by Tom Farley
Paterson’s proposal stirred up a national conversation about the sugary drinks, obesity, and taxes. Health experts generally loved the sugary drink tax. The big soda companies hated it, which we took as a signal that it would work. A spokesman for the American Beverage Association, the lobby group for Coke, Pepsi, and the other soda companies, promised to fight, calling the tax “purely a money grab that would be paid for by hard-working New York families” and that would damage and industry and kill jobs.
Frieden mobilized his team to do two things at once: support the idea but change it to an excise tax. Gaining the support of the Greater New York Hospital Association (GNYHA) and of the SEIU 1199 union, opponents in wage negotiations, was crucial. The hospitals floated on state Medicaid funding, which Paterson proposed to cut. The GNYHA would lobby hard against the $1 billion cut, but if the sugary drink tax failed, the governor would likely reduce Medicaid even more. The SEIU 1199 union represented health care workers, like nurses’ aides, clerks, and maintenance workers at hospitals, nursing homes, and home care agencies. To them, Medicaid cuts meant job losses. At Frieden’s urging, the groups issued a joint statement saying they strongly supported the tax, then pivoted to propose changing it to a penny-per-ounce excise tax.
Voters, who never like taxes, weren’t enthusiastic. A community organization called the Citizen’s Committee for Children found that 52 percent of voters supported “a one-cent-per-ounce tax on all sugar-sweetened beverages—and using a portion of the money to combat obesity in children and adults.” But a polling unit at Quinnipiac University, asking the question differently, got a far worse answer. Only 32 percent of voters supported “an ‘obesity tax’ or ‘fat tax’ on non-diet sugary soft drinks.”
Then Paterson—who struggled in the governor role—undercut himself. Only a few weeks after proposing the tax, at a town hall meeting with college students in Morrisville, he told the “soda addicts” not to worry. “The tax on soda was really a public policy argument,” he said. “In other words, it’s not something that we necessarily thought we would get.” His spokesperson tried to backpedal, saying that “the governor stands firmly behind his soda tax proposal,” but the damage was done. Soon the federal government passed a financial stimulus package, sending money to New York, which relieved some of the budget pressure. In budget negotiations with legislators, Paterson abandoned the soda tax.
They say it takes three years to get anything through Albany, I was told. My colleagues at the health department and I consoled one another that we got the idea “out there.” Next year or the year after, we would get it passed.
Paterson’s proposal certainly succeeded in getting the idea out there. Silver and Frieden’s idea channeled a growing national frustration about the obesity epidemic toward a specific, simple solution. Suddenly people around the country were talking about soda taxes. Frieden and Kelly Brownell, a longtime anti-obesity researcher and advocate, wrote a piece in The New England Journal of Medicine promoting them. David Leonhardt, an economic columnist for The New York Times, wrote a column calling their arguments “fairly compelling.” In Washington, congresspeople trying to figure out how to finance Obama’s health care reform plan proposed a soda tax. Obama himself, when asked about it, said, “It’s an idea we should be exploring. There’s no doubt our kids drink way too much soda.” Fox News stalwart Sean Hannity attacked it: “We can’t live anymore!”
Even Stephen Colbert, in faux-conservative character, ranted against the soda tax, saying those who wanted it would have to pry the can of soda “from my cold, diabetic hands.” He ridiculed American Beverage Association president Susan Neely’s remark that “soft drinks don’t play any role in the obesity epidemic. Soft drinks are just a fun beverage along with a lot of other beverages and foods that we like to eat or drink.”
“Yeah, things that are fun are never bad for you,” Colbert shouted. “We learned that from unprotected sex!”
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“In the end, it’s just ketchup.”
It finally caught up with her. After many years doing everything right, Sylvia Birnbaum (not her real name) learned that she had high blood pressure. Even months later she said, “I’m still in shock.”
Sylvia Birnbaum had always protected her health. Her husband, not so much. He smoked a cigarette first thing in the morning and last thing before going to bed, and in between he always seemed to have a cigarette in his mouth. One day when he was on a business trip at age forty-three, he had a heart attack. Unlike Chris Gallin, he never came home.
