Unregulated taste for salty foods: Enhancer for hypertension, heart attack and kidney damage

“This food is tasteless. There is no salt in this soup. How can you cook without salt? Please come and take away this food,” Mr. Obiwenite Okongwu blurted out to his wife Chizoba.

“Please give me that table salt. There is no salt in this rice,” Miss Biodun Adekunle asked her friend, Bisi.

“There is too much salt in this chicken and chips meal. No, no, I cannot take this,” Musa Abdullahi complained to his sister, Amina, when they went for lunch at a fast-food joint.

Different strokes for different folks; Obiwenite, Biodun and Musa have different perceptions about taste for salt.

Experts have warned that a person who eats excessive amounts of salt may be at risk of enlarged heart muscles, headaches, obesity, heart attack, kidney disease, osteoporosis, stroke, heart failure, high blood pressure, kidney stones and gastric/stomach cancer.

They endorsed reducing salt consumption to prevent hypertension, kidney damage, heart attack, stroke and other cardiovascular diseases, which are the leading causes of death in the country.

Former President, Nutrition Society of Nigeria (NSN), Prof. Ngozi Nnam, told The Guardian that salt is a good source of sodium, an essential mineral for the body. Nnam, however, said if a person consumes too much salt, he or she may be at risk of certain health conditions. Salt is present in a wide range of foods and drinks. Salt may occur naturally in certain foods, or manufacturers may add salt during the production process.

The Professor of Community and Public Health Nutrition affiliated to the Department of Nutrition and Dietetics, at the University of Nigeria Nsukka, Enugu State, said: “The major concern about salt is that when you take a lot of it, it causes an imbalance in terms of electrolyte because there is a drastic increase in sodium. The tendency is that there is a high concentration of sodium and the water balance is also distorted. The body system will try to restore the balance and this will affect the way water is pumped into the kidney and the way blood is pumped into the heart. This is because the body is trying to get a balance. The rate blood is pumped into the heart increases and also there is a concomitant increase in blood pressure. This imbalance also affects the kidney and could lead to kidney dysfunction and damage.

“The ways in which too much sodium can harm the body are well understood. Too much sodium leads the body to retain water, which is pulled into the blood vessels. This can increase the volume of blood. It is like turning up the water supply to a garden hose — the pressure in the hose increases as more water is blasted through it. And, over time, this leads to disease. The kidneys get stressed, the blood vessels get stressed, the heart gets stressed.”

According to the World Health Organisation (WHO), cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels. They include coronary heart disease – a disease of the blood vessels supplying the heart muscle; cerebrovascular disease – a disease of the blood vessels supplying the brain; peripheral arterial disease – a disease of blood vessels supplying the arms and legs; rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; congenital heart disease – birth defects that affect the normal development and functioning of the heart caused by malformations of the heart structure from birth; and deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

The WHO said heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can be caused by bleeding from a blood vessel in the brain or from blood clots.

Burden
The WHO said excessive salt in food and beverages is putting people at greater risk of potentially fatal heart disease and strokes, even as it issued fresh guidelines for limiting sodium content.

According to a report by WHO, an estimated 11 million deaths globally are associated with poor diet each year, including three million attributable to high sodium intake.

A nationwide population survey of salt intake in Nigeria published November 2020 in European Heart Journal concluded: “Salt intake among Nigerians is higher than the recommended. The impact of sodium intake on blood pressure (BP) appears to be evident only among individuals with high salt intake.”

Population-wide salt reduction programmes are cost-effective strategies for the control of cardiovascular diseases (CVDs). Obtaining nationwide salt consumption data in a multi-cultural setting as Nigeria’s is key for proper implementation and monitoring of such strategy.

Recommended levels in Nigeria
On the recommended salt limit in Nigeria, Professor of Nutrition and Dietetics with Doctorate in Community Nutrition at the University of Agriculture, Abeokuta, Ogun State, and current NSN President, Wasiu Afolabi, told The Guardian: “5 grammes of salt per day or 2 grammes sodium. This must be iodised salt.”

