We read with interest the article by Kang et al. [1], “Hemoglobin distributions and prevalence of anemia in a multiethnic United States pregnant population,” as well as the accompanying Editorial by Merz and Achebe [2], “Iron deficiency in pregnancy: a health inequity [2].” Both Kang et al. [1] and Merz and Achebe [2] incorrectly stated that the Centers for Disease Control and Prevention (CDC) recommend use of lower race-adjusted thresholds to define anemia for Black individuals. The CDC does not recommend separate diagnostic thresholds to define anemia for Black individuals or any other race/ethnic group. Here, we clarify misinterpretations in recent American Journal of Clinical Nutrition publications regarding the CDC anemia threshold recommendations. | | The 1998 “Recommendations to prevent and control iron deficiency in the United States” [3], the most recent CDC publication providing guidance on thresholds to define anemia in individuals, did not recommend race-specific cutoff values for anemia. The 1998 recommendations included criteria for anemia threshold adjustments based on age, sex, pregnancy status, gestational age, altitude, and smoking status [3]. To guide the development of these 1998 CDC recommendations, the CDC requested that the Institute of Medicine (IOM) convene an expert committee to develop recommendations for preventing, detecting, and treating iron deficiency anemia among children and women of reproductive age in United States. The IOM report published in 1993 [4] is independent and not an official institutional CDC/federal recommendations publication. The 1998 CDC recommendations considered inputs from the IOM report [4], conclusions of a CDC expert panel convened in April 1994, and from other multidisciplinary subject matter experts [3].

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17-September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,(dagger) primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0-12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13-17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)-level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

Monkeypox, a zoonotic infection caused by an orthopoxvirus, is endemic in parts of Africa. On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox outbreak, which began on May 17, to be a public health emergency (1,2). After detection of the first U.S. monkeypox case), CDC and health departments implemented enhanced monkeypox case detection and reporting. Among 2,891 cases reported in the United States through July 22 by 43 states, Puerto Rico, and the District of Columbia (DC), CDC received case report forms for 1,195 (41%) cases by July 27. Among these, 99% of cases were among men; among men with available information, 94% reported male-to-male sexual or close intimate contact during the 3 weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White (White) persons, 28% among Hispanic or Latino (Hispanic) persons, and 26% among non-Hispanic Black or African American (Black) persons. Forty-two percent of persons with monkeypox with available data did not report the typical prodrome as their first symptom, and 46% reported one or more genital lesions during their illness; 41% had HIV infection. Data suggest that widespread community transmission of monkeypox has disproportionately affected gay, bisexual, and other men who have sex with men and racial and ethnic minority groups. Compared with historical reports of monkeypox in areas with endemic disease, currently reported outbreak-associated cases are less likely to have a prodrome and more likely to have genital involvement. CDC and other federal, state, and local agencies have implemented response efforts to expand testing, treatment, and vaccination. Public health efforts should prioritize gay, bisexual, and other men who have sex with men, who are currently disproportionately affected, for prevention and testing, while addressing equity, minimizing stigma, and maintaining vigilance for transmission in other populations. Clinicians should test patients with rash consistent with monkeypox,(†) regardless of whether the rash is disseminated or was preceded by prodrome. Likewise, although most cases to date have occurred among gay, bisexual, and other men who have sex with men, any patient with rash consistent with monkeypox should be considered for testing. CDC is continually evaluating new evidence and tailoring response strategies as information on changing case demographics, clinical characteristics, transmission, and vaccine effectiveness become available.(§).