Afterward Sylvia Birnbaum was even more vigilant. Every workday, instead of taking the elevator to her desk on the third floor, she walked up the stairs. She read food labels and tried to choose healthy food. She ate no-added-sugar cereal for breakfast, salads for lunch, fruit for snacks, and chicken or fish, with a vegetable on the side, for dinner. With that, she stayed thin—120 pounds, five foot three. And for many years she did what almost no one else who doesn’t already have high blood pressure does: she avoided salt. She didn’t have a saltshaker in her apartment. She ate no-salt cottage cheese, crackers with unsalted tops, and—for an occasional treat—no-salt potato chips. Taking in so little salt, she lost her taste for it, so now if she gets something salty, she doesn’t like it.
But one day her doctor said her blood pressure was 140 over 90. Several visits and measurements later, her pressure was still high. The doctor told her she should take a pill every day for the rest of her life to reduce her risk of a stroke or heart attack.
Looking back on it, she realizes that there was plenty of salt that she hadn’t been avoiding. She had a taste for canned butternut squash soup. Her breakfast cereal had salt in it. The crackers had sodium in the wafers. And when she went to a restaurant, she had no idea how much salt was in the food.
• • •
By one estimate, hypertension—high blood pressure—kills nearly 400,000 Americans a year by causing heart attacks and strokes. That’s the size of the city of Minneapolis. Almost two-thirds of people over sixty have the condition. That means hypertension shares with obesity the disturbing combination of being distinctly unhealthy yet so common that we can only call it normal.
Tom Frieden wanted to nudge doctors to do a better job treating patients with hypertension. But in early 2005 Lynn Silver came across a report from a nutrition advocacy group that made her think very differently about the problem.
The report carried the menacing title Salt: The Forgotten Killer. For decades, researchers have eyed sodium, as in sodium chloride, as the prime suspect for hypertension. Give lab rats extra sodium, and they get high blood pressure. The same is true for dogs, chickens, rabbits, baboons, and even our very near cousins, chimpanzees. Put people on low-salt diets, and within weeks their blood pressure falls. In two isolated tribes of Solomon Islanders, the one that used seawater for cooking had higher blood pressure than the one that didn’t.
In the 1980s a huge team of researchers carried out a study called INTERSALT, in which they measured sodium intake and blood pressure in fifty-two strikingly different populations around the world, from residents of Beijing to the Yanomami Indians of the Amazon jungle. The populations that consumed more sodium had higher average blood pressures. Among the study’s four remote native populations who took in a fraction of the salt that we do, virtually no one had high blood pressure, even as they got older. The scores of studies on salt fit together to tell a story that people have hypertension today mostly because, over their lifetimes, they eat way too much sodium. High blood pressure isn’t an inevitable part of the aging process, then. It is more like a marker for chronic sodium intoxication.
Ever since our ancestors abandoned the oceans for dry land, they have needed to eat salt for their internal biochemistry. But for most of evolutionary history, away from the sea, salt was difficult to find. That’s why land animals constantly seek it out, why hunters can attract game with salt licks, and why we humans crave salt. Salt was so scarce in the Paleolithic period that, by th
e best estimates of archaeologists and nutritionists, our hunter-gatherer forebears took in less than a third of the sodium we do—but about as much as those remote tribes consumed in the 1980s. It is an anomaly in human history that salt is now plentiful and cheap.
Salt now costs far less than spices and other ingredients, so food companies pour salt into processed food to play to our craving. Salt appears in processed foods even where we don’t expect it or taste it. Ham and canned soup are full of salt, but so is breakfast cereal and bread. A blueberry muffin has almost twice as much salt as a serving of potato chips. All that salt leaves Americans taking in about 3,500 mg of sodium (about 1½ teaspoons of salt) per day. Fewer than a third of Americans take in below 2,300 mg, and fewer than one in ten take in below 1,500 mg, two recommendations for healthy sodium intake.
