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Research Letters |

Sodium Content of Lunchtime Fast Food Purchases at Major US Chains FREE

Christine M. Johnson, MBA; Sonia Y. Angell, MD, MPH; Ashley Lederer, MS, RD; Tamara Dumanovsky, PhD; Christina Huang, MPH; Mary T. Bassett, MD, MPH; Lynn D. Silver, MD, MPH
[+] Author Affiliations

Author Affiliations: New York City Department of Health and Mental Hygiene, New York, New York.


Arch Intern Med. 2010;170(8):732-734. doi:10.1001/archinternmed.2010.72.
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Published online

Cardiovascular disease is the leading cause of death in the United States,1 and high blood pressure is a leading risk factor. An extensive body of research describes a direct association between sodium intake and blood pressure.2 Current US recommendations advise adults to limit sodium intake to less than 2300 mg/d,3 and several demographic groups (blacks, middle-aged and older adults, and people with hypertension), which together compose 69% of US adults,4 to limit daily intake to 1500 mg. Despite these suggestions, adults consume an average of approximately 3500 mg of sodium per day.5

Individual efforts to reduce sodium intake have limited effect, likely because more than 75% of dietary sodium comes from packaged and restaurant foods.6 The American Medical Association has called on industry to reduce the sodium content of processed and restaurant foods by 50%. A reduction by this amount would save tens of thousands of lives each year,7,8 and this reduction could save almost $20 billion in health care costs annually.8

There are limited published data on the relationship between restaurant food and sodium intake. Using data from a large cross-sectional survey of patrons exiting fast food chain restaurants in New York City (NYC),9 we assessed the amount of sodium in meal purchases by fast food chain and by chain category.

All NYC fast food chains licensed by the NYC Department of Health and Mental Hygiene that provided nutrition information publicly as of March 1, 2007, were considered for inclusion in the study. When ice cream chains were excluded, 13 chains composed almost 90% of all eligible restaurants. From approximately 1625 eligible locations across the 5 boroughs of NYC, a random sample of 300 chain restaurants was selected. Eleven fast food chains and 2 coffee chains were represented; the 2 coffee chains were excluded from our analysis.

Data were collected from noon to 2:00 PM on weekdays from March 27 to June 8, 2007. Adult patrons (age ≥18 years) exiting the restaurant answered a brief survey and provided their purchase receipt in exchange for a $2 MetroCard.

Nutrition information was ascribed to each menu item using information posted on company Web sites as of March 1, 2007. A meal was defined as any purchase with at least 1 entrée. An entrée was defined as any item that was not a side order (eg, French fries, side salad) or a dessert.

To examine the distribution of sodium content, meals were categorized by sodium level: 600 mg or less, 601 to 1499 mg, 1500 to 2299 mg, and 2300 mg or greater. To assess the relationship between calorie and sodium intake, we calculated sodium density, defined as milligrams of sodium per 1000 calories.

SPSS 15.0 software (SPSS Inc, Chicago, Illinois) was used for statistical analyses. A 2-tailed t test (α level <.05) was used to test for differences in mean sodium levels. For bivariate tables, the χ2 test was used to obtain P values.

The final sample size for the analysis of fast food meals was 6580 receipts from 167 locations, after purchases without entrees were excluded (n = 466). Meals averaged 1751 mg of sodium; 20% had greater than 2300 mg. At fried chicken chains, 55% of meals had more than 2300 mg of sodium, which was higher than the mean percentage at all chains (P < .001). Fried chicken chain meals averaged 66 more calories than burger chain meals (999 calories vs 933 calories; P = .007) but contained almost 900 mg more sodium (2441 mg vs 1548 mg; P < .001). Over half (57%) of all purchases exceeded the 1500-mg recommended daily sodium limit applicable to most Americans, this rose to 84% in fried chicken chains. Mean sodium density for all meals purchased was 2136 mg per 1000 calories (Table).

Table Graphic Jump LocationTable. Mean Sodium, Mean Calories, Mean Sodium Density, and Percentage of Meals by Sodium Content at 11 New York City Fast Food Chains by Collection of Consumer Receiptsa

This study extends analyses of the nutritional content of fast food from calorie to sodium content and shows that fast food is high in sodium as well as calories. Only 1 in 36 purchased meals met the Food and Drug Administration “healthy” sodium level for meals (600 mg), whereas 1 in 5 exceeded the recommended daily limit (2300 mg). Excess sodium intake was not simply the result of large portion size. Average sodium density was 2136 mg sodium per 1000 calories purchased, so even a patron who was mindful of calorie intake would likely exceed standards for healthy sodium intake.

Fast food is an important and growing contributor to dietary intake. Chain restaurant visits, both fast food and casual dining, now represent almost 75% of all restaurant eating occasions.10 However, reducing sodium content in fast food is possible and already under way in some settings. The United Kingdom has worked with fast food chains to obtain commitments to sodium reductions11; in 2004, McDonald's committed to a 30% sodium reduction in its chicken nuggets. The National Salt Reduction Initiative in the United States, coordinated by the NYC Health Department, is now working with the restaurant industry to define sodium targets and to secure industry commitments to reductions.

Important strengths of this study include the use of receipts of meals purchased rather than reliance on patron self-report and the large sample of patrons from randomly selected locations. Limitations include a lack of patron demographic data. In addition, participants were not asked about salt added at the table, potentially underestimating sodium content per meal. A meal as defined in this study may not include purchases that a patron considers a meal, such as a large order of French fries, and may classify as a meal for some purchases that the patron viewed as a snack. Finally, the food establishments studied may not be representative of all fast food restaurants.

