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Reducing Sodium:
A Look at State Savings in Health Care
Costs
May 21, 2015
Copyright © May, 2015 by Center for Science in the Public Interest
The Center for Science in the Public Interest (CSPI), founded in 1971, is a non-profit
health-advocacy organization. CSPI conducts innovative research and advocacy programs
in the areas of nutrition and food safety, and provides consumers with current
information about their own health and well-being. CSPI is supported by the 900,000
subscribers in the United States and Canada to its Nutrition Action Healthletter and by
foundation grants. CSPI does not accept funding from government or industry.
Credits: Thanks to Aviva Musicus for data analysis.
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Introduction
The Scientific Report of the 2015 Dietary Guidelines Advisory Committee calls for Americans to
reduce their sodium consumption. In doing so, it joins a more-than-40-year-long chorus of public
health organizations and authoritative scientific bodies that have called for actions to reduce
sodium intake to prevent strokes, heart attacks, and other diseases associated with excessive
sodium in the diet. 1,2,3,4,5,6
According to the government’s 2010 Dietary Guidelines for Americans, adults should consume no
more than 2,300 milligrams (mg) of sodium per day. The Guidelines also recommended that people
at greater risk of cardiovascular disease—those with hypertension, adults 51 years and older, and
African Americans—should limit sodium to 1,500 mg per day. 7 The latter group accounts for the
majority of adults, according to the Centers for Disease Control and Prevention (CDC). 8 In contrast
to those recommendations, the 2011–2012 National Health and Nutrition Examination Survey
(NHANES) shows that the average American consumes 3,478 mg of sodium per day. 9
Exact sodium consumption is not known with great accuracy. Importantly, NHANES data
underestimate actual sodium consumption because they do not include salt added in cooking and at
the table, and survey participants tend to underreport the amount of food they consume. 10 Reviews
of generally small studies that used 24-hour urine analyses also found that adults in the U.S.
consume about 3,500 mg per day. 11 However, even those studies may underestimate sodium
because some sodium is lost in sweat and feces and subjects do not adhere perfectly to collection
protocols. Nevertheless, this report will err on the conservative side and assume that current
average sodium consumption is 3,500 mg of sodium per day. Excess sodium consumption boosts
blood pressure, and hypertension is a leading cause of cardiovascular disease, accounting for twothirds of all strokes and half of all cases of heart disease. 12
Sodium Intake for Last Quarter Century
As can be seen from Figures 1 and 2, NHANES monitoring has found that sodium intake since 1988
has been fairly constant and far too high. A quarter-century-old report found that almost
80 percent of the sodium in the average American’s diet comes from processed and restaurant
foods, 13 meaning that sodium intake is largely out of the consumer’s control. That figure is likely to
be higher today.
Figure 1.
A M E R I C A N S' AV E R AG E S O D I U M C O N S U M P T I O N
( M G / DAY ) B A S E D O N D I E TA RY - R EC A L L S U R V E YS
Average Male and Female Consumption (ages 2 and older)
2010 Dietary Guidelines for Americans: recommended daily sodium intake limit for people over 50,
people with hypertension, and African Americans (majority of adults)
2010 Dietary Guidelines for Americans: recommended daily sodium intake limit for other adults
4,000
3,500
3,427
3,375
3,329
3,436
3,408
3,357
3,330
3,463
3,478
SODIUM (MG/DAY)
3,000
2,500
2,300
2,000
1,500
1,500
1,000
500
0
NHANES III NHANES IV NHANES NHANES NHANES NHANES NHANES NHANES NHANES
1988–1994 1999–2000 2001-2002 2003-2004 2005–2006 2005–2008 2007-2008 2009-2010 2011-2012
MG SODIUM/CALORIES CONSUMED PER DAY
Figure 2. *
1.8
1.6
S O D I U M / C A L O R I E R AT I O S , B A S E D O N D I E TA RY - R E C A L L
SURVEYS
( AV E R A G E O F M A L E S A N D F E M A L E S 2 Y E A R S A N D O L D E R )
1.61
1.57
1.53
1.55
1.59
1.61
1.66
1.63
NHANES III
1988–1994
NHANES IV
1999–2000
NHANES
2001-2002
NHANES
2003-2004
NHANES
2005–2006
NHANES
2007-2008
NHANES
2009-2010
NHANES
2011-2012
1.4
1.2
1
0.8
0.6
0.4
0.2
*Figure
0
2 uses sodium-to-calorie ratios to show that sodium consumption has remained constant even when
accounting for changes in caloric intake.
