13 

18-49 71 14 7 5 

50-69 21 19 16 27 1

70+ 14 13 17 35 1

Non-Hispanic White 48 21 13 13 

Men 36 27 17 16 

18-49 45 30 14 10 

50-69 21 23 21 27 

70+ 13 16 22 33 1

Women 59 16 10 11 

18-49 78 13 6 3 

50-69 28 24 19 23 

70+ 12 14 18 32 1

Mexican American 46 21 15 13 

Men 37 24 20 13 

18-49 49 29 15 7 

50-69 15 17 31 22 1

70+ 9 12 29 25 1

Women 56 16 10 12 

18-49 77 14 6 2 

50-69 19 24 20 27 

70+ 10 12 15 40 2

aBased on categories established in the Fifth Report of the Joint National Committee on Detection, Evaluation, and 

of High Blood Pressure, 1992.

Note: Rows may not total 100 percent due to rounding.

Table A
These research findings on salt/sodium intake and

BP, as well as those on other lifestyle factors that

contribute to observed adverse BP patterns in our

population (excessive consumption of calories,

physical inactivity, excessive alcohol consumption,

and deficient intake of potassium), have led to a

major national priority for addressing elevated BP

as a public health problem. The results achieved

with unifactorial interventions probably underestimate those that can be obtained under circumstances where an effective combined or multifactorial intervention is applied. From a practical

point of view, many of the interventions are

mutually supportive and reinforcing.

Combination interventions (e.g., sodium reduction and weight reduction) have been applied in a

number of trials.18-22 Nevertheless, the research

study results indicate a need for salt/sodium

reduction for hypertension prevention independent of the need for other lifestyle changes.

RECOMMENDATIONS FOR SODIUM INTAKE

Specific quantitative recommendations for

salt/sodium intake for the public and for hypertensive patients have been available since the

mid-1970s and have evolved over time. In 1977,

the U.S. Senate Select Committee on Nutrition

and Human Needs first addressed the issue of

nutrition in the prevention of chronic disease 

and recommendations for dietary salt were quantified.23 Since then, reduction of dietary salt/sodium for the prevention of hypertension has been

advocated by a myriad of public agencies and

health organizations.24-31

In 1993, the NHBPEP’s Fifth Report of the Joint

National Committee on Detection, Evaluation, and

Treatment of High Blood Pressure (JNC V)32 recommended lifestyle modifications, including moderation of salt/sodium intake, as definitive or adjunctive therapy for hypertension. The NHBPEP’s

Working Group Report on Primary Prevention of

Hypertension2 recommends moderation of dietary

sodium to a level of no more than 100 mmol

(about 2,400 mg sodium or approximately 6,000

mg salt) per day as a method to prevent blood

pressure from rising, in effect preventing 

hypertension.

SALT AND SODIUM INTAKE

Data on dietary sodium intake and discret

salt usage are currently collected as part of 

1988-91 National Health and Nutrition

Examination Survey (NHANES III).33 Me

sodium intake (not including discretionary 

added to prepared foods at the table) was 

mmol (3,289 mg) (or 70 mmol [1,598 mg

1,000 kcal) for all ages,34 which greatly ex

the estimated minimum requirements of h

nonpregnant, nonlactating adults (about 5

sodium/day)7 and the NHBPEP’s recomm

daily intake for adults of no more than 2,4

sodium/day.

2,32 Intake by adults reporting 

were told by a physician or another health 

sional on two or more occasions that they 

had hypertension was not different from th

nonhypertensives. In these data, mean sod

intake of adults appears to be unrelated to

income, poverty status, education, region, 

race/ethnicity by univariate analyses.34

Quantification of discretionary salt, which 

been done consistently over the several na

surveys, must be estimated by the survey 

dent. The absence of adequate detail resu

underestimation of sodium intake from die

surveys and may render monitoring based 

dietary data insensitive to changes in popu

sodium intake from discretionary sources.3

On the other hand, food industry represen

state that sodium has been silently lowered 

food products over the past 20 years. It is 

ble that the sodium content of some produ

may not have been accurately captured in 

industry nutrient composition databases, r

in overestimation of sodium intake in nati

surveys. However, efforts to compare estim

calculated sodium intake with laboratory a

of the same foods provide little support fo

claims.36 Some efforts are being made to 

and improve the level of sodium detail in 

U.S. Department of Agriculture (USDA) s

databases to permit retrospective trend ev

tion. If nutrient data banks are kept curre

if food manufacturers contribute to these e
4

the level of detail on food product consumption

that is now collected in national dietary surveys

will permit improved estimates of intakes of sodium consumption from processed foods and detection of trends could be enhanced.

Given the aforementioned caveats, dietary 

trends are difficult to assess. Nevertheless,

national survey (table B)37-41 and clinical trial

data (table C)17,20-22,42-48 indicate little change

compared to the median levels in the 1970s.

SOURCES OF SODIUM

Studies of the sources of sodium49-52 indicate

about 75 percent comes from food processing, 10

to 11 percent is inherent (naturally occurring),

about 15 percent is discretionary (half of which is

contributed by table salt and half by cooking),

and less than 1 percent is from water.

A year 2000 Public Health Service objective is

that 80 percent of the population not use salt at

the table.53 Overall, about 53 percent of persons

under 20 years of age, and 41 percent over 20,

report not using salt at the table.54 Of the population that does report using salt at the table,

about 33 percent of adults and 20 percent of

children “frequently” use salt. The proportion of

the adult population who report using sodiumreduced salt or a salt substitute is 4 to 5 percent

and 1 to 2 percent, respectively.

A broad look at food groups contributing to 

sodium intake over the past decade is provided

by comparing national survey data from the

NHANES II (1976-80)55 and the Continuing

Survey of Food Intakes by Individuals (CSFII)

(1989-91) (personal communication, 1994) (table

D); both surveys used a 24-hour dietary recall,

although methods and databases have changed

over time. The top three groups combined

(breads, rolls, crackers; hot dogs, ham, lunchmeats; soups) represented 31 percent and 25 percent of the totals for these two time periods,

respectively. Other important food group sources

of sodium are pasta dishes, rice, pizza, and

cheese.

Conclusions regarding food contr

um intake are very sensitive to th

grouped and combined, but the T

(TDS) conducted by the Food and 

Administration’s (FDA) — which 

8940 and used 12 different major 

had similar results. The TDS, N

CSFII surveys all indicate that gr

TDS grouped as grains; in NHAN

grouped as breads, rolls, crackers

cookies; pasta; rice; etc.) represen

quarter of the total sodium intake 

Other major contributors from th

mixed dishes (e.g., pizza, soups in 

CSFII), animal flesh (e.g., beef, h

lunchmeats in NHANES and CS

products (e.g., cheese, milk, milk 

NHANES and CSFII), the relativ

of which is about half of the total 

There has been little change in th

ings of these groups during the 1

relative contributions were very s

the age groups in the TDS.

NUTRITION LABELING

In 1990, Congress passed the Nu

and Education Act (NLEA) to am

Drug, and Cosmetic Act and man

be included on nutrition labels.56 

January 6, 1993, the FDA promu

nutrition labeling regulations tha

content be declared in the absolu

ligrams) as well as a percent of th

(2,400 mg) in a serving.57 For fo

for children under 4 years of age, 

FDA has not established Daily Re

only the absolute amount is requ

sodium content is allowed to dev

from the label declaration by no m

percent. Definitions for the optio

tent claims — free, very low, low, 

lite/light, unsalted — have been 

(table E). Claims for salt — salt 

added, lightly salted — that are b

sodium content have also been de
T RENDS I N MEAN 1 - D A Y DIET A R Y SODIUM INT AKE

