Top Food Category Contributors to Sodium and Potassium Intake — United States, 2015–2016

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.

This analysis used data from the 2015–2016 NHANES, a nationally representative survey and physical examination of the U.S. civilian, noninstitutionalized population. NHANES uses a multistage probability sampling design with oversampling of some age, race, and ethnicity (Hispanic or non-Hispanic). Among 9,544 participants (58.7% unweighted response rate), 7,976 (83.6%) were included in this analysis. Respondents were excluded if they were aged <1 year (4.0%), had an incomplete or unreliable initial 24-hour dietary recall or reported no energy intake (i.e., 0 kcal/day; 16.5%), consumed any human milk on the day of the recall (1.8%), were pregnant or had unknown pregnancy status (1.6%), or were lactating (0.5%).

The first of two, nonconsecutive, 24-hour dietary recalls was used for this analysis. The NHANES participant or a proxy completed the recall in person with trained interviewers using the U.S. Department of Agriculture’s automated multiple-pass method,^§ which is designed to enhance complete and accurate food recall. Components of each reported food or beverage were assigned to mutually exclusive food codes with corresponding nutrient profiles, which provide the energy (in kilocalories) and nutrient content per 100 g.^¶ Respondent total daily energy and sodium and potassium intake were calculated by summing the amount of each food consumed (in grams), multiplied by its assigned food code values. Sodium and potassium density were defined as milligrams of each nutrient per 1,000 kcal. For this analysis, food codes were grouped into 87 mutually exclusive categories adapted from the WWEIA Food Categories** (Supplementary Table, https://stacks.cdc.gov/view/cdc/91457) and included sandwiches and burgers as consumed (e.g., cheese sandwich rather than bread and cheese separately). Sodium included salt added in food preparation but did not include salt added at the table.

Data were analyzed with SAS-callable SUDAAN (version 9.3; RTI International) using day one dietary sample weights and accounting for the complex sampling design. The population proportions (4) of intake for each food category were estimated and ranked overall, and by age group (1), sex, race, ethnicity (Hispanic or non-Hispanic), and, for adults aged ≥19 years, by hypertension status (using the 2017 American College of Cardiology/American Heart Association [ACC/AHA] guideline)^†† and weight status.^§§

Among the U.S. population aged ≥1 year, mean sodium intake was 3,397 mg/day (Table 1). For that population, 40% of sodium was consumed from the top 10 food categories: deli meat sandwiches (6.3%), pizza (5.4%), burritos and tacos (5.3%), soups (4.1%), savory snacks (e.g., chips, crackers, popcorn) (3.8%), poultry (excluding nuggets and tenders) (3.7%), pasta mixed dishes (excluding macaroni and cheese, 3.0%), vegetables (excluding white potatoes) (2.9%), burgers (2.8%), and eggs and omelets (2.7%). The top five food categories contributing to sodium intake for almost all population subgroups (age [Table 1]; sex, race and Hispanic ethnicity [Table 2]; and blood pressure status and weight status [Table 3]) were among the top 10 categories for the U.S. population overall. Exceptions included unflavored milk (7.5%) among children aged 1–3 years; breads, rolls, and buns (4.0%) among adults aged ≥71 years; rice (9.0%) and breads, rolls, and buns (3.6%) among non-Hispanic Asians; quesadillas, tamales, fajitas, and enchiladas (4.3%) among Hispanics; and other meat sandwiches (3.6%) among adults aged ≥19 years with elevated blood pressure.

Mean potassium intake was 2,497 mg/day overall (Table 1). Overall, 43% of potassium was consumed from the top 10 food categories: unflavored milk (6.4%); fruit (6.4%); vegetables (excluding white potatoes) (6.1%); coffee (5.1%); savory snacks (e.g., chips, crackers, popcorn) (3.5%); 100% fruit juice (3.3%); mashed, baked, or boiled white potatoes (3.2%); deli meat sandwiches (3.1%); poultry (excluding nuggets and tenders) (2.9%); and burritos and tacos (2.9%). These food categories contributed varying amounts to total potassium intake by age subgroup, ranging from 39.5% among youths aged 14–18 years to 56.1% among children aged 1–3 years. For almost all population subgroups, the top five food categories contributing to potassium intake were among the top 10 categories for the overall population (Tables 1, 2, and 3). Exceptions included flavored milk among children aged 4–8 years (7.0%) and 9–13 years (4.2%), pizza among youth aged 14–18 years (5.7%), and soups among non-Hispanic Asians (6.5%).

Acknowledgments

Participants in the 2015–2016 National Health and Nutrition Examination Survey; Alexandra Wickson; Katherine Overwyk.

Corresponding author: Rebecca C. Woodruff, [email protected], 404-498-5986.

¹Epidemic Intelligence Service, CDC; ²Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC; ³Beltsville Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture; ⁴Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC; ⁵Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, CDC.