Sodium Reduction: Saving Money and Lives
In 2010, the Institute of Medicine (IOM) called on the Food and Drug Administration (FDA) to
reduce sodium by setting gradually decreasing mandatory limits on sodium in various categories of
processed and restaurant foods. 14 The IOM additionally called on the Secretary of Health and
Human Services to convene and lead a nationwide campaign that would involve industry, public
health groups, and consumer advocates to support the FDA initiative. 15 The recent Scientific Report
of the 2015 Dietary Guidelines Advisory Committee calls for the FDA to act on the Institute of
Medicine’s 2010 recommendations, noting: “The FDA should expeditiously initiate a process to set
mandatory national standards for the sodium content of foods.” 16
Researchers estimate that reducing current sodium consumption rates by 1,200 mg a day (such as
from 3,500 to 2,300 mg per day) would prevent 60,000 to 120,000 cases of coronary heart disease
and save 44,000 to 92,000 lives per year. 17 Such a shift in sodium consumption is also estimated to
reduce health care costs by $10 billion to $24 billion annually. 18
To date, studies have not estimated the savings in health care costs in individual states if sodium
consumption is reduced from the current level of about 3,500 mg per day to the recommended
2,300 mg.
Methods
To determine the costs saved by sodium reduction on a state-by-state basis, we began with national
estimates of health care costs saved as calculated by Bibbins-Domingo and her team at University of
California, San Francisco. 19 They determined that a 1,200 mg reduction in sodium would save $10
billion to $24 billion nationally per year, or an average of $17 billion. We used that average to
determine the costs that would be saved by reducing sodium from 3,500 mg to 2,300 mg per day.
Next, we calculated the cost saved per person by dividing the national cost estimate of $17 billion
by the 2009 national population of 306.9 million. 20 We adjusted that cost estimate for inflation,
giving a per capita cost saving of $61.12 from a 1,200 mg reduction in sodium. To determine the
health care cost saved per state, we multiplied the per capita cost by the population of each U.S.
state. 21 Our figures are only rough estimates, because sodium intake presumably varies from state
to state, and the vulnerability of a state’s population to develop hypertension varies depending on
the state’s ethnic, gender, health, and age distributions. Our estimates do not take those variables
into account.
Results
As shown in Figures 3 and 4, we estimate that a 1,200 mg per day sodium reduction would reduce
annual health care costs in four states by more than $1 billion each, with the most savings being
achieved in California at about $2.37 billion. In eight additional states the savings are estimated to
be between $500 million and $1 billion annually. Even the state with the least estimated savings,
Wyoming, totals about $36 million annually.
Figure 3.
Figure 4.
A N N UA L H E A LT H C A R E C O ST S ( I N M I L L I O N S ) SAV E D
WITH 1,200 MG REDUCTION IN SODIUM
CONSUMPTION
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
$296
$45
$411
$181
$57
$40
$2,372
$327
$220
$87
$100
$787
$403
$81
$190
$177
$270
$284
$365
$412
$183
$334
$606
$371
$63
$115
$174
$81
$546
$127
$709
$237
$243
$64
$400
$1,648
$180
$113
$0
$782
$295
$52
$36
$1,207
$608
$45
$38
$1,216
$617
$509
$432
$352
$500
$1,000
$1,500
$2,000
$2,500
Discussion
As seen by even these rough cost estimates, the health care cost savings achievable at the state level
through the recommended levels of sodium reduction are likely to be substantial. The importance
of such savings is well documented. The Pew Charitable Trusts’ State Health Care Spending project,
for instance, notes: “When it comes to health care spending, the bill just keeps getting bigger.
Health care’s growing claim on state budgets is competing with other important priorities,
including education, public safety, and transportation.” 22
These estimates also underline the importance of current efforts by public health authorities to
obtain state-level sodium reduction. Several states and localities are seeking to achieve reductions
in sodium intake with support from the federal Centers for Disease Control and Prevention (CDC).
