The WHO recommends limiting sodium intake per person to below 2 grams per day to reduce blood pressure and risk of CVDs.

One of the initial heroes of what was possibly the most successful and biggest public health campaigns in the country was salt. Introduced, fortified with iodine, in the 1950s, it marshalled a public health amelioration that improved the lives of people across generations, nearly wiping out iodine deficiency in India (except in a few hard-to-reach regions) and its vast array of attendant problems, including the slowed growth of children with hypothyroidism. Now, it seems as if salt’s time has come, once again, to effect major health changes in the population, improving the health of Indians all over again.

The WHO released a set of guidelines on Sunday recommending the use of lower-sodium salt substitutes (LSSS), essentially including potassium chloride and reducing the percentage of sodium chloride in table salt. This comes after the international body strongly recommended reducing sodium intake to less than 2 g/day. Notably, the WHO has proposed to launch this LSSS revolution from within homes, providing its recommendations for table salt that is used in households. The recommendation does not pertain to salt used in packaged foods or foods cooked outside of home. Also, this recommendation is for adults (not pregnant women or children) and excludes individuals with kidney impairments or with other conditions that might compromise potassium excretion. 

The WHO, however, with this set of guidelines, is talking to not just the people, but hopes to address and provide guidance on the use of low-sodium salt substitutes for policy-makers, programme managers, health professionals, and other stakeholders in their efforts to reduce sodium intake and reduce the risk of hypertension and related NCDs through a range of policy actions and public health interventions.

Salt’s impact on the body

Why is salt important, and why is it that salt has again become a vehicle to bring about sweeping public health behaviour change. To answer that, we would have to look at the widespread use of salt, and its impact on the human body itself. Sodium, the primary ingredient in salt, hitches a ride with water and travels the bloodstream. Sodium forces the body to retain water and more salt naturally means more water in the blood vessels, which increases the pressure, literally and figuratively. “Reducing salt consumption, therefore, reduces the load on the system, by significantly decreasing the volume in the blood, thus impacting directly, positively on blood pressure,” says Priya Chockalingam, founder, Cardiac Wellness Institute, Chennai. “This is significant, particularly given the culture in India, where topping up with salt is almost a given. If you reduce your consumption of salt, there is no doubt that it will have an impact on  cardiovascular health and prevent strokes,” she adds.

Hypertension is also a major risk factor for atherosclerosis, where fatty deposits (plaques) build up inside the arteries, causing them to narrow and harden, thereby restricting blood flow and increasing the risk of getting heart attacks and stroke. Excessive salt consumption also leads to vascular stiffness, making blood vessels less flexible. Potassium also improves vascular function. “There is no doubt that any reduction in salt consumption is good to prevent atherosclerosis. The benefits of low sodium salt substitutes are quite wide ranging, and will bear testing out further on project mode,” says J. Amalorpavanathan, vascular surgeon, and member, Tamil Nadu State Planning Commission.  

The statistics are sobering and if we truly paid attention to these facts, we might have as a race decided to leave salt out of our diets. Globally, each year, 8 million deaths are associated with poor diets, and of these, 1.9 million are attributable to high sodium intake. Way back in 2013, an updated systematic review of studies (published in the British Medical Journal), where salt was reduced by 4.4 g/day for at least 4 weeks found that systolic blood pressure was reduced by 4 mmHg and diastolic blood pressure by 2 mmHg, having a positive impact on cardiovascular health.  

Studies from across the world have proven this, repeatedly, prompting the WHO to recommend limiting the sodium intake per person to below 2 grams per day to reduce blood pressure and risk of CVDs. Reducing salt consumption is an effective way to reduce noncommunicable diseases (NCDs) such as cardiovascular diseases (CVDs), and chronic kidney disease by lowering blood pressure. It also lowers the risks of other conditions associated with high sodium intake, such as gastric cancer, the guideline says. 

The Chennai-based Sapiens Health Foundation, last year, launched the ‘Losalter Group’, emphasising the need to cut salt intake and also took online, a website to create awareness on the impact of salt on health. Rajan Ravichandran, chairman of the foundation, said the Losalter Group will create awareness on the problems caused by an excess consumption of salt. “We will train 300 physicians throughout the country. They will be educated on salt and health and given toolkits to propagate the message to the people,” he explains. He adds that the onus of reducing salt intake is with the public, government, and the food industry, while stressing on ‘signal labelling’ for food products, in order to guide people to make healthy choices.

Vivekanand Jha, executive director, The George Institute for Global Health in India, terms this initiative of the WHO as “killing two birds with one stone”, particularly in the Indian context. “While the consumption of sodium in the salt comes dowm, there is also a perspective that the normal intake of potassium is low, substituting sodium with potassium will address this second issue as well, again with a beneficial impact on cardiovascular health,” he explains.  

Low salt options are costly

While there are some brands that do sell low NaCl (sodium chloride) with KCl (potassium chloride added) in the market, the problem is that these products are more expensive than regular salt, that costs very little, Prof. Jha adds. “The way to change behaviour effectively is to change what is available to consume. Costs will also come down with wider use. Government policy must mandate use of low sodium salt alternatives in the country and the state should work with industry to ensure proper display (at eye level) of these alternatives on supermarket shelves and shops,” he says.

While the benefits of a low sodium salt are plentiful, experts also caution that upping potassium intake is not for all, particularly those with kidney disease. The WHO makes it clear that those who have conditions that do not support increasing the consumption of potassium must stay away from the proposed alternative. However, Dr. Priya Chockalingam while agreeing that salt is grossly overused in India, adds that it is possible there is a huge population with undetected kidney disease, and to put them on a potassium enhanced salt diet might not be advisable.

She makes it clear that reducing sodium chloride consumption would, on the whole, be beneficial in India, given the staggering burden of cardiovascular and other non communicable diseases including hypertension and diabetes. But, it is equally essential to keep a watchful eye on the possibility of hyperkaelemia (excess potassium levels in the blood), given poor health seeking behaviour in the country and undiagnosed cases of kidney failure, she adds.

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