Developmental delays, disorders, or disabilities (DDs) manifest in infancy and childhood and can limit a person's function throughout life* (1-3). To guide strategies to optimize health for U.S. children with DDs, CDC analyzed data from 44,299 participants in the 2014-2018 National Health Interview Survey (NHIS). Parents reported on 10 DDs,(†) functional abilities, health needs, and use of services. Among the approximately one in six (17.3%) U.S. children and adolescents aged 3-17 years (hereafter children) with one or more DDs, 5.7% had limited ability to move or play, 4.7% needed help with personal care, 4.6% needed special equipment, and 2.4% received home health care, compared with ≤1% for each of these measures among children without DDs. Children with DDs were two to seven times as likely as those without DDs to have taken prescription medication for ≥3 months (41.6% versus 8.4%), seen a mental health professional (30.6% versus 4.5%), a medical specialist (26.0% versus 12.4%), or a special therapist, such as a physical, occupational, or speech therapist, (25.0% versus 4.5%) during the past year, and 18 times as likely to have received special education or early intervention services (EIS) (41.9% versus 2.4%). These percentages varied by type of disability and by sociodemographic subgroup. DDs are common, and children with DDs often need substantial health care and services. Policies and programs that promote early identification of children with developmental delays and facilitate increased access to intervention services can improve health and reduce the need for services later in life.(§) Sociodemographic inequities merit further investigation to guide public health action and ensure early and equitable access to needed care and services.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network conducts active surveillance of ASD. This report focuses on the prevalence and characteristics of ASD among children aged 8 years in 2018 whose parents or guardians lived in 11 ADDM Network sites in the United States (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin). To ascertain ASD among children aged 8 years, ADDM Network staff review and abstract developmental evaluations and records from community medical and educational service providers. In 2018, children met the case definition if their records documented 1) an ASD diagnostic statement in an evaluation (diagnosis), 2) a special education classification of ASD (eligibility), or 3) an ASD International Classification of Diseases (ICD) code. RESULTS: For 2018, across all 11 ADDM sites, ASD prevalence per 1,000 children aged 8 years ranged from 16.5 in Missouri to 38.9 in California. The overall ASD prevalence was 23.0 per 1,000 (one in 44) children aged 8 years, and ASD was 4.2 times as prevalent among boys as among girls. Overall ASD prevalence was similar across racial and ethnic groups, except American Indian/Alaska Native children had higher ASD prevalence than non-Hispanic White (White) children (29.0 versus 21.2 per 1,000 children aged 8 years). At multiple sites, Hispanic children had lower ASD prevalence than White children (Arizona, Arkansas, Georgia, and Utah), and non-Hispanic Black (Black) children (Georgia and Minnesota). The associations between ASD prevalence and neighborhood-level median household income varied by site. Among the 5,058 children who met the ASD case definition, 75.8% had a diagnostic statement of ASD in an evaluation, 18.8% had an ASD special education classification or eligibility and no ASD diagnostic statement, and 5.4% had an ASD ICD code only. ASD prevalence per 1,000 children aged 8 years that was based exclusively on documented ASD diagnostic statements was 17.4 overall (range: 11.2 in Maryland to 29.9 in California). The median age of earliest known ASD diagnosis ranged from 36 months in California to 63 months in Minnesota. Among the 3,007 children with ASD and data on cognitive ability, 35.2% were classified as having an intelligence quotient (IQ) score ≤70. The percentages of children with ASD with IQ scores ≤70 were 49.8%, 33.1%, and 29.7% among Black, Hispanic, and White children, respectively. Overall, children with ASD and IQ scores ≤70 had earlier median ages of ASD diagnosis than children with ASD and IQ scores >70 (44 versus 53 months). INTERPRETATION: In 2018, one in 44 children aged 8 years was estimated to have ASD, and prevalence and median age of identification varied widely across sites. Whereas overall ASD prevalence was similar by race and ethnicity, at certain sites Hispanic children were less likely to be identified as having ASD than White or Black children. The higher proportion of Black children compared with White and Hispanic children classified as having intellectual disability was consistent with previous findings. PUBLIC HEALTH ACTION: The variability in ASD prevalence and community ASD identification practices among children with different racial, ethnic, and geographical characteristics highlights the importance of research into the causes of that variability and strategies to provide equitable access to developmental evaluations and services. These findings also underscore the need for enhanced infrastructure for diagnostic, treatment, and support services to meet the needs of all children.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates ASD prevalence and monitors timing of ASD identification among children aged 4 and 8 years. This report focuses on children aged 4 years in 2018, who were born in 2014 and had a parent or guardian who lived in the surveillance area in one of 11 sites (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin) at any time during 2018. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement (diagnosis) in an evaluation, 2) a special education classification of ASD (eligibility), or 3) an ASD International Classification of Diseases (ICD) code. Suspected ASD also was tracked among children aged 4 years. Children who did not meet the case definition for ASD were classified as having suspected ASD if their records contained a qualified professional's statement indicating a suspicion of ASD. RESULTS: For 2018, the overall ASD prevalence was 17.0 per 1,000 (one in 59) children aged 4 years. Prevalence varied from 9.1 per 1,000 in Utah to 41.6 per 1,000 in California. At every site, prevalence was higher among boys than girls, with an overall male-to-female prevalence ratio of 3.4. Prevalence of ASD among children aged 4 years was lower among non-Hispanic White (White) children (12.9 per 1,000) than among non-Hispanic Black (Black) children (16.6 per 1,000), Hispanic children (21.1 per 1,000), and Asian/Pacific Islander (A/PI) children (22.7 per 1,000). Among children aged 4 years with ASD and information on intellectual ability, 52% met the surveillance case definition of co-occurring intellectual disability (intelligence quotient ≤70 or an examiner's statement of intellectual disability documented in an evaluation). Of children aged 4 years with ASD, 72% had a first evaluation at age ≤36 months. Stratified by census-tract-level median household income (MHI) tertile, a lower percentage of children with ASD and intellectual disability was evaluated by age 36 months in the low MHI tertile (72%) than in the high MHI tertile (84%). Cumulative incidence of ASD diagnosis or eligibility received by age 48 months was 1.5 times as high among children aged 4 years (13.6 per 1,000 children born in 2014) as among those aged 8 years (8.9 per 1,000 children born in 2010). Across MHI tertiles, higher cumulative incidence of ASD diagnosis or eligibility received by age 48 months was associated with lower MHI. Suspected ASD prevalence was 2.6 per 1,000 children aged 4 years, meaning for every six children with ASD, one child had suspected ASD. The combined prevalence of ASD and suspected ASD (19.7 per 1,000 children aged 4 years) was lower than ASD prevalence among children aged 8 years (23.0 per 1,000 children aged 8 years). INTERPRETATION: Groups with historically lower prevalence of ASD (non-White and lower MHI) had higher prevalence and cumulative incidence of ASD among children aged 4 years in 2018, suggesting progress in identification among these groups. However, a lower percentage of children with ASD and intellectual disability in the low MHI tertile were evaluated by age 36 months than in the high MHI group, indicating disparity in timely evaluation. Children aged 4 years had a higher cumulative incidence of diagnosis or eligibility by age 48 months compared with children aged 8 years, indicating improvement in early identification of ASD. The overall prevalence for children aged 4 years was less than children aged 8 years, even when prevalence of children suspected of having ASD by age 4 years is included. This finding suggests that many children identified after age 4 years do not have suspected ASD documented by age 48 months. PUBLIC HEALTH ACTION: Children born in 2014 were more likely to be identified with ASD by age 48 months than children born in 2010, indicating increased early identification. However, ASD identification among children aged 4 years varied by site, suggesting opportunities to examine developmental screening and diagnostic practices that promote earlier identification. Children aged 4 years also were more likely to have co-occurring intellectual disability than children aged 8 years, suggesting that improvement in the early identification and evaluation of developmental concerns outside of cognitive impairments is still needed. Improving early identification of ASD could lead to earlier receipt of evidence-based interventions and potentially improve developmental outcomes.