( MILLIGRAMS ), B Y SEX AND AGE , FROM SELECTED

N A TIONAL SUR VEYS : 1971 THROUGH 1991 a

Table B

Sex and Age NHANES I NHANES II CSFII NHANES III CS

(Years) 1971-74 1976-80 1985-86 1988-91 1989

Males and Females

<1b – 1,046 – 575 4

1-2 1,631 1,828 1,873 1,938 1,8

3-5 1,925 2,173 2,169 2,531 2,3

6-11 2,393 2,716 – 2,998 3,0

Males

12-15 2,923 3,405 – 4,018 3,8

16-19 3,219 4,030 – 4,783 4,4

20-29 3,123 3,916 4,021 4,659 4,3

30-39 2,928 3,550 3,604 4,445 3,9

40-49 2,839 3,542 3,330 3,960 3,9

50-59 2,515 3,278 – 3,640 3,8

60-69 2,381 2,975 – 3,409 3,4

>70c 2,114 2,804 – 3,072 3,2

Females

12-15 2,094 2,567 – 2,927 3,0

16-19 1,812 2,336 – 3,097 2,7

20-29 1,928 2,404 2,593 3,002 2,6

30-39 1,822 2,354 2,491 2,977 2,6

40-49 1,793 2,327 2,486 2,919 2,4

50-59 1,713 2,186 – 2,575 2,3

60-69 1,548 2,108 – 2,578 2,4

>70c 1,473 1,903 – 2,360 2,2

a Sources: National Center for Health Statistics (NCHS), First National Health and Nutrition Examination Survey,

1971-74; NCHS, Second National Health and Nutrition Examination Survey, 1976-80; USDA, Continuing Survey of

Food Intakes by Individuals, 1985-86 (data for males for 1985 only); NCHS, Third National Health and Nutrition

Examination Survey, 1988-91; USDA, Continuing Survey of Food Intakes by Individuals, 1989-91.

b NHANES II includes data for 6- to 11-month-olds only. NHANES III includes data for 2- to 11-month-olds only.

c NHANES I and NHANES II include data for 70- to 74-year-olds only.
Sample Average Body Mass 

Baseline Size Age Index Weight 

Trial Years (% female) (years) (kg/m2) (kg) 

NORMOTENSIVE

PPHa,18 79-81 201 38 NA 84 

(13%)

HPT19,92 82-83 841 39 27 81 

(35%) 27M 86M

26F 71F

HIPc,42 84-85 407 39 27 NA 

(13%) 28M

data on 169 23F

TOHP I43 87-88 2,182 43 28 NA 

(29.9%) 28M 

27F 

TOHP II44 90-92 2,382 44T 31 NA 

1,566M 43M 31M 

816F 44F 31F

(34%)

HYPERTENSIVE

HCPa,21 80 189 56 NA 77 

(36%)

TAIMd,45 85-87 878 48 NA 86 

(44%) 48M 92M 

49F 79F 

TOMHS22,46,93 86-88 902 55 29 NA 

38%F 55M 29M 

55F 29F 

DISHd,47 80 496 57 NA 80 

(41%)

HIT48 84-85 166 48 NA NA 

a Stamler R, personal communication, 1995.

b Extrapolated from 8-hour urine sodium by multiplying by 3.8.

c Caggiula A, personal communication, 1995.

d Davis B, personal communication, 1995.

6

R EPOR T S O F BASELINE URINE SODIUM EXCRETION I N

CLINICAL TRIALS O F NORMOTENSIVE AND HYPER TEN

ADUL T S

Table C
The potential benefits of the new nutrition labeling are not only to provide information to the

consumer at the time of purchase, a key time

when making food selection decisions, but also

to encourage food manufacturers to reformulate

foods and make their sodium content lower.

SALT TASTE

Salt is known to increase food palatability in two

conceptually distinct ways. First, it adds its own

salty taste to foods. Second, and less widely

appreciated, it appears to modify other tastes

and flavors favorably and suppresses bitterness,

without necessarily making the foods taste salty.

Thus, when salt is reduced or removed from a

food, not only is the saltiness of that food

altered, but the balance of other flavors is

changed. Also, sodium contributes to the 

and stability of many products and serves 

tion, which may be difficult to replace, in 

leavening agents.

A technical barrier to sodium reduction is 

there is presently no acceptable substitute 

that provides similar taste satisfaction. Be

the sodium-sensitive channels in human ta

receptors are highly specific for sodium, it 

be difficult to develop an acceptable subst

However, it is theoretically possible that a 

enhancer (e.g., a substance that creates mo

channels or keeps them open longer) could 

developed. Some potential salt enhancers 

been proposed.

NHANES II (55) CSFIIa

(1976-80) (1989-91)

Ages 19+ years Ages 18+ years

Food Group % Food Group %

Breads, rolls, crackers 14 Breads, rolls, crackers 11

Hot dogs, ham, lunchmeats 10 Hot dogs, ham, lunchmeats 8

Soups 7 Soups 6

Cheese 6 Pasta 6

Potatoes 5 Beef (ground) 4

Milk, milk beverages 4 Potatoes 4

Donuts, cakes, cookies 4 Rice 4

Pasta 4 Pizza 4

Beef (ground) 3 Cheese 3

Pizza 2 Milk, milk beverages 3

Beef (solid) 2 Donuts, cakes, cookies 2

Cumulative % 61 Cumulative % 55

a Subar, personal communication, 1994.

P ERCENT O F SODIUM CONTRIBUTED B Y FOOD GROUPS I N

ADUL T S

Table D
8

CLAIM DEFINITIONb

Sodium free less than 5 mg/reference amountc and per labeled se

ingredient that is sodium chloride or generally unde

to contain sodium without asterisked statement)d

Very low sodium not more than 35 mg/reference amountc and 50 mg f

reference servinge

Low sodium not more than 140 mg/reference amountc and 50 mg 

small reference amounte

Reduced or less sodium at least 25 percent less sodium than reference food a

erence food is not “low sodium”

Lite/light in sodium at least 50 percent less sodium than reference foodf

Salt free meets criteria for sodium free

No salt added, unsalted no salt added during processing; the food it resembl

for which it substitutes is normally processed with sa

sodium free, declare “not a sodium free food” on inf

tion panel

Lightly salted at least 50 percent less sodium than normally added 

ence food; if not low sodium, so state on informatio

a Office of the Federal Register. Code of Federal Regulations. Chapter 21, Parts 101.56 (nutrient content claims 

“lite”) and 101.61 (nutrient content claims for the sodium content of foods).

b These definitions apply to food products other than meal products and main dish products. The latter types 

have different requirements.

c Reference amount customarily consumed per eating occasion, as defined in the FDA regulation.

d Asterisked statement may say “adds a trivial amount of sodium,” “adds a negligible amount of sodium,” or 

insignificant amount of sodium.”

e Small reference amount is defined as 300 g or less or 2 tablespoons or less.

f If the food is also “low calorie” and “low fat,” can use a “light” or “lite” claim without reference to sodium.

D EFINITIONS O F SODIUM CONTENT CLAIMS O N FOOD L

Table E

Factor/Year 1988 1990 1992 19

Taste 88 88 89 9

Nutrition 72 75 77 7

Price 65 66 75 7

Product safety 83 71 71 6

Ease of preparation 39 33 36 3

P ERCENT O F RESPONDENTS FOR WHOM V ARIOUS F AC

I N FOOD SELECTION ARE VER Y IMPOR T ANT 64-68,74

Table F
The basis for the human preference for salted

foods probably involves a combination of an

innate preference and postnatal (and perhaps prenatal) experience.59,60 The preference may be

innate but may not be evident at birth. The

emergence of this preference in infants may be

linked to the postnatal maturation of the sodiumsensitive channels rather than to diet. However,

there is evidence in adults that salt preference in

a food is related to dietary exposure.61,62

Several studies of hypertensive and normotensive

adults have demonstrated that after 2 to 4

months on a lower sodium diet, a person’s level

of salt preference in food declines.61,63 A few

studies have also demonstrated the corollary, that

is, a higher sodium diet increases one’s level of

salt preference.61 There is no experimental evidence in children, even though we assume they

experience a similar effect. Thus, people can

become adapted to a lower sodium diet, but such

adaptation requires forgoing the experience of

foods with clearly salty tastes and an acclimatization to changes in the complex of other flavors in

common foods.

FOOD INDUSTRY

Taste is the key determinant of success for new

food products — particularly for repeat usage.

Several consumer surveys indicate that taste is a

more important factor than nutrition or health in

choosing foods in grocery stores (table F),64-68

and at restaurants (table G).69-72 Other major

factors involved in food selection are convenience/ease of preparation, price/value, and product safety. Taste, as the driving market force,

remains paramount over the years (table F) and

in all age categories (table G). Another important market force is that consumers are aging.