On renewed concerns over salt intake, Afolabi said kidney complications and failure and cancer are other manifestations of excessive salt intake.

On alternatives to salt if any, the nutritionist said the most reliable option is a salt reduction in processed foods, which is the source of high salt intake in Nigeria.

Are there benefits to extra salt intake considering the recommendation in diarrhoea and some viral infections? “No, there are no benefits to extra salt intake unless medically recommended. Salt alone cannot be used to treat diarrhoea. It is usually combined with sugar and recently zinc to provide electrolyte balance and correct electrolyte/fluid loss due to diarrhoea,” he said.

Supporting studies
ACCORDING to research by Queen Mary University of London, England’s salt reduction programme will have led to nearly 200,000 fewer adults developing heart disease and £1.64 billion of healthcare cost savings by 2050.

However, the researchers warn that the recent stalling of salt reduction programmes is endangering the potential health gains, as salt intake remains significantly higher than recommended levels.

Excess salt intake is strongly linked with raised blood pressure and increased risks of cardiovascular disease, as well as kidney disease, gastric cancer and osteoporosis. Raised blood pressure is responsible for half of the burden of ischemic heart disease and more than 60 per cent of strokes.

The new research, published in the journal Hypertension, used 2000-2018 population survey salt intake data and disease burden data to project the impact of the salt reduction programme and found that:

The 2003 to 2018 salt reduction programme in England achieved an overall salt intake reduction of 1 gram/day per adult, from 9.38 grams/day in 2000 to 8.38 grams/day in 2018.

If 2018 salt intake levels are maintained, by 2050 the programme would have led to 193,870 fewer adults developing premature cardiovascular disease (comprising 83,140 cases of premature ischemic heart disease and 110,730 premature strokes), and £1.64 billion of healthcare cost savings for the adult population of England.

If the World Health Organization recommended salt intake of 5 grams/day is achieved by 2030 in England, these benefits could double, preventing a further 213,880 premature cardiovascular disease cases and further health and social care savings to the UK government of £5.33 billion.

And most recently, a study published in The New England Journal of Medicine from China points to similar benefits. When groups of people in Chinese villages substituted potassium chloride for table salt, “they saw significant reductions in heart attacks and strokes.”

Investigation
The Guardian investigation revealed that restaurant food and packaged foods are often high in salt to make them more palatable. It found that sodium plays a key role as a preservative and taste enhancer in packaged food and “sodium reduction is complex.”

A survey showed sodium content in packaged foods varies a great deal by brand, with a slice of frozen cheese pizza, for example, ranging between 370 mg and 730 mg of sodium. Even the foods used to make a pizza at home, such as canned tomato sauce and pepperoni, can have high sodium levels, which consumers may not be aware of.

The Guardian investigation revealed that food companies are already working to reduce sodium “by offering a variety of products to meet consumer demands – lower sodium, reduced sodium, lightly salted, and no salt options.”

Efforts at enforcement in Nigeria
BUT regulators such as National Agency for Food and Drug Administration and Control (NAFDAC) and the United States Food and Drug Administration (FDA) want to see the food industry gradually reduce sodium levels in these foods.

On what NAFDAC is doing to enforce it especially in fast foods and confectioneries like biscuits, the NSN President said: “NAFDAC already has an approved food grade table or cooking salt regulation which has been passed into law. This is to ensure the quality of food-grade salt in Nigeria. NAFDAC and some non-state actors are currently developing a framework for the reduction of salt in processed foods.”

On recommended salt limit in Nigeria, Director-General, NAFDAC, Prof. Mojisola Christiana Adeyeye, told The Guardian that Nigeria is a WHO Member State and works with WHO global recommendation of consumption of dietary sodium at levels less than 2 g/day of sodium (less than 5 g/day of salt). Adeyeye said Nigeria is presently working in line with the WHO target of reducing dietary sodium consumption by 30 per cent by 2025.