Hypertension, which can be brought on by excess sodium intake, affects nearly one half of U.S. adults and is a major risk factor for heart disease, the leading cause of death in the United States (1). In 2019, the National Academies of Sciences, Engineering, and Medicine (NASEM) established the Chronic Disease Risk Reduction (CDRR) intake, a chronic-disease-specific recommendation for dietary sodium of 2,300 mg/day. Reducing daily sodium to CDRR intake is expected to reduce chronic disease risk among healthy persons, primarily by lowering blood pressure (2). Although the 2019 sodium CDRR intake is equivalent in number to the 2005 Tolerable Upper Limit (UL) released by NASEM (then known as the Institute of Medicine), the UL was intended to provide guidance on safe intake levels, not to serve as an intake goal (2). To describe excess sodium intake in the context of the CDRR intake goal, this report analyzed National Health and Nutrition Examination Survey (NHANES) data from 2003 to 2016 to yield temporal trends in usual sodium intake >2,300 mg/day and in mean sodium intake, unadjusted and adjusted for total energy intake, among U.S. adults aged ≥19 years. The percentage of U.S. adults with sodium intake above CDRR intake was 87.0% during 2003-2004 and 86.7% during 2015-2016. Among U.S. adults overall, no significant linear trend was noted from 2003 to 2016 in unadjusted or energy intake-adjusted mean sodium intake. Small, significant declines were observed in mean usual sodium intake among some groups (adults aged 19-50 years, non-Hispanic White adults, adults experiencing obesity, and adults without hypertension). However, after energy adjustment, only adults aged ≥71 years and Mexican American adults demonstrated significant change in usual sodium intake. Many U.S. adults might be at risk for chronic disease associated with sodium intake above CDRR intake, and efforts to lower sodium intake could improve population cardiovascular health. The results of this report support enhanced efforts to reduce population sodium intake and cardiovascular disease risk, including the Food and Drug Administration's (FDA's) recently released guidance for the reduction of sodium in the commercially processed, packaged, and prepared food supply.

Children can transmit SARS-CoV-2, and although lower risk, can experience serious outcomes from infection. Vaccinating children against COVID-19 is essential to protecting their health and establishing higher population immunity. In 2015–2017, 1 in 6 children aged 3–17 years had a developmental disability (DD) such as cerebral palsy, autism spectrum disorder (ASD), or intellectual disability (ID).1 DDs are a diverse group of chronic conditions that begin in childhood and can impact functioning throughout life. Despite limited data in public health surveillance systems, some evidence suggests that some children with DDs might be disproportionately affected by COVID-19, both by the illness itself, and the pandemic’s impact on receipt of services. Children with DDs often have medical conditions that contribute to higher risk for severe illness from COVID-19,2 and can experience barriers to accessing needed health care and possess other characteristics increasing their risk from COVID-19, including limited mobility, direct care requirements, and challenges practicing preventive measures and communicating illness symptoms.3 We describe the limited available data relevant for children with DDs and highlight other considerations for COVID-19 vaccination.

OBJECTIVE: Population reductions in sodium intake could prevent hypertension, and current guidelines recommend that clinicians advise patients to reduce intake. This study aimed to estimate the prevalence of taking action and receiving advice from a health professional to reduce sodium intake in 10 US jurisdictions, including the first-ever data in New York state and Guam. DESIGN: weighted prevalence and 95% confidence intervals (CI) overall and by location, demographic group, health status, and receipt of provider advice using self-reported data from the 2017 Behavioral Risk Factor Surveillance System optional sodium module. SETTING: seven states, the District of Columbia, Puerto Rico, and Guam. PARTICIPANTS: adults aged ≥18 years. RESULTS: Overall, 53.6% (CI: 52.7, 54.5) of adults reported taking action to reduce sodium intake, including 54.8% (CI: 52.8, 56.7) in New York and 61.2% (CI: 57.6, 64.7) in Guam. Prevalence varied by demographic and health characteristics and was higher among adults who reported having hypertension (72.5%; CI: 71.2, 73.7) vs. those who did not report having hypertension (43.9%; CI: 42.7, 45.0). Among those who reported receiving sodium reduction advice from a health professional, 82.6% (CI: 81.3, 83.9) reported action vs. 44.4% (CI: 43.4, 45.5) among those who did not receive advice. However, only 24.0% (CI: 23.3, 24.7) of adults reported receiving advice from a health professional to reduce sodium intake. CONCLUSIONS: The majority of adults report taking action to reduce sodium intake. Results highlight an opportunity to increase sodium reduction advice from health professionals during clinical visits to better align with existing guidelines.

Persons identified in early childhood as having autism spectrum disorder (autism) often have co-occurring health problems that extend into adolescence (1-3). Although only limited data exist on their health and use of health care services as they transition to adolescence, emerging data suggest that a minority of these persons receive recommended guidance* from their primary care providers (PCPs) starting at age 12 years to ensure a planned transition from pediatric to adult health care (4,5). To address this gap in data, researchers analyzed preliminary data from a follow-up survey of parents and guardians of adolescents aged 12-16 years who previously participated in the Study to Explore Early Development (https://www.cdc.gov/ncbddd/autism/seed.html). The adolescents were originally studied at ages 2-5 years and identified at that age as having autism (autism group) or as general population controls (control group). Adjusted prevalence ratios (aPRs) that accounted for differences in demographic characteristics were used to compare outcomes between groups. Adolescents in the autism group were more likely than were those in the control group to have physical difficulties (21.2% versus 1.6%; aPR = 11.6; 95% confidence interval [CI] = 4.2-31.9), and to have additional mental health or other conditions(†) (one or more condition: 63.0% versus 28.9%; aPR = 1.9; 95% CI = 1.5-2.5). Adolescents in the autism group were more likely to receive mental health services (41.8% versus 22.1%; aPR = 1.8, 95% CI = 1.3-2.6) but were also more likely to have an unmet medical or mental health service need(§) (11.0% versus 3.2%; aPR = 3.1; 95% CI = 1.1-8.8). In both groups, a small percentage of adolescents (autism, 7.5%; control, 14.1%) received recommended health care transition (transition) guidance. These findings are consistent with previous research (4,5) indicating that few adolescents receive the recommended transition guidance and suggest that adolescents identified with autism in early childhood are more likely than adolescents in the general population to have unmet health care service needs. Improved provider training on the heath care needs of adolescents with autism and coordination of comprehensive programs(¶) to meet their needs can improve delivery of services and adherence to recommended guidance for transitioning from pediatric to adult health care.