Older people tend to be more health-conscious

and willing to make dietary changes. According

to self-reported data, health supersedes cost and

convenience as people age (table G). Health is a

less important force in younger age groups. In

addition, 92 percent of consumers are not in a

traditional household — singles, single parents,

two working adults, empty nests — which often

leads to harried lifestyles.73 There are mo

women in the workforce (46 percent of th

force) than ever before.73 Americans are w

more hours than ever, and about 50 perce

meals are prepared outside the home.73 M

today’s harried consumers believe that tim

convenience are frequently more importan

economic considerations.

Although nutrition is an important factor 

choice, it is not a leading factor, and salt/s

is currently not seen as important a messa

the consumer as fat reduction (table H).64-

In the mid-1980s, surveys of consumer att

indicated that salt/sodium was the highest

dietary concern among the population, bu

then interest in salt/sodium has been on a 

ward slope relative to other concerns. Sixt

seven percent of respondents of a quick-se

restaurant market survey said they were ve

interested in nutritious items on the menu

When probed regarding what they are int

in, 86 percent of customers and 83 percen

noncustomers of quick services reported be

extremely or very concerned about the fres

of foods, e.g., crisp lettuce. About 84 perc

reported being concerned about fat and sa

fat; only 64 percent were concerned about

salt/sodium, less than their concern for cho

terol, balanced diet, chemicals in food, and 

This change in interest or concern for lowe

um foods is reflected by the proportion of 

sumers who have consciously changed the

dietary behavior. Survey respondents chan

dietary behavior currently do so more ofte

reducing high-fat foods than by reducing 

sodium foods.75,76 For example, the propo

of restaurant patrons who say that they ha

sciously restricted foods higher in fat has

increased slightly from 68 percent in 1986 

71 percent in 1992, and foods higher in sa

sodium has decreased from 68 percent to 5

cent.69,72,77 Food marketing surveys64- 68 

similar pattern in dietary behaviors among 

store patrons (table I). About 32 percent 

ed actively trying to restrict their fat intak
10

whereas only 7 percent reported actively trying

to reduce their salt/sodium intake, even though

almost 60 percent of respondents indicated they

were seriously concerned about nutrition.

Consumers may have to choose between lower fat

versus lower sodium because many foods that

meet lower fat criteria may not be lower in

salt/sodium.

Restaurant market research identifies three consumer groups categorized by nutritional attitudes

when eating away from home — unconcerned

(32 percent), committed (37 percent), or vacillating (31 percent) patrons.70,71,77 In 1992, the

majority of respondents agreed that diet and

nutrition are involved in disease prevention. As

expected, when consumers were asked what foods

they consciously restrict, a greater proportion in

each category restricted foods high in fat rather

than foods high in salt/sodium, and a greater

proportion of committed and vac

uncommitted, patrons restricted f

salt/sodium (table J). Those with 

nutritional attitudes are generally 

the ages of 18 and 34 who freque

restaurants (utilizing carryout and 

Those committed to eating lower 

foods are generally women betwe

35 and 54 who live in metropolit

when dining out behave consisten

views on nutrition. The vacillatin

age 45 and older, are more likely 

quick-service restaurants and self-

and place taste and occasion over 

health when eating out. Consum

quently dine on the premises at q

restaurants are generally uncomm

whereas infrequent restaurant eat

more committed to health-promo

Issue/Age 18-24 Years 25-34 Years 35-44 Years 45

Taste 43 43 45 

Convenience 22 18 15 

Cost 18 11 8 

Health 17 28 32 

P ERCENT O F CONSUMERS , B Y AGE , SELECTING FOODS 

QUICK - SER VICE REST AURANTS BASED O N T ASTE , 

CONVENIENCE , COST , O R HEAL T H 64-68,74

Table G

Concern/Year 1986 1988 1990 1992 

Fat content, low fat 17 27 46 50 

Salt content, less salt 20 26 30 21 

Cholesterol levels 13 22 44 30 

P ERCENT O F RESPONDENTS WHO ARE VER Y O R SOME

CONCERNED ABOUT SPECIFIED NUTRITION CONTENT 

FOOD 64-68,74

Table H
Successful companies identify what the consumer

wants and supply it (accommodate consumer

demands) better than their competitors.

Consumer demand drives the marketplace; therefore, the increased use and broader availability of

lower salt/sodium products depend, in part, on

the ability to generate demand for them. The

challenges to increasing this demand and use

include educational and communication strategies, as well as product-related constraints.

Nielsen data73 indicate that in virtually every

product category there are low-salt/sodium alternatives available. A survey of new products78

shows that more than 2,000 low- or reducedsalt/sodium products have been introduced, but

total sales of reduced-salt/sodium items have

been flat at about 3 to 4 percent in the las

years. There is low usage but consistent d

An examination of the factors that have co

tributed to the success of other nutritional

tioned products (particularly reduced-fat p

ucts) provides insight on how a demand fo

reduced-salt/sodium foods can be generate

Besides a high-quality product, there is a 

for consumer messages that are engaging, 

pelling, and simple; advance realistic goals

ly communicate tangible consumer benefit

provide actionable recommendations that 

easy to implement. Guidance that helps c

sumers integrate nutrient and health mess

with food choices should help create healt

eating patterns.

1989 1990 1991 1992 1993 19

Changes n=1,031 n=1,005 n=1,004 n=1,000 n=1,006 n=1

Reduce fat intake/eat low-fat foods 22 27 25 28 26 3

Eat more fruits and vegetables 59 57 57 60 62 6

Reduce cholesterol 12 15 12 8 6 

Reduce salt/sodium 13 15 10 8 8 

Reduce meat consumption 33 34 34 31 30 3

Eliminate fried foods 10 14 7 7 6 

Increase grains and fiber 13 16 16 8 8 

P ERCENT O F FOOD STORE P A TRONS CHANGING DIET A R Y

BEHA VIOR 7 7

Table I

Dietary Concern Percent of Restrict Foods Restrict Food

Sample 1992 High in Fat High in Salt

Patron Type

Unconcerned 32 44 35

Committed 37 93 73

Vacillating 31 74 62

P ERCENT O F REST AURANT P A TRONS CONSCIOUSL Y

RESTRICTING FOODS 64-68,74

Table J
12

BEHAVIOR CHANGE

Recent medical research and media attention on

diet and health issues have created both increased

public awareness and confusion about these

issues. In today’s environment, the salt/sodium

and blood pressure messages compete with

dietary recommendations about fat, fiber, 

calcium, and other nutrients and with prevention

of heart disease, cancer, osteoporosis, obesity, and

diabetes, for example. Consumers have difficulty

translating diet and health information into 

food choices compatible with all diet 

recommendations.

This dilemma is only too apparent from results of

the USDA’s 1989 Diet, Health, and Knowledge

Survey — CSFII.79 More than 80 percent of

respondents overall had heard of health problems

related to salt/sodium; however, only about 60

percent had heard of hypertension related to

salt/sodium. The majority (about 55 percent) of

individuals report that avoidance of salt/sodium is

personally of high importance. Yet, the mean

sodium intake for the low, moderate, and high

importance groups is comparable (about 70

mmol [1,600 mg] per 1,000 calories), suggesting

that awareness of the importance of salt/sodium

reduction is not translating to food selection.

More than half the respondents indicated that

their salt/sodium intake was about right, and

only about a third indicated it should be lower.

Again the actual sodium intakes of the two

groups were comparable. It appears from surveys

that the U.S. adult population has varied over

time in its level of awareness and practices in

salt/sodium reduction.

Blood pressure reduction trials80-84 have provided

practical tools and theories of behavior and

dietary change for current educational efforts.

Nevertheless, participants in these sodium reduction clinical trials have reported barriers to

salt/sodium reduction that challenge efforts to

promote lower salt/sodium diets. An often-perceived barrier derives from the observation that a

population average BP reduction of about 3/2

mmHg17 appears small to individuals and does

not translate into useful motivatio

In addition, some will have more 

of a response, but the majority of 

probably not notice this small an 

many BP measurements. Unders

potential barriers to a lower salt/s

including issues of food sources, p

behavioral idiosyncracies, as well 

cal, cognitive, perceptual, and em

(table K),85 will contribute to mo

planning and implementation of 

paign. Barriers must be dealt wit

change efforts. In order for peop

vated, they have to understand w

from change and receive feedback 

tion to continue to be motivated.

