According to the World Health Organization (WHO), more than 70% of deaths in low- and middle-income group countries are due to non-communicable diseases (NCDs). Poor lifestyles, smoking, the use of alcohol, lack of exercise, air pollution, and other factors contribute to this figure. It is of paramount importance to prevent NCDs, as their treatment can be a huge burden to the health budget of a country.
One of the easiest and most cost-effective ways of preventing NCDs is reducing salt consumption in the population. Salt consumption, the WHO says, should be less than 5 grams per day from all sources: this includes natural sources, salt added while cooking, and hidden salt in processed and packaged food. Indians consume way above the recommendation at around 8 to 11 grams per day. It is important to clarify the confusion between sodium and salt. Two grams of sodium is equal to 5 grams of common salt.
The relationship between salt and blood pressure is well known. High salt intake leads to increased blood volume, and unless the endothelium (lining of the blood vessels) produces nitrous oxide, the blood vessel fails to dilate, leading to hypertension. This is called salt-sensitive or resistant hypertension and is genetically determined. However, what is not common knowledge is that salt-resistant hypertension can become salt-sensitive over time. High salt in the absence of hypertension can also lead to endothelial dysfunction.
All NCDs have a common pathology of blood vessel damage. The ill effects of hypertension: contributing to heart attacks, strokes, and kidney failure are well known. And so, it is essential that salt intake is followed to the recommended level even in the absence of hypertension.
What the research says
There are more than 100 studies that have shown the benefit of salt reduction in the population. Studies from Japan, Portugal, and Finland are the oldest. A study from the U.K. showed a reduction of strokes by 24% and heart attacks by 18% when salt intake was reduced. The latest and the largest study from China, showed a considerable reduction in strokes with the use of low-sodium salt substitutes.
The other ill effects of salt, such as kidney stones, worsening of Chronic Obstructive Pulmonary Disease (COPD), stomach cancer, and osteoporosis, must be included in the benefits of salt control.
How to control salt consumption
The first step is creating awareness at all levels of the general population, health providers, the government, and food manufacturers.
The best way to find out daily salt consumption is by estimating urine sodium over 24 hours. In general, the salt we eat is removed from our urine. Only a very small quantity is lost in faeces or sweat. It is a common misconception that with increased sweating, the body requires more salt: only more water is required.
Unfortunately, only about 3,000-odd people have been studied for urinary sodium excretion, which is miniscule considering our population. Studies using dietary recall are not reliable, however, knowing the average family consumption may help to monitor and advise accordingly.
Salt meters have been used in some countries but do not help in determining salt in traditional Indian foods. Studies from our country still show that the majority of salt is added while cooking at home. But this is likely to change, since eating out and consumption of packaged food have been on the rise.
The average person cooking at home needs to be educated on the skill of lowering salt through the use of spices and condiments to improve taste. More salt is not required to improve taste. On the contrary, salt is a dominant taste and masks other flavours. The saltshaker need not be displayed on the table, since it is often used without tasting the food. Taste is often an acquired habit, and desensitisation may help with this.
Eating out is another source of salt intake with poor control. This has increased with families becoming small, and where both or all adults are working. The Sapiens Health Foundation in Chennai, which has been campaigning for low salt intake for the past 15 years, has successfully persuaded several restaurants to not display saltshakers on the table.
The public procurement of food is also an area where salt can be controlled. Midday meals at schools should be an important target. The benefit of this can be immense since the habit is inculcated from childhood. The United Kingdom, for instance, has a very strong policy where meals in schools are served without salt. There is also a lack of awareness about how much salt children require. It is only by the age of 12 that they must reach the recommended intake of 5 grams per day.
The transport sector is an important site of public procurement of food. For instance, travellers buy fresh food from stalls at railway stations. Unfortunately, a majority of the airlines serve packed food. These are areas that need to be looked into.
The need for food labelling
The government plays a very important role in controlling the salt intake of the population. Here, food labelling is crucial: labels for sodium should be made mandatory. Labels need to be on the front of the package and need to be clear and legible.
Food labels should be marked for high salt content since the common man may not be able to interpret the sodium content. Signal labelling, using red to indicate high salt has been used successfully in the UK.
The government can also increase taxes for high-salt items just as it has for cigarettes.
Creating awareness in the population is another step and should be taken up by the Ministry of Information and Broadcasting. The Food Safety and Standards Authority of India has initiated the ‘Eat Right India’ movement which is a collaborative effort with multiple sectors. These, and more, are needed to build awareness around reducing salt consumption.
The food industry has to gear up to reformulate food items. Low-salt alternatives for popular brand snacks should be freely available. We should take a leaf out of the UK’s book where, for 10 years, the salt content in bread was reduced slowly and progressively without most people realising it. The acceptance was widespread.
Lastly, salt substitutes, although available in India, are not popular. They have varying levels of sodium being replaced by potassium. Normally, in up to 20% of this replacement, there is no difference in taste. The only concern with this is in people with kidney impairments, as it may produce hyperkalemia or high serum potassium.
The WHO has recently released guidelines on the use of low-sodium salt substitutes. Low sodium salt substitutes should not be confused with other sodium salts in the market such as rock salt or pink salt, which still contain high sodium and have no benefits; on the contrary, they are non-iodised and might lead to iodine deficiency.
Salt targets must be set every three years so that ultimately, we achieve the WHO goal of 5 grams per day. The large-scale implementation of a campaign to reduce salt/sodium intake among the population remains the best and most cost-effective way to reduce strokes, heart attacks, kidney failure, and other NCDs.
(Dr. Rajan Ravichandran is director, MIOT Institute of Nephrology, Chennai, and founder, Sapiens Foundation.)
Published – May 30, 2025 04:00 pm IST