OBJECTIVE: The purpose of this study was to investigate the association of sodium intake with obesity in US children and adolescents. METHODS: Cross-sectional data were analyzed for 9,026 children and adolescents in the National Health and Nutrition Examination Survey (NHANES) 2009-2016. Usual sodium intake was estimated from 24-hour dietary recalls using a measurement error model. Logistic regression was used to assess the association of sodium intake with overweight/obesity, obesity, and central obesity (waist to height ratio [WtHR] ≥ 0.5; waist circumferences (WC) ≥ age- and sex-specific 90th percentile). RESULTS: Mean (SE) sodium intake was 3,010  (9) and 3,404  (20) mg/d for children and adolescents, respectively. The adjusted odds ratio (AOR) comparing Q4 versus Q1 (87.5th vs. 12.5th percentile of sodium intake) among children was 1.98 (95% CI: 1.19-3.28) for overweight/obesity, 2.20 (1.30-3.73) for obesity, 2.10 (1.12-3.95) for WC ≥ 90th percentile, and 1.68 (0.95-2.97) for WtHR ≥ 0.5, adjusting for demographics, energy, and sugar-sweetened beverage intake. Among adolescents, AOR was 1.81 (0.98-3.37) for overweight/obesity, 1.71 (0.82-3.56) for obesity, 1.62 (0.71-3.66) for WC ≥ 90th percentile, and 1.73 (0.85-3.50) for WtHR ≥ 0.5. CONCLUSIONS: Sodium intake was positively associated with overweight/obesity, obesity, and central obesity among US children independent of energy and SSB intake, but the association did not reach significance among adolescents.

BACKGROUND: Concern has been expressed by some that sodium reduction could lead to increased prevalence of hyponatremia and hyperkalemia for specific population subgroups. Current concentrations of serum sodium and potassium in the US population can help address this concern. METHODS: We used data from the National Health and Nutrition Examination Survey 2009-2016 to examine mean and selected percentiles of serum sodium and potassium by sex and age group among 25 520 US participants aged 12 years or older. Logistic regression models with predicted residuals were used to examine the age-adjusted prevalence of low serum sodium and high serum potassium among adults aged 20 or older by selected sociodemographic characteristics and by health conditions or medication use. RESULTS: The distributions of serum sodium and potassium concentrations were within normal reference intervals overall and across Dietary Reference Intake life-stage groups, with a few exceptions. Overall, 2% of US adults had low serum sodium (<135 mmol/L) and 0.6% had high serum potassium (>5 mmol/L). Prevalence of low serum sodium and high serum potassium was higher among adults aged 71 or older (4.7 and 2.0%, respectively) and among adults with chronic kidney disease (3.4 and 1.9%), diabetes (5.0 and 1.1%), or using certain medications (which varied by condition), adjusted for age; whereas, prevalence was <1% among adults without these conditions or medications. CONCLUSIONS: Most of the US population has normal serum sodium and potassium concentrations; these data describe population subgroups at higher risk of low serum sodium and high serum potassium and can inform clinical care.

OBJECTIVES: To describe the iron content of commercially available infant and toddler foods. METHODS: Nutrition Facts label data were used from a 2015 database of 1037 commercial infant and toddler food and drink products. Products were grouped into food categories on the basis of name, ingredients, target age, and reference amounts customarily consumed (RACC). Mean and median iron content per 100 g and per RACC were calculated. The proportion of products considered good and excellent sources of iron were determined on the basis of percent daily value (% DV) thresholds. RESULTS: Among products marketed for infants (aged 4-12 months), infant cereals had the highest mean (6.19 mg iron per RACC; 41.25 iron mg per 100 g) iron content. Among products marketed for toddlers (aged 12-36 months), vegetable-based mixtures or meals contained the highest mean iron in mg per RACC (mean: 2.97 mg) and dry, grain-based desserts had the highest mean iron in mg per 100 g (mean: 6.45 mg). Juice and drink products had the lowest mean iron contents in both infant and toddler products. CONCLUSIONS: Most commercially available infant cereals are considered to be an excellent source of iron, likely from fortification, but wide variability was observed in iron content by food category. Products that are considered good or excellent sources of iron (≥10% DV) can help consumers identify products with higher iron content, such as infant cereals or toddler vegetable-based mixtures/meals.

Most U.S. adults consume too much sodium and not enough potassium (1,2). For apparently healthy U.S. adults aged ≥19 years, guidelines recommend reducing sodium intake that exceeds 2,300 mg/day and consuming at least 3,400 mg/day of potassium for males and at least 2,600 mg/day for females* (1). Reducing population-level sodium intake can reduce blood pressure and prevent cardiovascular diseases, the leading causes of death in the United States (1,3). Adequate potassium intake might offset the hypertensive effects of excessive sodium intake (1). Data from the 2015-2016 What We Eat in America (WWEIA) dietary interview component of the National Health and Nutrition Examination Survey (NHANES)(†) were analyzed to identify top food categories contributing to sodium and potassium intake for U.S. residents aged ≥1 year. During 2015-2016, 40% of sodium consumed came from the top 10 food categories, which included prepared foods with sodium added (e.g., deli meat sandwiches and pizza). Approximately 43% of potassium consumed was from 10 food categories, which included foods naturally low in sodium (e.g., unflavored milk, fruit, vegetables) and prepared foods. These results can inform efforts to encourage consumption of foods naturally low in sodium, which might have the dual benefit of reducing sodium intake and increasing potassium intake, contributing to cardiovascular disease prevention.

