What WHO’s recommendation for low sodium salt alternatives means for India  Premium

WHO recommends low-sodium salt substitutes to reduce hypertension and cardiovascular diseases

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.

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.