References

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Abbreviations: kcal = kilocalories; SE = standard error.
* The population proportion (%) is defined as the sum of the amount of sodium or potassium consumed from each specific food category for all participants in the designated group, divided by the sum of the nutrient consumed from all food categories for all participants in the designated group, multiplied by 100. All estimates use one 24-hour dietary recall, reflect the complex sampling design, and use the day one dietary sample weights to account for nonresponse, weekend/weekday recalls, and oversampling.
^† This analysis used 87 food categories, which were adapted from What We Eat in America (https://www.cdc.gov/nchs/nhanes/wweia.htm). Food categories are ranked in descending order by population proportion among the total population aged ≥1 year.
^§ The following food categories were not ranked among the top 10 sodium food sources overall but contributed ≥3% to sodium intake within the specified age subgroups: 1–3 years: unflavored milk (7.5%), cheese (3.7%), bacon, frankfurters, sausages (3.3%), chicken patties, nuggets, and tenders (3.0%); 4–8 years: bacon, frankfurters, sausages (3.3%), hot dog and sausage sandwiches (3.3%), unflavored milk (3.1%), cookies, brownies, cakes (3.1%), ready to eat cereals (3.0%); 14–18 years: chicken patties, nuggets, and tenders (3.2%); 51–70 years: meat mixed dishes (3.4%), breads, rolls, buns (3.0%); ≥71 years: breads, rolls, buns (4.0%), cookies, brownies, cakes (4.0%).
^¶ Estimates are statistically unreliable, relative SE ≥30%.
** The following food categories were not ranked among the top 10 potassium food sources overall but contributed ≥3% of potassium intake within the specified age subgroups: 4–8 years: flavored milk (7.0%), pizza (3.4%); 9–13 years: flavored milk (4.2%), pizza (4.0%), pasta mixed dishes (excluding macaroni and cheese (3.0%); 14–18 years: pizza (5.7%), fried white potatoes (3.5%), burgers (3.0%); 19–30 years: fried white potatoes (3.6%), pizza (3.2%); 31–50 years: fried white potatoes (3.2%), alcoholic beverages (3.1%).

Abbreviations: kcal = kilocalories; SE = standard error.
* The population proportion (%) is defined as the sum of the amount of sodium or potassium consumed from each specific food category for all participants in the designated group, divided by the sum of the nutrient consumed from all food categories for all participants in the designated group, multiplied by 100. All estimates use one 24-hour dietary recall, reflect the complex sampling design, and use the day one dietary sample weights to account for nonresponse, weekend/weekday recalls, and oversampling.
^† This analysis used 87 food categories, which were adapted from What We Eat in America (https://www.cdc.gov/nchs/nhanes/wweia.htm). Food categories are ranked in descending order by population proportion among the total population aged ≥1 year.
^§ The following food categories were not ranked among the top 10 sodium food sources overall but contributed ≥3% to overall sodium intake. Non-Hispanic Asians: rice (9.0%); breads, rolls, buns (3.6%); soy-based condiments (3.2%); fried rice and lo/chow mein (3.1%). Hispanics: quesadillas, tamales, fajitas and enchiladas (4.3%).
^¶ The following food categories were not ranked among the top 10 potassium food sources overall but contributed ≥3% to overall potassium intake among sex and race/ethnic subgroups. Non-Hispanic blacks: fried white potatoes (4.3%); soft drinks, fruit drinks, and sport/energy drinks (3.1%). Non-Hispanic Asians: soups (6.5%). Hispanics: beans, peas, legumes (4.0%); soups (3.0%).

Abbreviations: BMI = body mass index; BP = blood pressure; kcal = kilocalories; SE = standard error.
* The population proportion (%) is defined as the sum of the amount of sodium or potassium consumed from each specific food category for all participants in the designated group, divided by the sum of the nutrient consumed from all food categories for all participants in the designated group, multiplied by 100. All estimates use one 24–hour dietary recall, reflect the complex sampling design, and use the day one dietary sample weights to account for nonresponse, weekend/weekday recalls, and oversampling.
^† This analysis used 87 food categories, which were adapted from What We Eat in America (https://www.cdc.gov/nchs/nhanes/wweia.htm). Food categories are ranked in descending order by population proportion among the total population aged ≥1 year.
^§ Blood pressure was defined as normal (<120/80 mmHg), elevated (systolic BP = 120–129 and diastolic BP <80 mmHg), or stage I or II hypertension (self–reported antihypertensive medication use or systolic BP ≥130, diastolic BP ≥80 mmHg) according to the 2017 American College of Cardiology/American Heart Association Hypertension Guideline.
^¶ BMI (kg/m²) was used to classify adults: normal weight (BMI = 18.5–24.9), overweight (BMI = 25.0–29.9), or obesity (BMI ≥30).
** The following food categories were not ranked as top 10 sodium food sources among respondents aged ≥19 years but contributed ≥3% to sodium intake among blood pressure and weight status subgroups. Elevated BP: other meat sandwiches (3.6%), poultry sandwiches (3.0%). Stage I or II hypertension: meat mixed dishes (3.1%).
^†† The following food categories were not ranked as top 10 potassium food sources among respondents aged ≥19 years but contributed ≥3% to potassium intake among blood pressure and weight status subgroups. Obese: fried white potatoes (3.5%).