INTRODUCTION: This study estimates the health, economic, and budgetary impact resulting from graduated sodium reductions in the commercially produced food supply of the U.S., which are consistent with draft U.S. Food and Drug Administration voluntary guidance and correspond to Healthy People 2020 objectives and the 2015-2020 Dietary Guidelines for Americans. METHODS: Reduction in mean U.S. dietary sodium consumption to 2,300 mg/day was implemented in a microsimulation model designed to evaluate prospective cardiovascular disease-related policies in the U.S. POPULATION: The analysis was conducted in 2018-2020, and the microsimulation model was constructed using various data sources from 1948 to 2018. Modeled outcomes over 10 years included prevalence of systolic blood pressure >/=140 mmHg; incident myocardial infarction, stroke, cardiovascular disease events, and cardiovascular disease-related mortality; averted medical costs by payer in 2017 U.S. dollars; and productivity. RESULTS: Reducing sodium consumption is expected to reduce the number of people with systolic blood pressure >/=140 mmHg by about 22% and prevent approximately 895.2 thousand cardiovascular disease events (including 218.9 thousand myocardial infarctions and 284.5 thousand strokes) and 252.5 thousand cardiovascular disease-related deaths over 10 years in the U.S. Savings from averted disease costs are expected to total almost $37 billion-most of which would be attributed to Medicare ($18.4 billion) and private insurers ($13.4 billion)-and increased productivity from reduced disease burden and premature mortality would account for another $18.2 billion in gains. CONCLUSIONS: Systemic sodium reductions in the U.S. food supply can be expected to produce substantial health and economic benefits over a 10-year period, particularly for Medicare and private insurers.

As the science surrounding population sodium reduction evolves, monitoring and evaluating new studies on intake and health can help increase our understanding of the associated benefits and risks. Here we describe a systematic review of recent studies on sodium intake and health, examine the risk of bias (ROB) of selected studies, and provide direction for future research. Seven online databases were searched monthly from January 2015 to December 2019. We selected human studies that met specified population, intervention, comparison, outcome, time, setting/study design (PICOTS) criteria and abstracted attributes related to the study population, design, intervention, exposure, and outcomes, and evaluated ROB for the subset of studies on sodium intake and cardiovascular disease risks or indicators. Of 41,601 abstracts reviewed, 231 studies were identified that met the PICOTS criteria and ROB was assessed for 54 studies. One hundred and fifty-seven (68%) studies were observational and 161 (70%) focused on the general population. Five types of sodium interventions and a variety of urinary and dietary measurement methods were used to establish and quantify sodium intake. Five observational studies used multiple 24-h urine collections to assess sodium intake. Evidence mainly focused on cardiovascular-related indicators (48%) but encompassed an assortment of outcomes. Studies varied in ROB domains and 87% of studies evaluated were missing information on >/=1 domains. Two or more studies on each of 12 outcomes (e.g., cognition) not previously included in systematic reviews and 9 new studies at low ROB suggest the need for ongoing or updated systematic reviews of evidence on sodium intake and health. Summarizing evidence from assessments on sodium and health outcomes was limited by the various methods used to measure sodium intake and outcomes, as well as lack of details related to study design and conduct. In line with research recommendations identified by the National Academies of Science, future research is needed to identify and standardize methods for measuring sodium intake.

To study the effect of formulas on the estimation of dietary sodium intake (sodium intake) and its association with mortality, we analyzed the TOHP (Trials of Hypertension Prevention) follow-up data. Sodium intake was assessed by measured 24-hour urinary sodium excretion and estimations from sodium concentration using the Kawasaki, Tanaka, and INTERSALT (International Cooperative Study on Salt, Other Factors, and Blood Pressure) formulas. We used both the average of 3 to 7 urinary measurements during the trial period and the first measurement at the beginning of each trial. Additionally, we kept sodium concentration constant to test whether the formulas were independently associated with mortality. We included 2974 individuals aged 30 to 54 years with prehypertension, not assigned to sodium intervention. During a median 24-year follow-up, 272 deaths occurred. The average measured sodium intake was 3766+/-1290 mg/d. All estimated values, including those with constant sodium concentration, were systematically biased with overestimation at lower levels and underestimation at higher levels. There was a significant linear association between the average measured sodium intake (ie, gold standard method) and mortality. This relationship was altered by using the estimated sodium intakes. There appeared to be a J- or U-shaped relationship for the average estimated sodium by all formulas. Despite variations in the sodium-mortality relationship among various formulas, a common pattern was that all estimated values including those with constant sodium appeared to be inversely related to mortality at lower levels of sodium intake. These results demonstrate that inaccurate estimates of sodium cannot be used in association studies, particularly as the formulas per se seem to be related to mortality independent of sodium.

This report provides an update from the U.S. Department of Agriculture - Centers for Disease Control and Prevention Sentinel Foods Surveillance Program, exploring changes in sodium and related nutrients (energy, potassium, total and saturated fat, and total sugar) in popular, sodium-contributing, commercially processed and restaurant foods with added sodium. In 2010-2013, we obtained 3432 samples nationwide and chemically analyzed 1654 composites plus label information for 125 foods, to determine baseline laboratory and label sodium concentrations, respectively. In 2014-2017, we re-sampled and chemically analyzed 43 of the Sentinel Foods (1181 samples), tested for significant changes of at least +/-10% (p < 0.05), in addition to tracking changes in labels for 108 Sentinel Foods. Our results show that the label sodium levels of a majority of the Sentinel Foods had not changed since baseline (~1/3rd of the products reported changes, with twice as many reductions as increases). Laboratory analyses of the 43 Sentinel Foods show that eight foods had significant changes (p < 0.05); sodium content continues to be high and variable, and there was no consistent pattern of changes in related nutrients. Comparisons of changes in labels and laboratory sodium shows consistency for 60% of the products, i.e., similar changes (or no changes) in laboratory and label sodium content. The data from this monitoring program may help public health officials to develop strategies to reduce and monitor sodium trends in the food supply.

BACKGROUND: To describe the availability and nutrient composition of U.S. commercially available squeeze pouch infant and toddler foods in 2015. MATERIALS AND METHODS: Data were from information presented on nutrition labels for 703 ready-to-serve, pureed food products from 24 major U.S. infant and toddler food brands. We described nutritional components (e.g., calories, fat) and compared them between packaging types (squeeze pouch versus other packaging types) within food categories. RESULTS: 397 (56%) of the analyzed food products were packaged as squeeze pouches. Differences in 13 nutritional components between squeeze pouch versus other packaging types were generally small and varied by food category. Squeeze pouches in the fruits and vegetables, fruit-based, and vegetable-based categories were more likely to contain added sugars than other package types. CONCLUSION: In 2015, squeeze pouches were prevalent in the U.S. commercial infant and toddler food market. Nutrient composition differed between squeeze pouches and other packaging types for some macro- and micronutrients. Although it is recommended that infants and toddlers under two years old not consume any added sugars, a specific area of concern may be the inclusion of sources of added sugar in squeeze pouches. Linking this information with children's dietary intake would facilitate understanding how these differences affect overall diet quality.