A campaign focus, therefore, need

on the awareness but also on the 

iors that one needs to adopt to ef

change. It will take different kin

to keep the individual motivated. 

theories that provide a rationale f

behavior change (Health Belief M

Reasoned Action, Social Cognitiv

to be considered.

MONITORING

Quantitative measurement needs 

at the population level to monito

national campaign. Information 

um in the American diet is availa

surveys and research activities in 

Government’s National Nutrition 

and Related Research Program.35

to sodium intake itself, factors to 

those that contribute to the causa

sodium intake — consumer awar

need to reduce salt/sodium, know

reduce salt/sodium intake, and pe

actual salt/sodium reduction beha

producer awareness and behavior

sodium in the food supply.

Total sodium intake may be adeq

purposes, but for tracking sources 

processing, table salt, cooking, an
to plan interventions, estimation of sodium

sources, e.g., by meal, by food group, or home

versus away from home, may be needed. For

research purposes, data on individuals to relate

sodium intake to blood pressure may be required,

and for surveillance, population data by relevant

subgroupings, e.g., age, ethnicity, region of the

country, food assistance program participation,

lifestyle/health habits, income, and risk status,

would be informative.

Total sodium intake can be estimated from urinary sodium because almost all consumed sodium

is excreted through this route under normal circumstances.50 At the individual level, measures

have to be more representative of the usual

intake than a measurement to reflect group

intake. Twenty-four-hour urine collection is considered the gold standard for quantifying d

total sodium intake of groups. To charact

individual, several 24-hour urine collection

needed.87,88 Overnight urine excretion, w

requires only a single collection upon arisi

be used to reflect group sodium intake, bu

does not estimate 24-hour excretion and is

therefore, not an alternative for measuring 

24-hour excretion in the population.89 Ot

methods of urine collection, e.g., casual (sp

untimed) specimens, sodium-creatinine rat

control for variation in urine flow rate, and 

stick methods (chloride titrator strips), ma

offer potential for measuring total sodium 

but may have other uses. Some dietary so

methods are more feasible than urinary sod

measurements in field surveys.

Structural/Food Source Behavioral Idiosyncracies

■ Emphasis on fat, not salt ■ Poor reinforcement source

■ Poor product availability ■ Feedback difficult/embarrassing

■ Have to buy off-brands ■ Very focused, few behaviors, few options

■ Poor availability across stores ■ More difficult with available food supply

■ Difficulty finding in store

■ Increased time shopping Cognitive/Perceptual

■ Products remain on shelves for

long periods ■ No opportunity to add something back upon 

■ Product rotation too great reaching goal

■ Few products low in sodium and fat ■ Difficulty achieving low-sodium diet

■ Misconceptions of methods to achieve

Social low-sodium diet

■ Frequent conflict with others:

■ Poor awareness of benefits/behaviors – restaurants

■ Fat is fashionable, salt is not – friends/family

■ Perceived by public as “ill” or “odd” – food sources

■ Few role models ■ Frequent frustration for those not achieving

■ Low support from low awareness lifestyle/cognitive change

■ No public pressure to reduce

■ Behaviors not evident; low support Physiologic Idiosyncrasies

■ Little health care support

■ No physiological feedback (except in taste extre

■ Less adherent may not have taste changes

M ODIFIABLE CHALLENGES T O SAL T / SODIUM REDUCTION 8 5

Table K
14

An approach to quantifying total sodium intake

is to perform chemical analyses of diets that

duplicate those consumed by a selected representative sample. Both this approach and 24-hour

urine collection pose feasibility problems in field

surveys. Moreover, neither approach provides

sodium source data that are available from

dietary intake data. Single measurements of

sodium intake do not correlate well with single

urinary sodium determinations,42,90,91 so dietary

methods should be validated, and if possible calibrated, against the more quantitative measures

(several 24-hour urines) in order to draw conclusions about trends over time.

There are several options for collecting dietary

and food supply data to provide quantitative estimates of sodium intake and to reflect attitude

and behavior associated with salt/sodium intake

(table L).86 Retrospective trend a

knowledge, attitudes, behaviors, 

these data sources, however, will 

because we are just reaching a de

quantification, and we will lack t

parisons. The year in which a su

and the frequency of its repetitio

tors in monitoring, as are the sur

and the questions they asked at t

Trends in dietary intake of sodium 

preted with caution because diffe

tions about the salting of foods w

ferent surveys. Moreover, over ti

ments have occurred in the nutri

databases (the reference data for 

dietary intake data into nutrient 

interviewing techniques to facilit

of detailed food intake.

M ONITORING CHANGE I N SODIUM REDUCTION BEHA VI

QUANTIFYING THE CHANGE I N SODIUM INT AKE 35,86

Table L

Monitoring Consumer Consumer Producer Producer 

Need Awareness Behavior Awareness Behavior Exposure 

Data

Source

BLS X

BRFSS (CDC) X X

CSFII (USDA) X X 

FDA X X X X X

INDUSTRY X X X X X

NFCS (38) (USDA) 

NHANES (NCHS) X X X 

NHIS (NCHS) X X

USDA X X X

BLS (Bureau of Labor Statistics); Consumer Expenditure Survey; BRFSS (Behavioral Risk Factor Surveillance 

(Centers for Disease Control and Prevention); CSFII (Continuing Survey of Food Intake by Individuals); FDA 

Drug Administration): Health and Diet Survey; Total Diet Study (“market baskets”); Industry (Consumer a

ket surveys); NCHS (National Center for Health Statistics); NFCS (Nationwide Food Consumption Survey); 

(National Health and Nutrition Examination Survey); NHIS (National Health Interview Survey); USDA (U

of Agriculture): Other than CSFII and NFCS; for example, A.C. Nielsen Scantrak, National Nutrient Data

Health Knowledge Survey
Consideration of additional analyses of the yet

unexplored, extensive, and, in some cases,

detailed dietary and food purchasing data collected in existing surveys should be investigated.

National surveys, however, exclude salt added at

the table and in cooking, thus underestimating

sodium intake. In addition, assessment of the

salt/sodium content of the U.S. food supply is

limited because such data are not currently available. To be current, nutrient databases require

frequent modification, which necessitates food

composition data based on adequate food sampling and chemical analysis, as well as pub

agency and private industry diligence and 

eration. The ability to interpret trends co

improved by methodological studies desig

assess the consequences of changes in surv

cedures and databases on the sodium intak

mates. Thus, further attention to those as

of nutrition monitoring described above is 

high priority for optimal implementation 

evaluation of the effectiveness of a nationw

dietary salt/sodium reduction campaign.
Eight working groups discussed issues and made

recommendations in four general areas: specific

target populations, various settings for implementing changes, monitoring, and research

needs. Each group was charged with addressing

one or more of the five workshop objectives: 

(1) identify and document intervention strategies

used in clinical trials and other intervention studies; (2) identify effective monitoring strategies

(dietary and urinary sodium) at the individual,

community, and national levels; (3) provide a

forum for discussion of the issues of salt/sodium

in the food supply; (4) identify research needs in

implementing dietary salt/sodium reduction; and

(5) synthesize the best approaches for salt/sodium

reduction for the Primary Prevention of

Hypertension initiative of the National High

Blood Pressure Education Program. Six broad

recommendations summarize the working group

deliberations.

Recommendation 1: The NHBPEP should develop

both public and professional education activities

within its primary prevention campaign to convey

the rationale for and benefits of lowering dietary

salt/sodium for hypertension prevention to the

appropriate target audiences.

Succinct communication of the scientific rationale

for and benefits of reducing dietary sodium consumption to both the public and professionals is

needed to promote the primary prevention of

hypertension and to counter misleading and confusing messages that are pervasive among the

public and health professionals. Many health

care providers still do not recognize the impact of

salt/sodium reduction on shifting the population

blood pressure curve downward, with resultant

decreased incidence and prevalence of heart 

disease, stroke, and other hypertensive 

complications.

Questions relating to the topic of dietary s

reduction and prevention could be part of 

or certification exams that are requiremen

many health professionals in order to prac

Formal curricula and postgraduate educat

could be offered as part of the professiona

tion campaign to increase awareness, know

and skills of health care providers.