Fast food is not only a high-calorie but also a high-sodium food. Its widespread consumption contributes to current high levels of daily sodium intake in the United States, higher blood pressure, and the resulting burden of cardiovascular disease. Consequently, reducing sodium levels in fast food meals is a public health priority. Our findings support the need for the fast food industry to focus on reducing sodium levels across product lines. Government, public health, and industry involvement to accelerate food reformulation will reduce blood pressure and save lives.

Correspondence: Ms Johnson, Cardiovascular Disease Prevention and Control Program, NYC Department of Health and Mental Hygiene, 2 Lafayette St, 14th Floor, CN-46, New York, NY 10007 (cjohnso8@health.nyc.gov).

Author Contributions: Ms Johnson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Johnson, Angell, Dumanovsky, Bassett, and Silver. Acquisition of data: Dumanovsky and Silver. Analysis and interpretation of data: Johnson, Angell, Lederer, Dumanovsky, Huang, Bassett, and Silver. Drafting of the manuscript: Johnson, Angell, and Lederer. Critical revision of the manuscript for important intellectual content: Johnson, Angell, Lederer, Dumanovsky, Huang, Bassett, and Silver. Statistical analysis: Dumanovsky and Huang. Obtained funding: Silver. Administrative, technical, and material support: Lederer, Huang, and Silver. Study supervision: Johnson, Angell, Bassett, and Silver.

Financial Disclosure: Ms Johnson formerly owned 200 shares of Yum! Brands Inc.

Funding/Support: This study was fully funded by NYC tax levy dollars.

Lloyd-Jones  DAdams  RCarnethon  M  et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Heart Disease and Stroke Statistics–2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119 (3) e21- e181
PubMed Link to Article
Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate.  Washington, DC National Academy Press2004;
US Department of Health and Human Services and U.S. Department of Agriculture, Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC Government Printing Office2005;
Centers for Disease Control and Prevention (CDC), Application of lower sodium intake recommendations to adults–United States, 1999-2006. MMWR Morb Mortal Wkly Rep 2009;58 (11) 281- 283
PubMed
Briefel  RRJohnson  CL Secular trends in dietary intake in the United States. Annu Rev Nutr 2004;24 (1) 401- 431
PubMed Link to Article
Mattes  RDDonnelly  D Relative contributions of dietary sodium sources. J Am Coll Nutr 1991;10 (4) 383- 393
PubMed Link to Article
Dickinson  BDHavas  SCouncil on Science and Public Health, American Medical Association, Reducing the population burden of cardiovascular disease by reducing sodium intake: a report of the Council on Science and Public Health. Arch Intern Med 2007;167 (14) 1460- 1468
PubMed Link to Article
Bibbins-Domingo  KChertow  GMCoxson  PG  et al.  Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362 (7) 590- 599
PubMed Link to Article
Bassett  MTDumanovsky  THuang  C  et al.  Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health 2008;98 (8) 1457- 1459
PubMed Link to Article
Keystone Forum on Away-From-Home Foods, Opportunities for Preventing Weight Gain and Obesity.  Washington, DC Keystone Center2006;
Food Standards Agency, Summary table of commitments to salt reduction. http://www.food.gov.uk/multimedia/spreadsheets/saltcommitmentsum.xls. Accessed December 08, 2009

Figures

Tables

Table Graphic Jump LocationTable. Mean Sodium, Mean Calories, Mean Sodium Density, and Percentage of Meals by Sodium Content at 11 New York City Fast Food Chains by Collection of Consumer Receiptsa

References

Lloyd-Jones  DAdams  RCarnethon  M  et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Heart Disease and Stroke Statistics–2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119 (3) e21- e181
PubMed Link to Article
Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate.  Washington, DC National Academy Press2004;
US Department of Health and Human Services and U.S. Department of Agriculture, Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC Government Printing Office2005;
Centers for Disease Control and Prevention (CDC), Application of lower sodium intake recommendations to adults–United States, 1999-2006. MMWR Morb Mortal Wkly Rep 2009;58 (11) 281- 283
PubMed
Briefel  RRJohnson  CL Secular trends in dietary intake in the United States. Annu Rev Nutr 2004;24 (1) 401- 431
PubMed Link to Article
Mattes  RDDonnelly  D Relative contributions of dietary sodium sources. J Am Coll Nutr 1991;10 (4) 383- 393
PubMed Link to Article
Dickinson  BDHavas  SCouncil on Science and Public Health, American Medical Association, Reducing the population burden of cardiovascular disease by reducing sodium intake: a report of the Council on Science and Public Health. Arch Intern Med 2007;167 (14) 1460- 1468
PubMed Link to Article
Bibbins-Domingo  KChertow  GMCoxson  PG  et al.  Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362 (7) 590- 599
PubMed Link to Article
Bassett  MTDumanovsky  THuang  C  et al.  Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health 2008;98 (8) 1457- 1459
PubMed Link to Article
Keystone Forum on Away-From-Home Foods, Opportunities for Preventing Weight Gain and Obesity.  Washington, DC Keystone Center2006;
Food Standards Agency, Summary table of commitments to salt reduction. http://www.food.gov.uk/multimedia/spreadsheets/saltcommitmentsum.xls. Accessed December 08, 2009

Correspondence

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