Over the past decade, blood pressure and sodium intake declined among children and adolescents (ie, youths) in the United States. We updated temporal trends and determined if secular changes in blood pressure might be partly associated with usual sodium intake. We included 12 249 youths aged 8 to 17 years who participated in the National Health and Nutrition Examination Survey from 2003 to 2016 and had blood pressure and dietary data. Logistic regression was used to describe secular trends and the association between usual sodium intake and blood pressure categorized according to 2017 Hypertension Guidelines. The prevalence of youths with combined elevated blood pressure/hypertension (ie, either elevated blood pressure or hypertension) significantly declined from 16.2% in 2003-2004 to 13.3% in 2015-2016 ( P<0.001 for trend), as did hypertension from 6.6% to 4.9% ( P=0.005 for trend). Across the same time period, mean usual sodium intake decreased from 3381 to 3208 mg/day ( P<0.001 for trend). Holding constant survey cycle, sex, age, race and Hispanic origin, and weight status, the adjusted odds ratio per 1000 mg/day of usual sodium intake for elevated blood pressure/hypertension was 1.18 (95% CI, 1.03-1.35) and for hypertension was 1.20 (95% CI, 0.96-1.50). From 2003 to 2016, blood pressure and usual sodium intake declined among youths. Although 1000 mg/day higher usual sodium intake was associated with approximately 20% higher odds of elevated blood pressure/hypertension and hypertension, the association with hypertension was not statistically significant.

BACKGROUND: Excess sodium intake can increase blood pressure, and high blood pressure is a major risk factor for cardiovascular disease. Accurate population sodium intake estimates are essential for monitoring progress toward reduction, but data are limited on the amount of sodium consumed from discretionary salt. OBJECTIVES: The aim of this study was to compare measured sodium intake from salt added at the table with that estimated according to the Healthy People 2020 (HP 2020) methodology. METHODS: Data were analyzed from the 2014 Salt Sources Study, a cross-sectional convenience sample of 450 white, black, Asian, and Hispanic adults living in Alabama, Minnesota, and California. Sodium intake from foods and beverages was assessed for each participant through the use of 24-h dietary recalls. Estimated sodium intake from salt used at the table was assessed from self-reported frequency and estimated amounts from a previous study (HP 2020 methodology). Measured intake was assessed through the use of duplicate salt samples collected on recall days. RESULTS: Among all study participants, estimated and measured mean sodium intakes from salt added at the table were similar, with a nonsignificant difference of 8.9 mg/d (95% CI: -36.6, 54.4 mg/d). Among participants who were non-Hispanic Asian, Hispanic, had a bachelor's degree or higher education, lived in California or Minnesota, did not report hypertension, or had normal BMI, estimated mean sodium intake was 77-153 mg/d greater than measured intake (P < 0.05). The estimated mean sodium intake was 186-300 mg/d lower than measured intake among participants who were non-Hispanic black, had a high school degree or less, or reported hypertension (P < 0.05). CONCLUSIONS: The HP 2020 methodology for estimating sodium consumed from salt added at the table may be appropriate for the general US adult population; however, it underestimates intake in certain population subgroups, particularly non-Hispanic black, those with a high school degree or less, or those with self-reported hypertension. This study was registered at clinicaltrials.gov as NCT02474693.

BACKGROUND: Understanding measurement error in sodium and potassium intake is essential for assessing population intake and studying associations with health outcomes. OBJECTIVE: The aim of this study was to compare sodium and potassium intake derived from 24-h dietary recall (24HDR) with intake derived from 24-h urinary excretion (24HUE). DESIGN: Data were analyzed from 776 nonpregnant, noninstitutionalized US adults aged 20-69 y who completed 1-to-2 24HUE and 24HDR measures in the 2014 NHANES. A total of 1190 urine specimens and 1414 dietary recalls were analyzed. Mean bias was estimated as mean of the differences between individual mean 24HDR and 24HUE measurements. Correlations and attenuation factors were estimated using the Kipnis joint-mixed effects model accounting for within-person day-to-day variability in sodium excretion. The attenuation factor reflects the degree to which true associations between long-term intake (estimated using 24HUEs) and a hypothetical health outcome would be approximated using a single 24HDR: values near 1 indicate close approximation and near 0 indicate bias toward null. Estimates are reported for sodium, potassium, and the sodium: potassium (Na/K) ratio. Model parameters can be used to estimate correlations/attenuation factors when multiple 24HDRs are available. RESULTS: Overall, mean bias for sodium was -452 mg (95% CI: -646, -259), for potassium -315 mg (CI: -450, -179), and for the Na/K ratio -0.04 (CI: -0.15, 0.07, NS). Using 1 24HDR, the attenuation factor for sodium was 0.16 (CI: 0.09, 0.21), for potassium 0.25 (CI:0.16, 0.36), and for the Na/K ratio 0.20 (CI: 0.10, 0.25). The correlation for sodium was 0.27 (CI: 0.16, 0.37), for potassium 0.35 (CI: 0.26, 0.55), and for the Na/K ratio 0.27 (CI: 0.13, 0.32). CONCLUSIONS: Compared with 24HUE, using 24HDR underestimates mean sodium and potassium intake but is unbiased for the Na/K ratio. Additionally, using 24HDR as a measure of exposure in observational studies attenuates the true associations of sodium and potassium intake with health outcomes.