Because most of the U.S. adult population 

medical care at least once within 2 years, 

professionals will play a critical role in crea

awareness and providing the impetus to ch

Once the motivation is there, restaurant, f

service, and food production industries can 

ply lower salt/sodium alternatives as the d

for them increases. Therefore, the profess

education component of a primary preven

campaign should be directed to health car

providers, leaders in the food production i

(manufacturers, retailers, distributors, mar

restaurant and food service personnel, and 

members concerned with science, health, o

The public education campaign should em

the fact that the same lifestyle changes tha

prevent high blood pressure (weight mana

ment, increased physical activity, and mod

of alcohol consumption) are also valuable 

treatment and have a favorable effect on g

health. Furthermore, it should underscore 

fact that prevention and control of high b

pressure represent only one of several imp

strategies for the prevention of coronary h

disease and stroke.

Although the campaign is recommended t

populationwide, a targeted campaign to th

lic to achieve awareness and facilitate chan

high- risk groups — e.g., low socioeconom

groups, people who live in the Stroke Belt

WORKING GROUP RECOMMENDATIONS — WHERE ARE

WE GOING?
18

African Americans — should be integrated without “labeling” these subgroups. Targeting both

ends of the age spectrum — children and the

elderly — should also be a high priority because

prevention naturally starts in childhood and

many elderly are already primed for change and

many more could be primed with appropriate

health promotion messages. In addition, the

elderly suffer the highest rates of heart attack

and stroke and may be more sodium-sensitive

than younger people.

Recommendation 2: In addition to conveying the

rationale and benefits for lowering dietary

salt/sodium for hypertension prevention, the

salt/sodium messages must be consistent with

and often integrated into the overall healthful

lifestyle/diet messages, such as those imparted by

the DHHS/USDA Dietary Guidelines for Americans,

the USDA Food Guide Pyramid, and FDA food

label approaches.

Because the public is overwhelmed with a variety

of competing health-related messages, over the

past decade consumer interest in salt/sodium has

been decreasing from being the highest to one of

the lowest dietary concerns. Other factors that

have led to the general confusion about the efficacy or importance of sodium reduction include

the stigma of a salt/sodium-reduced lifestyle,

which historically has been negatively associated

with response to a medical diagnosis; inconsistent terminology (e.g., salt versus sodium versus

sodium chloride, milligram versus milliequivalent

or millimole); fewer tangible or perceived benefits of lower sodium than of lower fat (e.g.,

weight control); the perceived expense of a lower

sodium lifestyle; and no identifiable goal (such as

“know your number” for blood cholesterol reduction campaigns). It is now time that the

salt/sodium message be linked with the fat message and integrated with messages on healthful

lifestyles in general.

Multiple media (print, television, 

been major vehicles for dissemina

for the NHBPEP in the past, and 

has already aired public service an

on radio and television and produ

materials for the general public to 

tension. The working groups not

types of materials when targeted 

ences need to be culturally and ag

and written at appropriate literac

Public and private institutions (su

place, schools, medical centers, ch

ping malls, community centers, s

military installations, prisons, hea

restaurants, and senior citizen cen

opportunities for salt/sodium redu

Any prevention campaign or prog

easily into the existing social stru

munity. For example, school is th

for targeting children and parents

that serve as a community focus h

past, successfully hosted peer lead

ion leaders in train-the-trainer pr

Health care institutions appear to 

channels for implementing salt/so

programs or disseminating educa

In these settings the opportunity 

poration of salt/sodium reduction 

existing programs, frequent coun

through sodium monitoring, and 

logical aids such as videos and co

Barriers to this strategy, however, 

include lack of financial compens

provider, limited provider knowle

behavioral change, and the patien

imize the burden and to encourag

ment, only those at high risk of h

e.g., African Americans or individ

overweight, have excess sodium i

cally inactive, consume excess alc

high normal blood pressure, or ha

tory of hypertension — could be 
Recommendation 3: Experiences with intervention studies, to the extent possible, should be

transferred to clinical and/or community settings

after reviewing/evaluating and adapting, if necessary, strategies, methods, and materials.

There is a large body of research experience in

making changes in sodium intake — results of

research in adults with high-normal blood pressure and with hypertension indicate successful

lowering of dietary sodium for up to several

years. These studies offer a large body of methods, materials, strategies, etc., which have not

been applied and tested in the field. However,

because these intervention studies have consistently fallen short of targeted levels of sodium

intake (60-80 mmol/day or 1,380-1,840 mg/day)

for most of the participants, the “food environment” must also be addressed. Individuals will

be more successful in making recommended

changes when lower sodium foods are more widely available and when the broader educational

environment encourages such change.

Recommendation 4: Gradual “silent” or “transparent” lowering of salt/sodium in the food supply

will need to occur along with the opportunity for

effective marketing strategies and the promotion

of reduced-sodium, as well as low-sodium, lowsalt, and no-salt food products. These recommendations are applicable to the food production

industry, as well as restaurant, catering, and food

service industries. 

Because processed foods contribute about 75 percent of the sodium in the food supply, product

reformulation and food preparation changes to

reduce the sodium content in standard food products overall and increasing their availability in all

communities, especially disadvantaged and rural

communities, will help reduce the Nation’s

dietary sodium consumption. “Silent” lowering

of the salt/sodium in the food supply is a passive,

nonvisible, environmental change that has been

shown to be effective in studies where the population consumes a substantial portion of its diet

in an institutional setting. At some point this

effort must become not so silent or transp

to the public. It could be counterproduct

the American public to not recognize the

changes that have occurred or to not be p

the opportunity to support those brands t

have made progress toward reducing sodiu

without compromising flavor. Obviously, 

tion education needs to go hand in hand w

such an industry-based shift.

To develop and supply more low-salt/sodiu

no-salt foods will necessitate a demand gr

than what currently exists. Because these 

ucts represent only a very small portion of 

food sales, the bigger impact on sodium in 

food supply will result from the silent low

of sodium in the foods most commonly ea

Continuing and generating this reduction 

necessitate education of and continued dia

with food industry leaders while concurren

educating the public.

Recommendation 5: Data from completed 

trials should be analyzed for the adequacy 

simpler methods, e.g., casual urine collectio

chloride titrator strips, as measures of sodi

intake and for the validity of dietary recall

order to consider the best feasible method

individual and national level assessments o

um intake.

The intent of these analyses would be to i

the most accurate and affordable method 

assessing sodium intake — affordable to i

uals in clinical settings and to investigator

large nutrition surveys. In addition, it ma

feasible to apply these methods in large su

to permit analysis by levels of socioeconom

tus, ethnicity, State, or region of the count

Although a number of methods have been 

to monitor sodium intake in study particip

none is clearly known to be generally app

or sufficiently accurate in an unselected po

tion. There are simple methods that can b

examined on a small scale, but their utility 

large scales has not been applied. A secon
20

analysis of existing data could be conducted so

that the utility of simple urine collection methods can be correlated with more traditional

detailed urinary sodium collection methods.

These clinical methods of assessing sodium intake

should also be correlated with dietary recall

methods that use varying degrees of probing for

salt/sodium intake. The aim would be to identify

where additional probing no longer contributes

to the quality of the data. An additional aim

would be to build a bridge or conversion factor

that would allow for correction of biased estimates of sodium intake from dietary recall.

Thus, dietary recall could be a more accurate tool

to assess dietary salt/sodium consumption.

Analysis of dietary data can only be as good as

the nutrient database from which it draws.

Although databases are continually updated,

nutrient data of brand-specific items in the past

may have been proprietary information, although

the Nutrition Labeling and Education Act now

requires them to be publicly available. Coalitions

between Government, industry, and other users

of nutrient databases would promote more complete and current information in the databases.

Recommendation 6: In addition to investigating

adequate monitoring methods, other research

needs were identified in the areas of food technology, basic mechanisms of salt taste, and knowledge, attitudes, and skills of the public.

In light of the recommendation for “silent”

reduction of salt/sodium in the food supply, a

major unknown is the minimal level of salt needed to enhance flavors — that is, the dose

response of salt versus flavor enhancement. A

co-consideration is the safety of s

preservation of individual foods. 

research to develop salt enhancer

substitutes could be encouraged.