If Americans were to take in a little less salt, far fewer of us would have high blood pressure. Changing people’s diets has big advantages over treating them with medicine for hypertension. First, it would save many doctors and patients the trouble of making the diagnosis, getting the prescriptions, and swallowing those pills every day for a lifetime. Second, it would make it easier to treat hypertension when it happens anyway. Third, and most important, it would lower the blood pressure even of people in the “high normal” range—much of the entire nation—which would cut their risk of heart attack or stroke also.
Doctors recommend that people with high blood pressure go on a low-salt diet. But cutting salt significantly is nearly impossible, as Sylvia Birnbaum found out, because nearly 80 percent of the sodium that Americans eat comes in packaged and restaurant food. The only way to prevent millions of Americans from developing hypertension is to get food companies and restaurants to stop loading their foods with salt.
That’s where it gets complicated. People love the taste of salt itself, and salt enhances other flavors. Take salt out of canned soup, and it tastes like dishwater. But it is possible to reduce sodium in food without making food taste awful. Food companies often use salt or sodium for reasons that have nothing to do with taste, like leavening or food texture. And competing foods made by different companies have wildly different sodium levels, which shows that companies can cut the salt in their recipes sharply without hurting taste. Scientists have shown that when people eat less salt, even for as little as two months, their preference for a salty taste drops. Sylvia Birnbaum saw this. If all companies were to reduce the amount of salt they use gradually, their customers’ taste buds would adjust without anyone noticing.
Lynn Silver was always looking for the Holy Grail in public health: actions that have a big health benefit, can reach a lot of people, and are inexpensive. Prohibiting trans fat met those three criteria. Cutting salt in food felt to her like another Holy Grail, a change that no one would notice but that could save many thousands of lives. Finland once had astronomical rates of heart disease. In the 1970s the government started a national campaign against salt, and in 1993 it required manufacturers to post high-salt warning labels on foods that were really loaded. The food companies cut back, salt intake dropped by one-quarter, and deaths from heart disease plummeted.
In this country, the federal government had been trying—feebly, but trying—to cut salt in the food supply for decades. It first asked food companies to reduce sodium in 1969. In 1978 the Center for Science in the Public Interest petitioned the FDA to regulate sodium levels and to require companies to put warning labels on high-sodium foods. Ronald Reagan’s FDA wasn’t about to create new regulations for food companies, but in 1981 the FDA said it would “encourage” the companies to cut back “where this is safe and feasible.” Two years later it called the results “encouraging.” But the FDA didn’t track salt levels in foods, and a quarter-century later surveys showed that Americans’ sodium intake had instead increased.
Silver handed the Forgotten Killer report to Sonia Angell and asked her to think what the New York City health department could do. How could a city agency change America’s food industry when the federal government had failed for so long?
Their authority wasn’t clear. State and local health departments in the United States generally don’t regulate the content of food. The FDA does that, and federal law preempts state and local laws. Still, “we had this lovely example of an effective model” in trans fats, said Angell. “There was no reason we couldn’t do it ourselves.”
But salt proved much more complicated than trans fats. Because humans need salt, the health department couldn’t ban it. Angell wanted only to reduce it. But to what level, and in what foods? Salt showed up in thousands of foods, from sausage to cookies. No one category of food was a standout culprit. The top five—bread, cheese, ham, salad dressings, and sweet baked snacks—together accounted for only about 25 percent of Americans’ salt intake. And lowering the salt levels in some foods would be tough. Ham was laden with salt less for taste than as a preservative. “You’re never going to outlaw a pickle,” an expert told me. Setting a maximum level for salt that accommodated ham or pickles would be like setting a national speed limit at 150 mph; it could only make things worse. What the food companies needed was a set of standards for salt, with different levels allowed for different types of foods. And those standards had to cover thousands of food items on grocery shelves.
