You are what you eat: salt consumption and hypertension

Abstract

I have been working in the Maldives for the past 12 years, employed in many different capacities. Presently, I am the Medical Officer in Charge at Thinadhoo Regional Hospital, a referral hospital serving the people of three atolls. Before joining the service in the Maldives, I was of the opinion that the Maldivians would be free from hypertension as it is a non-communicable disease, uncommon in seafood-dependent communities. At least, that is what we were taught at medical school! However, my view was incorrect. The striking thing about Maldivians is the prevalence of hypertension, which is no less than in any other country in this region. Nearly 15% of adults are hypertensives. This prevalence of hypertension is a matter of concern, and there are several theories that can be put forward for this paradox. The stress of everyday life has definitely increased due to the fast development the country is undergoing, making the Maldives the fastest growing nation in South Asia. This may be a factor, but the nation has many islands that are still remote where people still have relatively stress-free lives. The prevalence of hypertension does not show a marked difference between urban and rural areas, so this clearly indicates that there must be other factor(s) playing a role. Traditional food in the Maldives consists of refined wheat flour made into unleavened bread (‘Roshi’) and boiled rice. This staple food is, as a rule, mixed with fish soup, which is made by boiling tuna fish in plain salt water (brine). This fish soup is called ‘Karudhiya’, literally meaning salty liquid. There is a famous Indian saying: ‘it is what you eat, what you become’. The salt content of the food must be a factor that is not given due importance, because Karudhiya has become a part of Maldivian living. As a result, I decided to perform a qualitative survey of salt consumption among people in Thinadhoo, the Atoll capital. A random survey of more than 50 households was conducted, and the average consumption of table salt was found to be nearly 10.5 g/day/person. This is much higher than all international standards for the daily recommended allowance (the World Health Organization’s global recommendation is 6.0 g/day/ person). Clearly, there may be a simple reason for many common disorders, including hypertension. However, initiating health education programmes on sensititive issues within the community, such as lifestyle modifications and food habits, is a real challenge for both the community and the healthcare provider. It would be just like telling the Japanese not to drink tea. We have now started, with the utmost caution, advising people about the fish soup that they have been eating for ages: ‘Sure! You can have your fish soup but let it be mixed with less salt and let there be at least a day off!!’ The people of the island have slowly started to understand the issue and hopefully the seafood that they consume in abundance will start to reduce the prevalence of hypertension in the future. Public Health (2004) 118, 78