Indians, Alert to Dangers of High Salt Intake, Are Changing Diets

Indians aware of the dangers of excessive salt intake are modifying their diets, unlike other international communities like Australians who are sticking to high-salt foods though they are aware of its effects, according to a new study.

Populations in 181 of 187 nations consume more than the WHO-recommended daily upper limit of 5 gm of salt. Indians consume 9 percent more salt than the global average – 10.06 gm.

Claire Johnson, a research fellow with The George Institute for Global Health, Australia, led an India-centric study on salt intake in February this year.

It included a cross section of 1,395 respondents across India – educated and uneducated, urban and rural, male and female, and of different ages averaging 40 years.

Also Read: The Fault in Our Salt! Time to Shake Sodium Out of Your Diet

Nine of 10 respondents, 90 percent, said they were aware that a diet high in salt is bad for their health. When asked the question: “How important to you is lowering salt in your diet?” as many answered affirmatively. Not just that, participants actually acted upon this knowledge, lowering their salt intake.

For instance, 98 percent participants reported using spices other than salt, 61 percent said they avoided eating out and 52 percent maintained that they avoided processed foods.

This implies that greater awareness about the health risks of excessive salt intake could benefit Indians significantly because they are open to lifestyle changes.

Also Read: A Thyroid Diet: Adding Colour to Your Fruit Plate and ‘Going Nuts’

Every measure to cut down on salt will benefit Indians, said Johnson.

Claire Johnson, research fellow, The George Institute for Global Health, AustraliaBy lowering your salt consumption by 1 gm, you lower your heart attack and stroke risk by 4.8 percent. And the more you cut down, the more you gain.

One in four Indians living in villages and one in three in its cities suffers from hypertension, commonly referred to as high blood pressure.

The control of hypertension requires a reduction in salt intake because too much sodium constricts arteries, thus raising blood pressure, and impairs kidney function, leading to extra fluid and extra strain on the associated blood vessels.

Hypertension is a leading cause of cardiovascular disease. Thus the impact of excessive salt intake on the health of the average Indian is clear.

Also Read: Average Indian Consumes 119% More Salt Per Day Than WHO Recommends

India’s health gains could be “enormous,” Johnson told IndiaSpend, if we could cut our average salt/sodium intake by 30 percent. This would meet one of nine WHO targets to cut premature deaths caused by four major non-communicable diseases. It would also cut the risk of Indians dying by heart attack or stroke by about 15 percent.

The average Indian consumes 10.98 gm salt a day, according to an earlier Johnson-led study, IndiaSpend reported on 7 November 2016. This is over twice the WHO-recommended upper limit per day, 5 gm, which is just under a teaspoon, and seven times what the body actually needs.

Photo Courtesy: IndiaSpend

There is a widespread belief in India that in warm weather when the body sweats and loses salt it is imperative to consume more salt. Johnson refutes it.

Claire Johnson to IndiaSpendIrrespective of the weather, physiologically, humans need just one-quarter teaspoon of salt: 1-2 grams which equals 500 mg of sodium daily.

90 % Salt Consumed by Indians is Added While Cooking or at the Table

About 10 percent of the 10.98 gm daily salt intake of an Indian occurs naturally in fruit, vegetables, cereal and other raw ingredients, said Johnson. The rest is added during cooking or at the table.

So, cutting down for Indians involves adding less salt during cooking and on the table.

Both are more doable than making the major dietary changes implicated in controlling salt-intake in the West, where the excess consumption generally comes from salt added to processed foods such as pasta sauces.

India has seen great dietary changes in the last 30 years, noted Johnson.

Indians are eating less pulses, fruits and vegetables and lots more processed and fast foods, and as a result, their diets now include excess salt, sugars and harmful fats.Claire JohnsonThese are driving up rates of high blood pressure, obesity and cardiovascular diseases, such as heart attack and stroke.

Currently it is impossible to reckon how much salt you are getting from packaged foods in India.

Consider: a) 1 in 4 products fail to meet the (so far, voluntary) nutrition information labelling guidelines of the Food Safety and Standards Authority of India, and b) 2 in 3 products do not list salt on the nutrition information panel and fail International Codex Alimentarius requirements, a collection of standards, guidelines and codes of practice aiming at protecting consumer health and promoting fair practices in the food business.  