Other unknowns concern the bas

of salt taste. For example, is salt 

by age or ethnicity? Does salt ta

other nutrients or medications? A 

ommendation made by health pr

limit salt/sodium intake in young 

what is known about salt taste an

children and the influence of earl

later demands is negligible becau

taste studies have been conducted 

In addition, most salt taste studie

mented abrupt sodium reduction 

behavioral interventions impleme

um reduction. The benefit of slo

change is unknown as is the mag

duration of recidivism, although 

data to indicate less recidivism in 

intake than, for example, caloric 

To date, few intervention studies 

sodium reduction intervention w

prehensive or inclusive nutrition 

other than weight reduction. Re

be conducted on the effect of sod

intervention integrated with an o

message either concurrently or se

sodium reduction interventions h

they have become more behavior

little is known about the readines

to change (that is, how they adop

maintain behavioral change) relat

reduction, different population ne

incentives, cues, or feedback wor
Programs respond to new policy slowly and by

changing priorities. The USDA-created school

meal programs; Women, Infants, and Children

Supplemental Food Program (WIC); food

stamps; and commodity food distribution programs were originally based on nutrient deficiencies. Currently, excess and imbalances are major 

problems. Although hunger is still a problem 

in some population subgroups, policies to reduce

salt/sodium along with other improvements in

the American diet need to be addressed in the

USDA programs.

Direct services, such as the USDA feeding and

supplemental food programs, constitute only one

part of new directions in lowering salt/sodium.

To produce change in consumption patterns, a

major nutrition education campaign accompanied

by a specific series of public and private partnerships rounds out implementation of the new

directions. Coordinated efforts building on the

FDA’s education efforts to implement the 

Nutrition Labeling and Education Act, the

DHHS/USDA’s Dietary Guidelines for Americans,

and the USDA’s Food Guide Pyramid will help

maintain consistency of the salt/sodium message

across public and private sectors.

To have a major impact on sodium consumption,

it is critical that the food industry reduce (or continue to reduce, in some cases) the content of

sodium in generally available processed foods, in

addition to offering special low-salt products,

e.g., gradually lower salt in bread by 10, 20, and

30 percent. However, patience and a realistic

perspective are needed. Technologically, the food

industry is at a standstill without a salt substitute

on the horizon and with flavor enhancers still

under development. In addition, reformulation

of food to reduce sodium content takes research

and development. Because industry’s success

depends on consumers’ demands, incentiv

industry to silently lower sodium content 

foods will have to be created and demand 

lower sodium and lower salt foods must p

their availability. Silent lowering could re

increased preference for lower salt/sodium 

However, more skill at using salt substitu

could maintain the preference for high-sal

um foods and perpetuate the overall dema

a salty-tasting food supply.

The NHBPEP has initiated a national cam

the specific goal of which is the primary p

tion of high blood pressure. Primary prev

represents a natural extension of the NHB

mission and would complement its initiati

facilitate the detection, evaluation, and tre

ment of high blood pressure. To accompli

goal of sodium reduction, the campaign a

minimum should include public education

grams to encourage food industry to prov

public with more healthful foods, educatio

food service institutions to prepare healthf

alternatives, and education of health care 

sionals.

In conclusion, observational and experime

studies provide compelling evidence of the 

of reducing sodium intake in the primary 

vention of hypertension. It provides an at

tive opportunity to interrupt and prevent 

continuing cycle of managing hypertensio

its complications. Changes in food manuf

as well as public and professional educatio

tiatives, provide a basis for achievement of 

stantial reductions in sodium consumption

NHBPEP is well positioned to provide lea

for a national campaign for salt/sodium re

as a major step toward the primary preven

hypertension.

CLOSING PANEL — HOW DO WE GET THERE?
22

Planning Committee

Jerome D. Cohen, M.D., St. Louis University 

(co-chair) 

Shiriki Kumanyika, Ph.D., R.D., M.P.H.,

University of Illinois at Chicago (co-chair)

Jeffrey Cutler, M.D., National Heart, Lung, and

Blood Institute (NHLBI), National Institutes of

Health (NIH)

Karen Donato, M.S., R.D., NHLBI, NIH

Patricia Elmer, Ph.D., University of Minnesota

Nancy Ernst, M.S., R.D., NHLBI, NIH

Marguerite Evans, M.S., R.D., NHLBI, NIH

R. Jerry Mann, M.D., Crestview Family Clinic

Nancy Houston Miller, R.N., B.S.N., Stanford

University School of Medicine 

Eva Obarzanek, Ph.D., R.D., NHLBI, NIH

James Raczynski, Ph.D., University of Alabama

at Birmingham

Edward J. Roccella, Ph.D., NHLBI, NIH

Rose Stamler, M.A., Northwestern University

Medical School

Paul Whelton, M.D., M.Sc., Johns Hopkins

Health Institutions

Other Invited Participants 

Lawrence Appel, M.D., M.P.H., Johns Hopkins

Health Institutions

Gary K. Beauchamp, Ph.D., Monell Chemical

Senses Center

Ronette R. Briefel, Dr.P.H., Nati

Health Statistics, Centers for Dis

and Prevention

Ellen Harris, Dr.P.H., U.S. Depar

Agriculture

Suzanne Harris, International Lif

Institute

Guy H. Johnson, Ph.D., Grand M

Food Sector

Barry Kaufman, D.M.D., Health

Eileen Kennedy, D.Sc., R.D., U.S

Agriculture

Cora E. Lewis, M.D., M.S.P.H., U

Alabama at Birmingham

Joaquin Pelaez, M.S., Taco Bell C

Claire Regan, M.S., R.D., Grocer

Manufacturer’s Association

Jeremiah Stamler, M.D., Northw

University Medical School

Ashlesha Tamboli, M.D., Nationa

Aging, NIH

Linda Van Horn, Ph.D., R.D., N

University Medical School

Paul Whelton, M.D., M.Sc., John

Health Institutions

Elizabeth Yetley, Ph.D., Food and 

Administration

Joyce M. Young, M.D., IBM Cor

ACKNOWLEDGMENTS
REFERENCES

1. Cutler JA, Kotchen TA, Obarzanek E (guest

eds). The National Heart, Lung, and Blood

Institute Workshop on Salt and Blood

Pressure. Hypertension 1991;17:I1-121.

2. National High Blood Pressure Education

Program. Working group report on primary

prevention of hypertension. Arch Intern Med

1993;153:186-208.

3. Burt VL, Whelton P, Roccella EJ, Brown C,

Cutler JA, Higgins M, Horan MJ, Labarthe

D. Prevalence of hypertension in adult US

population: results from the Third National

Health and Nutrition Examination Survey,

1988-91. Hypertension 1995;15:305-313.

4. Stamler J, Stamler R, Neaton JD. Blood

pressure, systolic and diastolic, and cardiovascular risks: US population data. Arch Intern

Med 1993;153:598-615.

5. American Academy of Pediatrics. Salt intake

and eating patterns of infants and children.

Pediatrics 1974;53:115-121.

6. Dahl LK. Salt intake and salt need. N Engl

J Med 1958;258:1152-1157.

7. National Research Council. Recommended

Dietary Allowances, 10th ed. Washington,

DC: National Academy Press; 1989.

8. Denton D. The Hunger for Salt: An

Anthropological, Physiological, and Medical

Analysis. Berlin: Springer-Verlag; 1982.

9. Tobian L. Salt and hypertension: lessons

from animal models that related to human

hypertension. Hypertension 1991;17:I52-58.

10. Dahl L. Possible role of salt intake in 

development of hypertension. In: Co

Bock KD (eds). Essential Hypertension—

International Symposium. Berlin: Sprin

Verlag; 1960, p 53-65.

11. Gleibermann L. Blood pressure and d

salt in human populations. Ecol Food 

1973;2:143-156.

12. Froment A, Milon H, Gravier C.

Relationship of sodium intake and art

hypertension. Contribution of geogra

epidemiology. Rev Epidemiol Sante Pub

1979;27:437-454.

13. INTERSALT Cooperative Research G

INTERSALT: an international study 

trolyte excretion and blood pressure: 

for 24 hour urinary sodium and potas

excretion. Br Med J 1988;297:319-32

14. Elliott P for the INTERSALT Coopera

Group. The INTERSALT study—an 

national co-operative study of electrol

excretion and blood pressure—further

results. J Hum Hyperten 1989;3:279-4

15. Mancilha Carvalho JJ, Baruzzi RG, H

PF, Poulter N, Alpers MP, Franco LJ,

Marcopito LF, Spooner VJ, Dyer AR, 

P, Stamler J, Stamler R. Blood pressu

four remote populations in the INTER

study. Hypertension 1989;14:238-246.

