Salt and the city: a preliminary examination of New York City's sodium warning labels

In New York City (NYC), 81% of citizens exceed the maximum daily recommended limit for sodium intakes, although there is considerable debate over the health effects of sodium reduction for all population subgroups. On December 1, 2015, NYC became the first city to adopt mandatory sodium warning labels on menus denoting items with 2300 mg of sodium or more in fast food chains and casual dining restaurants with 15 locations nationwide. Examining the impact and implementation of this policy may provide important insight into the development of future sodium reduction initiatives in NYC as well as worldwide. Thus, the objectives of this project were to examine the implementation and impact of the NYC sodium warning label policy by: 1) observing restaurant‐level implementation and compliance of the label on menus and menu boards; and 2) examining the impact of labels on consumer food purchasing behavior using a street intercept survey method. We completed an observational checklist to assess the implementation of the regulation in 30 restaurants representing 10 chains directly after the regulation was enacted (December 2015), before it was enforced (February 2015) and again after enforcement (November 2016). We conducted street‐intercept surveys at baseline (November 2015) and after the policy was enacted (November 2016) to examine awareness of calorie and sodium warning labels and their influence on consumer food purchasing behavior at four chain restaurants with the highest number of labeled items. Chain restaurants included all Applebee's (n=3) and IHOP (n=3) locations and 10 randomly‐selected Domino's and Subway locations within areas of NYC with the highest rates of hypertension (Harlem, Washington Heights and Bronx). We also asked consumers about their salt‐related knowledge, attitudes and behaviors and whether they had been told by a health professional that they have hypertension. The observational checklist showed that directly following the sodium warning label regulation coming into effect (December 2015), only 21.4% of restaurants implemented the labels. However, by the end of February 2015, 68.4% of restaurants (from six of the ten chains) had implemented labels at one location or more. Both Applebee's and IHOP restaurants had over 30 menu items with a sodium warning labels, indicating many options with high levels of sodium. Although the majority of restaurants included the sodium warning labels on their menus by November 2016, they were often difficult to read and interpret. In the baseline street intercept surveys (n=303), 15% of participants reported having hypertension, and the average sodium content of purchases across all restaurants was 3,806mg (standard deviation: 3,689mg). Self‐reported hypertension was not associated with the sodium content of foods purchased. There was no difference in the calorie content of foods purchased among consumers who reported seeing the calorie labels (n=108). At follow‐up, most consumers did not notice the sodium warning labels and, among those that did, the labels rarely influenced their food purchasing decisions. Our preliminary findings suggest that the majority of restaurants are complying with the sodium warning label policy, despite issues with visibility, but the labels may not be influencing consumer purchasing decisions. Additional evidence is needed to ascertain the full impact of the sodium warning labels on consumer food purchasing, as well as whether it leads restaurants to reformulate their products. Support or Funding Information We had no funding support for this project.