The International Consortium for Quality Research on Dietary Sodium/Salt (TRUE) is a coalition of intentional and national health and scientific organizations formed because of concerns low-quality research methods were creating controversy regarding dietary salt reduction. One of the main sources of controversy is believed related to errors in estimating sodium intake with urine studies. The recommendations and positions in this manuscript were generated following a series of systematic reviews and analyses by experts in hypertension, nutrition, statistics, and dietary sodium. To assess the population's current 24-hour dietary sodium ingestion, single complete 24-hour urine samples, collected over a series of days from a representative population sample, were recommended. To accurately estimate usual dietary sodium at the individual level, at least 3 non-consecutive complete 24-hour urine collections obtained over a series of days that reflect the usual short-term variations in dietary pattern were recommended. Multiple 24-hour urine collections over several years were recommended to estimate an individual's usual long-term sodium intake. The role of single spot or short duration timed urine collections in assessing population average sodium intake requires more research. Single or multiple spot or short duration timed urine collections are not recommended for assessing an individual's sodium intake especially in relationship to health outcomes. The recommendations should be applied by scientific review committees, granting agencies, editors and journal reviewers, investigators, policymakers, and those developing and creating dietary sodium recommendations. Low-quality research on dietary sodium/salt should not be funded, conducted, or published.

The governments of the United States and Canada have jointly undertaken the development of the Dietary Reference Intakes (DRIs) since the mid-1990s. The Federal DRI committees from each country work collaboratively to identify DRI needs, prioritize nutrient reviews, advance work to resolve methodological issues that is necessary for new reviews, and sponsor DRI-related committees through the National Academies of Sciences, Engineering and Medicine. In recent years, the Joint Canada-US DRI Working Group, consisting of members from both Federal DRI committees, developed an open and transparent nomination process for prioritizing nutrients for DRI review, by which sodium, the omega-3 (n-3) fatty acids, vitamin E, and magnesium were identified. In addition, discussions during the nutrient nomination process prompted the Federal DRI committees to address previously identified issues related to the use of chronic disease endpoints when setting DRIs. The development of guiding principles for setting DRIs based on chronic disease risk reduction will be applied for the first time during the DRI review of sodium and potassium. In summary, the US and Canadian governments have worked collaboratively to adapt our approach to prioritizing nutrients for DRI review and to broaden the scope of the DRIs to better incorporate the concept of chronic disease risk reduction in order to improve public health.

Background: Both excessive sodium intake and obesity are risk factors for hypertension and cardiovascular disease. The association between sodium intake and obesity is unclear, with few studies assessing sodium intake using 24-h urine collection. Objectives: Our objective was to assess the association between usual 24-h sodium excretion and measures of adiposity among US adults. Methods: Cross-sectional data were analyzed from a sample of 730 nonpregnant participants aged 20-69 y who provided up to 2 complete 24-h urine specimens in the NHANES 2014 and had data on overweight or obesity [body mass index (kg/m2) >/=25] and central adiposity [waist circumference (WC): >88 cm for women, >102 cm for men]. Measurement error models were used to estimate usual sodium excretion, and multiple linear and logistic regression models were used to assess its associations with measures of adiposity, adjusting for sociodemographic, health, and dietary variables [i.e., energy intake or sugar-sweetened beverage (SSB) intake]. All analyses accounted for the complex survey sample design. Results: Unadjusted mean +/- SE usual sodium excretion was 3727 +/- 43.5 mg/d and 3145 +/- 55.0 mg/d among participants with and without overweight/obesity and 3653 +/- 58.1 mg/d and 3443 +/- 35.3 mg/d among participants with or without central adiposity, respectively. A 1000-mg/d higher sodium excretion was significantly associated with 3.8-units higher BMI (95% CI: 2.8, 4.8) and a 9.2-cm greater WC (95% CI: 6.9, 11.5 cm) adjusted for covariates. Compared with participants in the lowest quartile of sodium excretion, the adjusted prevalence ratios in the highest quartile were 1.93 (95% CI: 1.69, 2.20) for overweight/obesity and 2.07 (95% CI: 1.74, 2.46) for central adiposity. The associations also were significant when adjusting for SSBs, instead of energy, in models. Conclusions: Higher usual sodium excretion is associated with overweight/obesity and central adiposity among US adults.

Background: Several cohort studies with inaccurate estimates of sodium reported a J-shaped relationship with mortality. We compared various estimated sodium intakes with that measured by the gold-standard method of multiple non-consecutive 24-h urine collections and assessed their relationship with mortality. Methods: We analysed the Trials of Hypertension Prevention follow-up data. Sodium intake was assessed in four ways: (i) average measured (gold standard): mean of three to seven 24-h urinary sodium measurements during the trial periods; (ii) average estimated: mean of three to seven estimated 24-h urinary sodium excretions from sodium concentration of 24-h urine using the Kawasaki formula; (iii) first measured: 24-h urinary sodium measured at the beginning of each trial; (iv) first estimated: 24-h urinary sodium estimated from sodium concentration of the first 24-h urine using the Kawasaki formula. We included 2974 individuals aged 30-54 years with pre-hypertension, not assigned to sodium intervention. Results: During a median follow-up of 24 years, 272 deaths occurred. The average sodium intake measured by the gold-standard method was 3769 +/- 1282 mg/d. The average estimated sodium over-estimated the intake by 1297 mg/d (95% confidence interval: 1267-1326). The average estimated value was systematically biased with over-estimation at lower levels and under-estimation at higher levels. The average measured sodium showed a linear relationship with mortality. The average estimated sodium appeared to show a J-shaped relationship with mortality. The first measured and the first estimated sodium both flattened the relationship. Conclusions: Accurately measured sodium intake showed a linear relationship with mortality. Inaccurately estimated sodium changed the relationship and could explain much of the paradoxical J-shaped findings reported in some cohort studies.