16. Stamler J, Rose G, Elliott P, Dyer A, M

M, Kesteloot H, Stamler R. Findings 

international cooperative INTERSALT 

Hypertension 1991;17:I9-15.
24

17. Cutler JA, Follmann D, Elliott P, Suh I. An

overview of randomized trials of sodium

reduction and blood pressure. Hypertension

1991;17:I27-33.

18. Stamler R, Stamler J, Gosch FC, Civinelli J,

Fishman J, McKeever P, McDonald A, Dyer

AR. Primary prevention of hypertension by

nutritional-hygienic means: final report of a

randomized, controlled trial. JAMA 1989;

262:1801-1807.

19. Hypertension Prevention Trial Research

Group. The Hypertension Prevention Trial:

three-year effects of dietary changes on blood

pressure. Arch Intern Med 1990;150:153-

162.

20. The Trials of Hypertension Prevention

Collaborative Research Group. The effects of

nonpharmacologic interventions on blood

pressure of persons with high normal levels.

Results of the Trials of Hypertension

Prevention, Phase I. JAMA 1992;267:1213-

1220.

21. Stamler R, Stamler J, Grimm R, Gosch FC,

Elmer P, Dyer A, Berman R, Fishman J, Van

Heel N, Civinelli J, McDonald A.

Nutritional therapy for high blood pressure:

final report of a four-year randomized controlled trial — the Hypertension Control

Program. JAMA 1987;257:1484-1491.

22. The Treatment of Mild Hypertension

Research Group. The Treatment of Mild

Hypertension Study: a randomized, placebocontrolled trial of a nutritional-hygienic regimen along with various drug monotherapies.

Arch Intern Med 1991;151:1413-1423.

23. US Senate. Dietary Goals for the United States,

2nd ed. Report of the Select Committee on

Nutrition and Human Needs. Stock No.

052-070-04376-8. Washington, DC: US

Government Printing Office; 1977.

24. US Department of Health, E

Welfare. Healthy People: The 

Report on Health Promotion and 

Prevention. DHEW (PHS) Pu

55071. Office of the Assista

Department of Health, Educ

Welfare. Washington, DC: 

Printing Office; 1979.

25. US Department of Agricultu

Department of Health and H

Nutrition and Your Health: D

for Americans. Home & Gard

228. Washington, DC: US 

Printing Office; 1980.

26. US Department of Agricultu

ment of Health and Human 

Nutrition and Your Health: D

for Americans, 2nd ed. Home 

Bulletin No. 232. Washingt

Government Printing Office; 

27. US Department of Agricultu

ment of Health and Human 

Nutrition and Your Health: D

for Americans, 3rd ed. Home 

Bulletin No. 232. Washingt

Government Printing Office; 

28. US Department of Health an

Services. The Surgeon General

Nutrition and Health. DHHS 

No. 88-50210. Public Healt

Department of Health and H

Washington, DC: US Gover

Office; 1988.

29. National Research Council. 

Implications for Reducing Chron

Washington, DC: National A

1989.

30. Inter-Society Commission for 

Resources. Primary preventio

sclerotic diseases. Circulation 

95.
31. American Heart Association. Dietary guidelines for healthy American adults: a statement for physicians and health professionals

by the Nutrition Committee, American Heart

Association. Circulation 1988;77:721A724A.

32. National High Blood Pressure Education

Program. The fifth report of the Joint

National Committee on Detection,

Evaluation, and Treatment of High Blood

Pressure. Arch Intern Med 1993;153:186-

208.

33. Plan and operation of the Third National

Health and Nutrition Examination Survey,

1988-94, National Center for Health

Statistics. Vital Health Stat 1(32), 1994.

34. Briefel R, Alaimo K, Wright J, McDowell M.

Dietary sources of salt and sodium.

Presented at the NHLBI Workshop on

Implementing Recommendations for Dietary

Salt Reduction, August 25-26, 1994.

35. Interagency Board for Nutrition Monitoring

and Related Research. Ervin B, Reed D (eds).

Nutrition Monitoring in the United States.

Chartbook I: Selected Findings From the National

Nutrition Monitoring and Related Research

Program. Hyattsville, MD: Public Health

Service; 1993.

36. Obarzanek E, Reed DB, Bigelow C, Glovsky

E, Pobocik R, Nicklas T, Clesi A, Zive M,

Trenkner L, Lakatos E. Fat and sodium content of school lunch foods: calculated values

and chemical analysis. Int Food Sci Nutr

1993;44:155-165. 

37. Pennington JA, Young BE, Wilson DB.

Nutritional elements in U.S. diets: results

from the Total Diet Study, 1982-1986. J Am

Diet Assoc 1989;89:659-664.

38. Nationwide Food Consumption Survey.

CSFII Report No. 86-3. Women 19-50 Years

and Their Children 1-5 Years. Hyattsville,

MD: US Department of Agriculture, Human

Nutrition Information Service; 1988.

39. Block GS, Subar AF. Estimates of nu

intake from a food frequency question

the 1987 National Health Interview S

J Am Diet Assoc 1992;92:969-977.

40. Pennington JA, Young BE. Total Die

nutritional elements, 1982-1989. J A

Assoc 1991;91:179-183.

41. Alaimo K, McDowell MA, Briefel RR

AM, Caughman CR, Loria CM, Johns

Dietary intake of vitamins, minerals, 

of persons ages 2 months and over in 

United States. Third National Healt

Nutrition Examination Survey, Phase 

91. Advance Data from Vital and Heal

Statistics; No. 258. Hyattsville, MD:

National Center for Health Statistics; 

42. Yamamoto ME, Caggiula AW, Olson 

Kelsey SF, McDonald RH. Applicatio

overnight urine collections and food r

for monitoring the sodium and potass

intakes of groups and individuals. J A

Assoc 1994;94:897-899.

43. Whelton PK, Hebert PR, Cutler J, et 

the Trials of Hypertension Prevention

Collaborative Research Group. Basel

acteristics of participants in Phase I o

Trials of Hypertension Prevention. A

Epidemiol 1992;2:295-310.

44. Appel LJ, Hebert PR, Cohen JD, Oba

E, Yamamoto M, Buring J, Stevens V,

Kirchner K, Borhani AN for the Trial

Hypertension Prevention (TOHP)

Collaborative Research Group. Basel

acteristics of participants in Phase II o

Trials of Hypertension Prevention (TO

Ann Epidemiol 1995;5:149-155.

45. Davis BR, Blaufox MD, Hawkins CM

Langford HG, Oberman A, Swencion

Wassertheil-Smoller S, Wylie-Rosett J

Zimbaldi N. Trial of Antihypertensiv

Interventions and Management. Cont

Trials 1989;10:11-30.
26

46. Mascioli ST, Grimm RH, Neaton JD,

Stamler J, Prineas RJ, Cutler JA, Elmer PJ,

McDonald R, Schnaper H, Schoenberger J

for the TOMHS Research Group.

Characteristics of participants at baseline in

the Treatment of Mild Hypertension Study

(TOMHS). Am J Cardiol 1990;66:32C-35C.

47. Langford HG, Blaufox MD, Oberman A,

Hawkins CM, Curb JD, Cutter GR,

Wassertheil-Smoller S, Pressel S, Babcock C,

Abernethy JD, Hotchkiss J, Tyler M.

Dietary therapy slows the return of hypertension after stopping prolonged medication.

JAMA 1985;253:657-664.

48. Lasser NH, Batey DM, Hymowitz N, 

Lasser VI, Kanders BS, Lehrer PM, for the

Hypertension Intervention Trial. In: 

Strasser T, Ganten D (eds). Mild Hypertension: From Drug Trials to Practice. 

New York: Raven Press; 1987.

49. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll

Nutr 1991;10:383-393.

50. Sanchez-Castillo CP, Warrender S,

Whitehead TP, James WP. An assessment of

the sources of dietary salt in a British population. Clin Sci 1987;72:95-102.

51. Sanchez-Castillo CP, Branch WJ, James WP.

A test of the validity of the lithium-marker

technique for monitoring dietary sources of

salt in men. Clin Sci 1987;72:87-94.

