It’s time for Pakistan to act on salt reduction. The World Health Organization (WHO) has published the first-ever global report on sodium intake with an important message: The world is consuming double the amount of salt than what it should—by reducing consumption, it can prevent two million deaths by 2025 and seven million by 2030.
Sodium, which constitutes 40% of the amount of salt we consume (60% is chloride), is a major cause of high blood pressure leading to heart problems, stroke and kidney failure. In Pakistan, a total of 350,000 yearly deaths are caused by these cardiovascular problems. Going by the WHO report, we can prevent 38,000 deaths in the next two years if we cut the amount of salt to half of what we consume today.
Unfortunately, Pakistan lacks the four policy actions, which include 1) Setting targets for sodium consumption and lowering the sodium content in food products, 2) Mandating front-of-pack labelling to help consumers select food products with lower sodium content, 3) Conducting campaigns to improve the behavior of salt consumption, and 4) Providing low-salt food in places where the government offers free food (e.g., hospitals, langar khana, jails) from the public exchequer.
Sodium is essential for brain and muscle activity, but excess can harm our bodies. The WHO recommends a daily intake of about two grams of sodium, equal to a small teaspoon, whereas an average Pakistani consumes double the recommended amount. The kidneys have trouble keeping up with this excess sodium accumulating in the blood.
As sodium accumulates, the body holds onto water to dilute the sodium. This water retention increases the fluid surrounding the body cells and the blood volume in arteries. Increased blood volume means more work for the heart and more pressure on blood vessels. Over time, the extra work and pressure can stiffen blood vessels, leading to high blood pressure, heart attack, and stroke. It can also lead to heart failure.
High blood pressure is a critical public health problem in Pakistan; some experts have even labelled it an epidemic. Close to 39 million Pakistani adults (38%) have high blood pressure. Every second person has this problem among people aged 45 years or older. Overall, in each household of five people, two are likely to have high blood pressure. Shockingly, estimates suggest that only one-third of those with hypertension are aware of their health problem, and only 7% have it under control.
Diagnosing such a disease that may not cause symptoms for a long time is difficult. Once diagnosed, its treatment can be expensive, leading to poor compliance. A public health measure of reducing salt is a highly cost-effective strategy, but it needs to be tackled as high priority through public policy and its implementation. Formulating and enforcing a salt policy is critical, including a component focusing on community behavior change.
Research tells us that even those conscious of salt have trouble reducing its consumption because they do not know its biggest source in their diet. It is important to remember that most of the salt in our diets comes from commercially prepared foods, and not from raw or unprocessed foods. The top sources include restaurant foods and packaged items like pizza, sandwiches, soups, savory snacks, fried chicken, and cheese. Soft drinks having soda (coke, pepsi, sprite) and bread (double roti) also have high sodium and usually go unnoticed.
The second biggest reason people cannot reduce their dietary salt is the lack of low-salt options on restaurant menus or even at household parties. Without this choice menu, people cannot exercise their options despite knowing about the dangers of salt and being willing to consume low-salt food. Here, official mandates for food outlets to include low-salt options become important—an area that, along with food labels, needs the attention of the Government of Pakistan.
Pakistan has one additional and highly significant reason to prioritize salt reduction. The effects of dietary excesses are not just limited to the elderly. Every fourth young man or woman aged 18-29 in Pakistan has high blood pressure. Given the food choices like burgers, potato fries, crackers, condiments, and soda drinks popular among youngsters, this high prevalence is understandable but must not be acceptable.
Historically, South Asians, including Pakistanis, belong to the race that evolved to carry out agricultural functions. Our ancestors successively reduced their body mass so they would suffer less heat exhaustion while working in the farms under the scorching sun. This evolution also brought a natural consequence of high blood pressure and other metabolic problems, which are disproportionately high among South Asians than any other race. Over -consumption of salt is adding fuel to the fire.
A safe and effective policy measure – a rare example where money will not be spent but saved – can protect lives, and is waiting for action.
The writer has a PhD in Health Promotion, Education and Behavior. He has worked with the Johns Hopkins University, UN, BMGF, and Pakistan’s National Ministry of Health (NHSR&C), and currently advises Gavi for the EMRO constituency.