Angell discovered that another government had created standards like that. The equivalent of the FDA in the United Kingdom, the Food Standards Agency, working with food companies, had divided the most important food items into eighty-five categories. They measured the amount of salt in each category, set salt-reduction targets in each category, and then asked the food companies to commit to meeting those targets gradually over time. The big food companies had made real changes: Heinz cut sodium by 19 percent in all its canned products, Kellogg’s cut the sodium in cornflakes by 25 percent, and Kraft cut the sodium in cheese spreads and snacks by a third. Only a few years into the program, people in the U.K. were taking in 9 percent less sodium without even noticing it.
During 2007 and 2008 Silver and Angell quietly invited representatives from a few major food manufacturers to chat about sodium. Lowering sodium levels in food wouldn’t be easy, the representatives said, but it was possible. They made a key request, though. Big manufacturers didn’t make different versions of food for different cities. They made food. Any changes they might make would have to be national. The federal government, not New York City, should do the asking. The food companies probably figured that, since the federal government would do nothing, that request would make the issue go away.
• • •
On a gray day in late October 2008, Tom Frieden, Christina Chang, Mary Bassett, Lynn Silver, Sonia Angell, and Frieden’s assistant Kelly Christ sat at round, linen-covered tables in the blue ballroom of Gracie Mansion for a lunch of grilled salmon, green salad, and unsweetened tea. Joining them were thirty-four representatives of seventeen of America’s major food companies and their trade associations. They had come to hear what the mayor of New York had to say about salt.
The health department staff had struggled for months to hold this gathering. After some forty years of inaction on salt, they didn’t want just another conversation. Frieden had labored over every word of the invitation. He wanted the tone to be a little ambiguous: a friendly invitation over an unstated threat. “I know that [company name] is committed to making its products healthier,” it said. “I hope to discuss with you and other food industry leaders setting and implementing voluntary standards to reduce salt content.” I imagined the CEOs puzzling over that. How could “standards” be voluntary?
Frieden wanted to talk directly with decision makers. He sent the companies’ CEOs an e-mail after the invitation, saying that the initiative would succeed only “if there is commitment at the highest levels. For this reason I urge you to personally attend the meeting. If you are unable to join Mayor Bloomberg, please send a representative who is authorized to make commitments on your company’s behalf.”
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p; The tone came through. One executive, speaking later anonymously to the Times, said, “I would say the invitations to come to Gracie Mansion weren’t very inviting. . . . There was definitely a feeling of ‘Don’t make us shame you.’” An industry insider we spoke to saw “high levels of suspicion and concern that companies are heading into a trap.”
In a later interview with the Times, Frieden was more direct. “If there’s not progress in a few years, we’ll have to consider other options, like legislation.” Even with federal preemption, could New York City somehow require companies to limit the sodium in food sold within its boundaries? No one at the health department knew for sure. But then neither did the food industry, and the health department team wanted to make the most of that uncertainty.
Mayor Bloomberg was the attraction at the meeting. The city health department lacked the clout of the FDA, but it had on its side the nation’s biggest voice in health. Showcasing Bloomberg for this particular initiative carried a risk, though—he loved salt. “He salts his bacon,” Frieden told me. When the newspapers got wind of this initiative, they would be unable to resist writing about the billionaire who loved salt for himself but forced bad-tasting food on everyone else. Bloomberg especially loved to snack on Cheez-Its crackers. They were the perfectly balanced snack food, he told Frieden, with enough fat to clog your arteries and then enough salt to push the blood through.
Sonia Angell had figured out how to deal with the problem of Bloomberg’s taste for salt. Most sodium is dissolved within food, but most of the taste zing happens when your tongue hits salt on a food’s surface. In one study, researchers put a group of eleven students in a research lab for thirteen weeks and, without telling them, varied the amount of salt cooked in their food. During the entire study, the students had saltshakers at the table. When the researchers cut the salt content in the food by half, the students compensated by sprinkling more salt from the shakers, but only enough to replace a fraction of what the researchers had removed. Net, the students ate 30 percent less sodium and were just as satisfied. The sodium the health department would be asking companies to remove from food was often the sodium people didn’t taste. And if people, like Bloomberg, wanted to use a saltshaker, they could sprinkle away and still come out ahead.