On what is NAFDAC doing to enforce it especially in fast foods and confectioneries like biscuits, etc., the DG said the reduction of salt in food due to its associated risks with cardiovascular diseases is a national burden and the implementation of its reduction requires actions and collaboration of all stakeholders. Adeyeye said Nigeria, on August 6, 2019, in Abuja, launched her first “National Multi-Sectoral Action Plan (NMSAP) for the Prevention and Control of Non-Communicable Diseases 2019 – 2025. She said this policy advocate for a multisectoral approach to reduce sodium in food by 30 per cent by the year 2025.

The pharmacist said as part of the implementation plan, NAFDAC is collaborating with the Cardiovascular Research Unit of the University of Abuja where a project titled “Evaluating the Implementation and Scale-Up of Nigeria National Sodium Reduction programme” is being conducted, also in collaboration with the Federal Ministry of Health and other partners and stakeholders. This, she said, is in recognition of the fact that data is the driver of all impactful action.

Adeyeye said this project is critical as it will generate data to inform salt reduction strategies in Nigeria. She said the first phase of this project has been conducted and incidentally, NAFDAC, together with the University of Abuja and partners will host a stakeholders’ meeting to share the results, engage stakeholders in discussions and increase the awareness of the positive impact of salt reduction on health in the food industry, amongst policymakers, consumers, and other stakeholders.

Besides hypertension, what are the concerns about salt intake in Nigeria? Adeyeye said: “Cardiovascular diseases with high blood pressure is a major risk associated with sodium intake found in salts. The disease burden attributable to excess sodium consumption in Nigeria is large, with 10 per cent of all deaths from cardiovascular diseases due to excess dietary sodium.

“High intakes of sodium is associated with progression of chronic kidney diseases

“Osteoporosis – a bone-thinning disease: the amount of calcium loss via urination increases with the amount of salt taken in. Diets with high sodium may have an additional unwanted effect

“Stomach cancers are associated with higher intakes of salt.”

What are the alternatives if any to salt? “Not aware of any alternatives to salt,” Adeyeye said.

Are there benefits to extra salt intake considering the recommendation in diarrhoea and some viral infections? “Not aware of any,” the pharmacist said.

MEANWHILE, Minister of Health, Dr. Osagie Ehanire, has disclosed the Federal Government’s plans to regulate sodium consumption by Nigerians through packaged foods.

Ehanire, at the first multi-sectoral stakeholders’ meeting of Nigeria’s Sodium Reduction Study, jointly organised by NAFDAC and the University of Abuja, said the framework would help in reducing morbidity and mortality of incidence by instituting cost-effective policies and social interventions that would interface behaviours and lifestyle changes.

Represented by the Director, Public Health in the Ministry of Health, Dr. Alex Oko, the minister said it would also reduce modifiable risk factors for the prioritised NCDs within health in all policies approach.

She said that some of the objectives of the NCDs Multi-sectorial Action Plan include promoting a healthy lifestyle and diet, as well as reducing salt intake through the reformulation of processed food products to contain less salt.

“The NCDs Multi-sectoral Action Plan which is an alignment with WHO global NCDs action plan as well as the WHO ‘SHAKE’ technical package for salt reduction.

“The implementation of the plan aims to achieve specific national subjects as an aspect of the global NCDs goal and SDGs to achieve among other things as an effective reduction in mean population in case of salt, and sodium, which means two grammes per day by 2025 through regulation and reformulation of processed food products to contain less salt,” she said.

Vice-Chancellor of the University of Abuja, Prof Abdul-Rasheed Na’Allah, said the current research on sodium consumption (salt consumption) is so crucial to the ability to live a good life.

“People think salt is sweet. In my place where I come from, we regard salt as the opposite of bitterness, but we are being told here that if you take too much salt, you risk hypertension, your kidney and different kinds of crisis.

“So, it is really about knowledge and our ability to know what it is we have to eat, and our ability to be able to afford and enforce this knowledge that we have.

“I call on the Nigerian government especially the NAFDAC that that is part of this to not shy away from making policies to help our people.

“Our policymakers must do policies to help all of us. This research will help NAFDAC and other policymakers to enforce. Also, especially in schools, we have to teach the young people in their curricula, health education and so on, that too much salt intake is dangerous. Probably, they will grow to be careful. These are the kind of topics that our curriculum should contain,” he said.