52. James WPT, Ralph A, Sanchez-Castillo CP.

The dominance of salt in manufactured food

in the sodium intake of affluent societies.

Lancet 1987;i:426-429.

53. US Department of Health and Human

Services. Public Health Service. Healthy

People 2000: National Health Promotion and

Disease Prevention Objectives. DHHS Pub. No.

(PHS) 91-50212. Washington, DC: US

Government Printing Office; 1991.

54. Lewis CJ, Crane NT, Moore B

versus Healthy People 2000

1994 nutrition progress revie

Today 1994;29:6-14.

55. Block G, Dresser CM, Hartm

MD. Nutrient sources in the 

quantitative data from the N

vey. I. Vitamins and mineral

Epidemiol 1985;122:13-26.

56. Food and Drug Administrati

ing; Reference daily intakes a

ence values; Mandatory statu

labeling and nutrient conten

Regist 1991;56(229):60366-6

57. Food and Drug Administrati

ing; Mandatory status of nut

and nutrient content revision

nutrition label. Fed Regist 19

2205.

58. Beauchamp GK, Engelman K

intake: sensory and behavior

Hypertension 1991;17:I176-18

59. Beauchamp GK, Cowart B. 

high salt concentrations amo

Develop Psychol 1990;26:539-

60. Beauchamp GK, Cowart BJ, 

Developmental changes in sa

in human infants. Develop Ps

1986;19:75-83.

61. Bertino M, Beauchamp GK, 

Long-term reduction in dieta

the taste of salt. Am J Clin N

1134-1144.

62. Bertino M, Beauchamp GK, 

Increasing dietary salt alters 

Physiol Behav 1986;38:203-2

63. Beauchamp GK, Bertino M, 

Sensory basis for human salt 

In: Horan MJ, Blaustein M, 

Kachadorian W, Kaplan NM
AP (eds). NIH Workshop on Nutrition and

Hypertension: Proceedings from a Symposium.

New York: Biomedical Information Corp.;

1985.

64. Food Marketing Institute. Trends 88:

Consumer Attitudes and the Supermarket 1988.

Washington, DC: Food Marketing Institute;

1988.

65. Food Marketing Institute. Trends 90:

Consumer Attitudes and the Supermarket 1990.

Washington, DC: Food Marketing Institute;

1990.

66. Food Marketing Institute. Trends 92:

Consumer Attitudes and the Supermarket 1992.

Washington, DC: Food Marketing Institute;

1992.

67. Food Marketing Institute. Trends 93:

Consumer Attitudes and the Supermarket 1993.

Washington, DC: Food Marketing Institute;

1993.

68. Food Marketing Institute. Trends 94: Trends

in the United States, Consumer Attitudes and the

Supermarket 1994. Washington, DC: Food

Marketing Institute; 1994.

69. National Restaurant Association. Tableservice

Restaurant Trends. Washington, DC:

National Restaurant Association; 1989.

70. National Restaurant Association. Attitudes

Toward Nutrition in Restaurants: Assessing the

Market. Washington, DC: National

Restaurant Associaton; 1990.

71. Regan C. Nutrition awareness and the food

service industry. Ann NY Acad Sci 1991;

623:392-399.

72. Pelaez J. Nutrition and quick service restaurants: a consumer perspective. Presentation

at the NHLBI Workshop on Implementing

Recommendations for Dietary Salt

Reduction. 1994.

73. Nielsen AC. ScantrakR Market Planner. A.C.

Nielsen. 1994.

74. Food Marketing Institute. Trends 86:

Consumer Attitudes and the Supermarket 1

Washington, DC: Food Marketing In

1986.

75. American Dietetic Association and

International Food Information Counc

How Are Americans Making Food Choice

1994 Update. Washington, DC: Ame

Dietetic Association and International 

Information Council, April 1994.

76. Food Marketing Institute and Prevent

Magazine. Shopping for Health, 1994. 

in America: Perception and Reality. A F

Marketing Institute and Prevention

Magazine Report. Conducted for Foo

Marketing Institute and Prevention

Magazine. Washington, DC: Parkwoo

Research Associates; 1994.

77. National Restaurant Association. Tab

Restaurant Trends. Washington, DC:

National Restaurant Association; 1992

78. Anonymous. Prepared Foods Magazine. 

1993.

79. Haines PS, Popkin BM, Guilkey DK,

DeVellis R. Knowledge and Attitudes Re

Dietary Choices Among US Men and Wom

The 1989 Diet and Health Knowledge Su

and the 1989 Continuing Survey of Food 

by Individuals. Hyattsville, MD: US

Department of Agriculture; 1994.

80. Caggiula AW, Milas NC, Wing RR. O

nutritional therapy in the treatment o

hypertension. Bibliotheca Cardiologica

1987;41:6-21.

81. Jeffery RW, Gillum R, Gerber WM, Ja

D, Elmer PJ, Prineas RJ. Weight and 

reduction for the prevention of hypert

comparison of group treatment and in

ual counseling. Am J Public Health

1983;73:691-693.
28

82. Lang CL, Weinberger MH, Miller JZ.

Dietary counseling results in effective dietary

sodium restriction. J Am Diet Assoc

1985;85:477-479.

83. Nugent CA, Carnahan JE, Sheehan ET,

Myers C. Salt restriction in hypertensive

patients. Comparison of advice, education,

and group management. Arch Intern Med

1984;144:1415-1417.

84. Lasser VI, Raczynski JM, Stevens VJ,

Mattfeldt-Beman MK, Kumanyika S, Evans

M, Danielson E, Dalcin A, Batey DM,

Belden LK, Brewer AA for the Trials of

Hypertension Prevention (TOHP)

Collaborative Research Group. Trials of

Hypertension Prevention, Phase II: structure

and content of the weight loss and dietary

sodium reduction interventions. Ann

Epidemiol 1995;5:156-164.

85. Raczynski J. Behavioral issues in promoting

low-salt diets among the American public.

Presentation at the NHLBI Workshop on

Implementing Recommendations for Dietary

Salt Reduction. 1994.

86. IBNMRR (Interagency Board for Nutrition

Monitoring and Related Research). Wright J

(ed). Nutrition Monitoring in the United States:

The Directory of Federal and State Nutrition

Monitoring Activities. Hyattsville, MD:

Public Health Service; 1992.

87. Liu K, Cooper R, McKeever J, McKeever P,

Byington R, Soltero I, Stamler R, Gosch F,

Stevens E, Stamler J. Assessment of the association between habitual salt intake and high

blood pressure: methodological problems.

Am J Epidemiol 1979;110:219.

88. Liu K, Cooper R, Soltero I, S

Variability in 24-hour urinar

tion in children. Hypertension 

89. Staessen J, Broughton PMG, 

Markowe HLJ, Marmot MG

Semmence A, Shipley MJ, Bu

assessment of the relationshi

pressure and sodium intake u

daytime and overnight urine 

J Hyperten 1991;9:1035-1040

90. Schacter J, Harper PH, Radi

AW, McDonald RH, Diven W

son of sodium and potassium 

excretion. Hypertension 1980

91. Dubbert PM, Rowland AK, 

Liggett MV, Terre L, Krug L

sodium intake by analyzing f

with augmented nutrition so

overnight urine collections. 

1992;92:87-89.

92. Meinert CL, Borhani NO, La

the Hypertension Prevention 

Group. Design, methods, an

the Hypertension Prevention 

Clin Trials 1989;10:1S-29S.

93. Neaton JD, Grimm RH, Pri

J, Grandits GA, Elmer PJ, C

JM, Schonberger JA, McDon

CE, Liebson PR for the Treat

Hypertension Study Research 

Treatment of Mild Hyperten

results. JAMA 1993;270:71

.
Discrimination P

Under provisions 

public laws enact

since 1964, no pe

United States sha

grounds of race, c

origin, handicap, 

excluded from par

be denied the ben

subjected to discr

any program or a

the basis of sex, w

any education pro

ty) receiving Fede

assistance. In add

tive Order 11141 

crimination on th

by contractors an

in the performanc

contracts, and Ex

11246 states tha

funded contractor 

minate against a

applicant for emp

of race, color, rel

national origin. 

National Heart, 

Blood Institute m

in compliance wit

and Executive Or
U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 55-728N

November 1996