In 2013 and 2014, four states—Maine, New York, Oregon, and Washington—and six large
municipalities—Los Angeles, Marion County (IN), New York City, Philadelphia, San Antonio, and
San Diego—received awards under the Sodium Reduction in Communities Program (SCRP) to
decrease sodium consumption in their populations. 23 Working through the Association of State and
Territorial Health Officials, CDC also provided support for technical assistance to seven states—
Arkansas, California, Delaware, Indiana, Massachusetts, Montana, and North Carolina—between
2010 and 2013 to achieve sodium reduction through procurement policies. 24
For the state-level benefits to be fully realized, however, it will take a coordinated national effort
led by the FDA. A national sodium reduction strategy will also require investment in monitoring
and evaluation to measure progress and provide accountability, especially given the lack of statelevel sodium intake data.
In the meantime, FDA’s failure to act is costing states hundreds of millions of health care dollars
they can ill afford to lose.
References
Taylor, C. L., & Henry, J. E. (Eds.). (2010). Strategies to reduce sodium intake in the United States.
Institute of Medicine, National Academies Press.
2 Yaktine, A. L., Oria, M., & Strom, B. L. (Eds.). (2013). Sodium Intake in Populations: Assessment of
Evidence. Institute of Medicine, National Academies Press.
3 World Health Organization. (2015). Global Strategy on Diet, Physical Activity, and Health.
http://www.who.int/dietphysicalactivity/reducingsalt/en/.
4 Sodium in food and high blood pressure : hearings before the Subcommittee on Investigations and
Oversight of the Committee on Science and Technology, U.S. House of Representatives, Ninetyseventh Congress, first session, April 13 and 14, 1981. Washington : U.S. G.P.O., 1981.
5 American Heart Association. (2015). Reducing Sodium in a Salty World.
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/ReducingSodium-in-a-Salty-World_UCM_457519_Article.jsp.
6 Harvard T.H. Chan School of Public Health. (2015). Salt and Sodium: Health Risks and Disease. The
Nutrition Source. http://www.hsph.harvard.edu/nutritionsource/salt-and-sodium/sodium-healthrisks-and-disease/.
7 U.S. Department of Health and Human Services, U.S. Department of Agriculture. (2010). “Dietary
Guidelines for Americans.”
http://health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf.
1
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Division for Heart Disease and Stroke Prevention. (12 April, 2013). “Most
Americans Consume Too Much Sodium.” http://www.cdc.gov/bloodpressure/sodium.htm.
9 NHANES. (2011-2012). What We Eat in America. USDA ARS.
http://www.ars.usda.gov/SP2UserFiles/Place/80400530/pdf/1112/Table_1_NIN_GEN_11.pdf.
10
Archer, E., Hand, G. A., & Blair, S. N. (2013). Validity of US nutritional surveillance: National Health
and Nutrition Examination Survey caloric energy intake data, 1971–2010. PloS One, 8(10), e76632.
11
Bernstein, A. M., & Willett, W. C. (2010). Trends in 24-h urinary sodium excretion in the United
States, 1957–2003: a systematic review. The American Journal of Clinical Nutrition, ajcn-29367.
12 He, F. J., & MacGregor, G. A. (2009). A comprehensive review on salt and health and current
experience of worldwide salt reduction programmes. Journal of Human Hypertension, 23(6), 363384.
13 Mattes, R. D., & Donnelly, D. (1991). Relative contributions of dietary sodium sources. Journal of
the American College of Nutrition, 10(4), 383-393.
14 Taylor, C. L., & Henry, J. E. (Eds.), 2010.
15 Ibid.
16 U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2015).
Scientific Report of the 2015 Dietary Guidelines Advisory Committee.
17 Bibbins-Domingo, K., Chertow, G. M., Coxson, P. G., Moran, A., Lightwood, J. M., Pletcher, M. J., &
Goldman, L. (2010). Projected effect of dietary salt reductions on future cardiovascular disease. New
England Journal of Medicine, 362(7), 590-599.
18 Ibid.
19 Ibid.
20 Ibid.
21 U.S. Bureau of the Census. July 2014 Population Estimates.
22 The Pew Charitable Trusts. (2015). “State Health Care Spending.”
http://www.pewtrusts.org/en/projects/state-health-care-spending/about.
23 Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention.
(December 3, 2014). “Sodium Reduction in Communities Program (SRCP).”
http://www.cdc.gov/dhdsp/programs/sodium_reduction.htm.
24 Association of State and Territorial Health Officials. (2015). “Sodium Reduction.”
http://www.astho.org/Programs/Prevention/Obesity-and-Wellness/Sodium-Reduction/.
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