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Examining Evidence on Sodium Intake in Children



A new paper discussing the importance of gradually reducing children’s sodium intakes has been published in The Journal of Clinical Hypertension, titled Reducing Sodium Intake in Children: A Public Health Investment. A key purpose of the paper is to support the case for continued sodium reduction in the foods offered at schools at a time when nutrition standards for school foods are under review by lawmakers. spoke with a few of the authors about their analysis of the current research regarding children and sodium intake. 

While most schools have already successfully achieved the first milestone in the planned schedule for reducing sodium gradually over the next several years, Congress is currently considering bill language that would stagnate any further decrease in sodium levels for school meals “until the latest scientific research establishes the reduction is beneficial for children.” According to Dr. Lawrence J. Appel, professor of Medicine in Epidemiology and International Health and director of the Welch Center for Prevention, Epidemiology and Clinical Research at Johns Hopkins, many in the science and public health community feel that the available evidence already supports action in sodium level reduction in children, which is one reason that the paper’s co-authors convened to summarize the research on this topic. 

One of the claims made by those who oppose further sodium reductions in school meals is that more evidence is needed to show that such reductions are beneficial for kids and do not harm their health. The paper recounts conclusions from the 2010 Dietary Guidelines Advisory Committee Report, explaining that “sodium intake in infants and children is of concern because BP during childhood tracks over time and elevated BP in childhood results in significant cardiovascular dysfunction and pathology both earlier and later in life.…taste preferences for salt, the major source of sodium in the diet, are established early and shaped by dietary exposure.” It also cites the 2015 Dietary Guidelines Advisory Committee Report that identified sodium as a nutrient consumed in excess of the maximum recommended levels. It goes on to specify that the majority of the US population aged 1 year and older, including more than 90 percent of 4-18-year-old children, exceeds sodium intake recommendations.

Opposition arguments have also claimed that further reducing sodium in school meals will not appeal to children’s taste preferences and subsequently result in increased food waste. The paper cites a survey of foodservice personnel indicating that 70 percent of respondents reported that students like the new school lunches. Dr. Appel noted studies showing that childhood food habits and preferences track later into life, so offering lower-sodium meals at a young age can benefit heart health, especially blood pressure, later in life. Dr. Appel indicated that advocates for reducing children’s sodium intakes are not calling for a total elimination of salt in foods, but rather a gradual reduction in prepackaged and prepared food. 

According to Emily Ann Callahan, MPH, RD, National Program Lead, Sodium Reduction Initiative at the American Heart Association, the U.S. food supply is rich in added salt such that more than three-fourths of the sodium in Americans’ diets is contributed by salt added to packaged and restaurant foods before we buy them. "The American Heart Association believes that people should have more choice and control over how much salt they eat, rather than letting the food industry decide for them. If sodium is lowered in the food supply, people will still have the option to add more salt but that decision shouldn’t be made for them before they even open the packaging,” said Callahan.

The 2015 Dietary Guidelines Committee noted that sodium is ubiquitous in the food supply and concerted efforts will be needed to reduce levels in commercially prepared and processed foods and encourage more food preparation at home. Dr. Appel adds, “There is a way to acclimate our taste preferences over time to prefer a lower-sodium diet. It can occur and if done correctly, the gradual tapered reduction of sodium is not associated with adverse consequences of taste or reactions.”

Some stakeholders have argued that it will be difficult for schools to acquire foods from their suppliers that will allow them to compose meals that meet the sodium standards. Dr. Appel said that this is a procurement issue, noting that “sodium is widespread throughout the food supply but levels in similar types of foods vary widely, and it’s likely that among the options available to foodservice operations are foods that are lower in sodium. For example, sodium levels in foods such as breads, spaghetti sauce, salsa and salad dressing can be remarkably different.” 

Another claim is that if children eat a less salty meal at school but their meals elsewhere continue to be rich in sodium, they will dislike the school meals and stop purchasing them. Callahan explains that there are a number of flavor alternatives and culinary methods to prepare tasty foods with less salt, and there are technical assistance resources available to help schools learn these techniques. Callahan noted that a number food manufacturers have decreased sodium in their portfolios, and some companies are working with schools to meet their specific needs. In addition, advocates for sodium reduction are focused not only on less sodium in schools but also in the broader food environment. Parents have a critical role to play including modeling healthy eating habits and exposing children to lower-sodium foods early in life, when eating habits and taste preferences are being formed. All adults have a stake in this as well; according to Dr. Appel, “virtually 90 percent of adults will develop hypertension in their lifetime. Parents can improve their own health as well as their children’s if they feed their families foods lower in sodium.”

In summary, the paper emphasizes that high blood pressure and other risk factors for heart disease begin in childhood and warrants preventive measures and corresponding policies to mitigate these risk factors early in life.  To read the full article, click here