This may change soon. New Food Safety and Standards Authority of India (FSAI) labelling regulations for all packaged foods are on the anvil.

Pawan Kumar Agarwal, CEO of Food Safety and Standards Authority of India, to IndiaSpendOur new guidelines, which should come into effect in a few months, will make it mandatory for packaged food labels to list their salt/sodium (and other nutrients) content, in total and against the recommended daily value.

Salt, alcohol and khaini: why eastern India’s villages are reporting high BP

In the mid-1950s, urban India reported a hypertension prevalence of 1.2 percent to 4.0 percent based on the WHO blood pressure diagnosis guidelines then in vogue –diastolic blood pressure exceeding 95 mmHg, a systolic reading exceeding 160 mmHg.

Salt, Alcohol and Khaini: Why Eastern India's Villages Are Reporting High BP

In the mid-1950s, urban India reported a hypertension prevalence of 1.2 percent to 4.0 percent based on the WHO blood pressure diagnosis guidelines then in vogue –diastolic blood pressure exceeding 95 mmHg, a systolic reading exceeding 160 mmHg.

The prevalence increased to 5 percent in the 1960s, then to 12 percent to 15 percent in the 1990s. Today, about 33 percent of urban Indians are hypertensive based on revised WHO guidelines – diastolic blood pressure exceeding 90 mmHg, and a systolic reading exceeding 140 mmHg.

Significant disparity exists between the urban and rural prevalence of hypertension, and also between different regions, as per the 2014 study, ‘Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension’.

In rural India, the east saw over twice the prevalence of the north, 31.7 percent as against 14.5 percent.

Raghupathy Anchala, Associate Professor, Public Health Foundation of India-IIPH, HyderabadAssam in particular has a higher prevalence because of the high consumption of salt, alcohol, and khaini among tea plantation workers; this impacts the average of rural east India.

Urban India showed markedly less variance, with the west seeing a slightly higher prevalence than the north, 35.8 percent as compared with 28.8 percent.

Hypertension is a silent killer with few symptoms such as headaches, shortness of breath or nosebleeds, according to Mayo Clinic.

In general, hypertension causes so few symptoms that by the time it becomes obvious, the body could have suffered irreparable damage.

Like Narendra Yadav, 45, supervisor of a laundry ironing service in district Sirohi, Rajasthan.

Doctors diagnosed Yadav with hypertension, mild left ventricular failure, and renal failure, the latter being one of the most severe outcomes of uncontrolled hypertension, which in his case has meant a weekly dialysis. “I had no idea that I had blood pressure,” said Yadav.

Why Is Hypertension Difficult to Control?

Physicians quoted the rule of 50 to explain poor hypertension control, which means: 50 percent of the hypertensive population is unaware of their condition.

Of those who know, only 50 percent are on appropriate treatment and 50 percent of those have their hypertension in check.

Tapan Ghose, Director & Head, Cardiology, Fortis Flt. Lt. Rajan Dhall Hospital, New DelhiPractically, that means barely a tenth of hypertensive people achieve adequate control over their condition.

“Low awareness about hypertension is a bigger problem in rural India than in urban settlements,” according to Jugal Kishore, director, professor and head, community medicine at Vardhman Mahavir Medical College, New Delhi, based on the findings of his 2016 study ‘Prevalence of Hypertension and Determination of Its Risk Factors in Rural Delhi’.

Jugal KishoreCost of treatment is also an issue, as only about 30 percent Indians avail free health services from the public sector. Also, the less privileged are intimidated by big hospitals, and the investigations involved in diagnosing a chronic problem, so they tend to ignore symptoms.

Blood pressure medication is typically prescribed for a lifetime, which can be hard to accept.

Vidhi Ahuja, 34, a communications professional working in Gurgaon, was diagnosed hypertensive at 27. She attributed this to “obesity, work stress and stress from balancing home and work, and my family history”.

Ahuja is forever fending off well-meaning comments from relatives who would like her to come off the medication.

“I have tried to go off the medicine but it hasn’t worked. But regular walks, cutting down on salt and eating healthier have helped to reduce my dose,” said Ahuja.

It also helps to manage stress.

One in six hypertensive cases can be attributed to the mind-body connection, albeit these are more likely to be people in high profile jobs who take a lot of stress from work.

(The article was first published on IndiaSpend. Charu Bahri is a freelance writer-editor based in Mount Abu, Rajasthan)