New York City’s Sodium Warning Regulation: From Conception to Enforcement

In 2015, the New York City Department of Health and Mental Hygiene (DOHMH) introduced a regulation in chain restaurants requiring warnings on high-sodium menu items. We describe the process used to create, support the passage of, defend, and ultimately implement and enforce the policy. This may be a resource to other jurisdictions considering similar approaches and could help advance public health and policy among a broader community.

A RATIONAL BASIS FOR ACTION

New York City adults consume more than 3200 milligrams of sodium per day—well above the 2300 milligram sodium limit recommended in the 2015 Dietary Guidelines for Americans¹ and substantiated in the 2019 sodium Dietary Reference Intake from the National Academies of Sciences, Engineering, and Medicine (https://doi.org/10.17226/25353). Disparities in consumption exist. Daily sodium intake by Black and Hispanic or Latino New York City adults exceeds that of White adults by approximately 300 to 400 milligrams.² An established body of evidence indicates a positive relationship between sodium intake and blood pressure.¹ Elevated blood pressure increases the risk for heart disease and stroke. Because cardiovascular disease is a leading cause of death, and Black and Hispanic or Latino New York City adults report higher hypertension rates than do White and Asian and Pacific Islander New York City adults,³ broad-scale sodium reduction presents an opportunity to reduce population-wide disease risk and address health inequities.

Restaurant and processed food contribute more than two thirds of the daily dietary sodium intake.⁴ Targeted DOHMH efforts to reduce sodium in packaged foods since 2008 have shown progress,⁵ but high sodium levels in restaurant foods persist. During the regulation’s development in 2014, 10% of the menu items sold in a sample of New York City chain restaurants contained at least 2300 milligrams of sodium (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). Because research on consumer warnings for foods and beverages shows that labels can increase consumer knowledge and facilitate healthier choices,⁶ the DOHMH pursued a new approach to address the problem of excess sodium in restaurant foods.

A REGULATORY, PUBLIC HEALTH APPROACH

To create a high-sodium warning policy, key steps included designing a warning label, defining the sodium threshold above which consumers should be alerted, and determining which restaurants would be required to comply. The DOHMH pursued a regulatory approach, introducing the policy as a proposed amendment to the New York City Health Code on June 10, 2015. The New York City Board of Health unanimously approved it, thereby establishing the nation’s first mandatory restaurant sodium warning, effective December 1, 2015.⁷ Warning icons alerting customers to menu items that contain more than the recommended total daily limit of sodium, along with a posted statement about the health risks associated with high sodium intake (Figure 1), debuted in New York City chain restaurants accordingly.

FIGURE 1—

Sodium Warning Rule Icon and Warning Statement

Days after the regulation went into effect, however, the National Restaurant Association filed a lawsuit to block its implementation, arguing that the rule violated the right to free speech guaranteed by the First Amendment, violated principles of separation of powers (because it was introduced by a regulatory body rather than the legislature), was preempted by federal law, and was “arbitrary and capricious.” After an 18-month legal challenge, the regulation ultimately prevailed, and enforcement began in 2016.

AWARENESS AND COMPLIANCE

The DOHMH moved forward building citywide awareness of the regulation and fostering restaurants’ compliance through a press event with industry and by mailing plain-language guidance to restaurants on how to meet the regulation’s requirements. Chain restaurants also can submit menu board mock-ups for the DOHMH’s review to ensure design compliance. In the three months after the enforcement date, chain restaurants received on-site education about the regulation from inspectors. The DOHMH also rolled out a media campaign (“Look Before You Eat”), educating New Yorkers about the icons in English and Spanish via print, television, and online media platforms. Media coverage of the rule helped provide an expanded understanding of the negative health effect of high sodium consumption throughout New York City and nationwide.

FUTURE CONSIDERATIONS

Eating behaviors arise from a complex interplay of many levels of influence, from individual to community and systems. Public health experts must leverage multiple available channels for maximum public health effect. From encouraging industry changes in the food supply to developing policies for informed decision-making, it is essential that local authorities continue to innovate, evaluate, and share findings with one another. Restaurants are a key source of dietary intake for Americans, yet a path to healthier restaurant dining has not always been achievable. This sodium warning regulation is the latest in an array of initiatives aimed at changing the way consumers navigate the food environment. When dining in New York City chain restaurants, consumers can use this regulation to help make healthier choices. Policymakers outside of the New York City jurisdiction can consider this approach when identifying mechanisms to provide consumers with information about the sodium content of meals in restaurants.