Elsewhere
ALSO, many countries have formally adopted salt reduction targets for commonly consumed processed foods as part of a strategy to reduce salt intake. WHO released a new set of global benchmarks for sodium levels in 2021 to help countries to achieve the WHO goal of a 30 per cent reduction in global salt and sodium intake by 2025.

The Pan American Health Organisation (PAHO) has announced new salt reduction targets for food products to help people in the Americas reduce consumption of sodium. After adoption by countries, the new targets will require regional manufacturers to reformulate processed and ultra-processed food products, where most of the sodium consumed in diets comes from.

The United States Food and Drug Administration (FDA) released new sodium targets, in October, aimed at nudging food companies to cut the amount of salt in processed and prepared foods. The cuts are intended to reduce Americans’ sodium intake by about 12 per cent over the next two and half years.

European Union (EU) the Member States agreed to the creation of a common European Union framework on voluntary national salt initiatives. The framework was approved in July 2008, with the overall goal to contribute towards meeting appropriate levels of salt intake.

10 countries in Europe have mandatory initiatives against high salt levels. The main initiatives are establishing maximum permitted salt levels in foods, particularly bread. 25 European countries have voluntary initiatives involving labelling, maximum salt targets in foods, and reformulation programs. Policies include strategies such as taxes on high-salt food (Hungary), mandatory high-salt content labels (Finland), and targets for reformulation and close monitoring of the food supply (United Kingdom).

After the agreement of the European Union Framework, some countries opted for a tougher approach, such as introducing new laws or tightening existing ones. For example, in 2011 Hungary implemented a tax called Public Health Product Tax (PHPT) on packaged foods and beverages that contain high levels of sugar and salt, such as soft drinks, confectionery, salty snacks, condiments and fruit jams. The aim of introducing taxes is to reduce the consumption of food products that are not beneficial to public health.

In Finland, numerous activities have been undertaken to reduce salt, in particular voluntary initiatives and compulsory front-of-pack warning labels. Warning labels are required if a specific product contains sugar or salt above a defined threshold. For example, foods that are high in salt are required to carry a “high salt content” warning. These warning labels have been very effective. Since their introduction, the average sodium content in food products in Finland has decreased by 20-25 per cent.

In recent years many countries have adopted similar front-of-pack labels displaying information on sodium (or salt).

Many countries in Latin America such as Chile, Mexico, Peru, Uruguay, and soon Brazil, have adopted front-of-pack black warning labels that indicate if a product is high in fat, sugar, or salt.

According to the latest figures from the UK National Diet & Nutrition Survey (NDNS), the biggest contributors of salt in the diet are bread, cheese and meat products like bacon. This is similar for Europe, with a large proportion of salt intake coming from foods that don’t necessarily taste salty such as potato products and tinned produce.

Recently Ireland published a Strategic Action Plan 2021-2025 that will finalise their ‘Reformulation Roadmap’ for HFSS foods as part of “Healthy Ireland”, a framework for improved health and wellbeing. Recently the UK released the fifth set of voluntary salt reduction targets.
Solutions

Nnam recommends moderation in salt intake. “You don’t need to add extra salt to your food. The keyword is moderation,” she said. “Salt reduction targets focus on reducing the sodium content of commonly consumed processed foods such as bread, cereals and grains, processed meats, and dairy products,” the nutritionist added.

The nutritionist said the reduction in the sodium content of the most frequently consumed packaged foods would help people reduce salt intake to less than the World Health Organisation (WHO)-recommended five grammes per day.

According to Medical News Today, if a person has consumed a lot of salt, they can try the following methods to rebalance their salt levels.

Drinking water can help to dilute the levels of salt within the body and readjust the body’s sodium-to-water ratio.

Potassium can help to counteract the effects of sodium on the body. A person who has consumed a lot of sodium may find the following potassium-rich foods beneficial: sweet potato, potato, greens, white or kidney beans, bananas, oranges, non-fat yoghurt and cantaloupe.

If a person has consumed a lot of salt, they should consider reducing the amount they have with other meals.