Background: 24-h urine collections are the suggested method to measure daily urinary potassium excretion (uK) but are costly and burdensome to implement. Objective: This study tested how well existing equations with the use of spot urine samples can estimate 24-h uK and if accuracy varies by timing of spot urine collection, age, race, or sex. Design: This cross-sectional study used data from 407 participants aged 18-39 y from the Washington, DC area in 2011 and 554 participants aged 45-79 y from Chicago in 2013. Spot urine samples were collected in individual containers for 24 h, and 1 for each timed period (morning, afternoon, evening, and overnight) was selected. For each selected timed spot urine, 24-h uK was predicted through the use of published equations. Difference (bias) between predicted and measured 24-h uK was calculated for each timed period and within age, race, and sex subgroups. Individual-level differences were assessed through the use of Bland-Altman plots and correlation tests. Results: For all equations, regardless of the timing of spot urine, mean bias was usually significantly different than 0. No one prediction equation was unbiased across all sex, race, and age subgroups. With the use of the Kawasaki and Tanaka equations, 24-h uK was overestimated at low levels and underestimated at high levels, whereas observed differential bias with the Mage equation was in the opposite direction. Depending on prediction equation and timing of urine sample, 61-75% of individual 24-h uKs were misclassified among 500-mg incremental categories from <1500 to ≥3000 mg. Correlations between predicted and measured 24-h uK were poor to moderate (0.19-0.71). Conclusion: Because predicted 24-h uK accuracy varies by timing of spot urine collection, published prediction equations, and within age-race-sex subgroups, study results making use of predicted 24-h uK in association with health outcomes should be interpreted with caution. It is possible that a more accurate prediction equation can be developed leading to different results.

High dietary sodium is estimated to be the leading dietary risk for death and disability according to the Global Burden of Disease Study.1, 2 The health risk associated with dietary sodium is largely related to a direct relationship between increasing dietary sodium and increasing blood pressure. Notably, increased blood pressure is a leading global risk factor for death and disability causing approximately 50% of cardiovascular disease.3 In both observational and interventional studies, 24‐hour urine sodium excretion is often used as the “gold standard” to estimate dietary sodium. Although it is generally stated that approximately 90% of dietary sodium is excreted in 24‐hour urine collections,4 to our knowledge, there has been no systematic review of the percentage of ingested sodium excreted in the urine. Previous studies in healthy people have reported that 24‐hour urine sodium excretion accounts for 61%‐107% of ingested sodium.5 We have conducted a systematic review of studies that examined the percentage of sodium excreted in 24‐hour urine collections in study participants ingesting known quantities of sodium. Accurately defining the percentage of dietary sodium excreted in urine is important to assess the validity of using urine excretion studies as the best evidence for assessing relationships between dietary sodium and health.

PURPOSE: To describe changes in consumer knowledge, attitudes, and behaviors related to sodium reduction from 2012 to 2015. DESIGN: A cross-sectional analysis using 2 online, national research panel surveys. SETTING: United States. PARTICIPANTS: A total of 7796 adults (18+ years). MEASURES: Sodium-related knowledge, attitudes, and behaviors. ANALYSIS: Data were weighted to match the US population survey proportions using 9 factors. Wald chi(2) tests were used to examine differences by survey year and hypertensive status. RESULTS: Despite the lack of temporal changes observed in respondent characteristics (mean age: 46 years, 67% were non-Hispanic white, and 26% reported hypertension), some changes were found in the prevalence of sodium-related knowledge, attitudes, and behaviors. The percentage of respondents who recognized processed foods as the major source of sodium increased from 54% in 2012 to 57% in 2015 ( P = .04), as did the percentage of respondents who buy or choose low/reduced sodium foods, from 33% in 2012 to 37% in 2015 ( P = .016). In contrast, the percentage of self-reported receipt of health professional advice among persons with hypertension decreased from 59% in 2012 to 45% in 2015 ( P < .0001). Other sodium-related knowledge, attitudes, and behaviors did not change significantly during 2012 to 2015. CONCLUSION: In recent years, some positive changes were observed in sodium-related knowledge and behaviors; however, the decrease in reported health professional advice to reduce sodium among respondents with hypertension is a concern.

Importance: In 2010, the Institute of Medicine (now the National Academy of Medicine) recommended collecting 24-hour urine to estimate US sodium intake because previous studies indicated 90% of sodium consumed was excreted in urine. Objective: To estimate mean population sodium intake and describe urinary potassium excretion among US adults. Design, Setting, and Participants: In a nationally representative cross-sectional survey of the US noninstitutionalized population, 827 of 1103 (75%) randomly selected, nonpregnant participants aged 20 to 69 years in the examination component of the National Health and Nutrition Examination Survey (NHANES) collected at least one 24-hour urine specimen in 2014. The overall survey response rate for the 24-hour urine collection was approximately 50% (75% [24-hour urine component response rate] x 66% [examination component response rate]). Exposures: 24-hour collection of urine. Main Outcomes and Measures: Mean 24-hour urinary sodium and potassium excretion. Weighted national estimates of demographic and health characteristics and mean electrolyte excretion accounting for the complex survey design, selection probabilities, and nonresponse. Results: The study sample (n = 827) represented a population of whom 48.8% were men; 63.7% were non-Hispanic white, 15.8% Hispanic, 11.9% non-Hispanic black, and 5.6% non-Hispanic Asian; 43.5% had hypertension (according to 2017 hypertension guidelines); and 10.0% reported a diagnosis of diabetes. Overall mean 24-hour urinary sodium excretion was 3608 mg (95% CI, 3414-3803). The overall median was 3320 mg (interquartile range, 2308-4524). In secondary analyses by sex, mean sodium excretion was 4205 mg (95% CI, 3959-4452) in men (n = 421) and 3039 mg (95% CI, 2844-3234) in women (n = 406). By age group, mean sodium excretion was 3699 mg (95% CI, 3449-3949) in adults aged 20 to 44 years (n = 432) and 3507 mg (95% CI, 3266-3748) in adults aged 45 to 69 years (n = 395). Overall mean 24-hour urinary potassium excretion was 2155 mg (95% CI, 2030-2280); by sex, 2399 mg (95% CI, 2253-2545) in men and 1922 mg (95% CI, 1757-2086) in women; and by age, 1986 mg (95% CI, 1878-2094) in adults aged 20 to 44 years and 2343 mg (95% CI, 2151-2534) in adults aged 45 to 69 years. Conclusions and Relevance: In cross-sectional data from a 2014 sample of US adults, estimated mean sodium intake was 3608 mg per day. The findings provide a benchmark for future studies.