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June 2023, Volume 73, Issue 6

Primary Care Diabetes

Sodium Literacy

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India; University Center for Research & Development, Chandigarh University, Mohali, India. )
Bharti Kalra  ( Department of Gynaecology, Bharti Hospital, Karnal, India )
Nitin Kapoor  ( Department of Endocrinology, Diabetes and Metabolism Christian Medical College & Hospital, Vellore, Tamil Nadu, India, Non communicable disease unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia. )


This communication describes the concept of sodium literacy as means of optimizing sodium intake and achieving better cardiovascular health. It also highlights the sources of sodium in South Asian cuisine which can be avoided or minimized.


Keywords: Cardiovascular disease, diet, hidden hunger, malnutrition, salt.


DOI: 10.47391/JPMA.23-42




Health literacy is a major determinant of health outcomes.1 Awareness about diet and nutrition is integral to self-care and self-management of chronic disease, including diabetes and hypertension. Discussion on dietary/food literacy however, tends to focus mainly on meal patterns and macronutrient adequacy. Micronutrients, which, are an equally important aspect of nutrition, are often neglected in routine discourse.2 Vitamins and minerals are necessary for optimal health, and can also lead to disease if taken in excess. Even if these are discussed, electrolyte balance is rarely even addressed. This is especially true for sodium. Just as obesity is included in the definition of malnutrition, excess sodium intake should be viewed as a form of malnutrition, along with other types of hidden hunger.

In this communication, we define and discuss the concept of sodium literacy and share pragmatic means of spreading and improving it.


Need For Sodium Restriction


Dietary sodium levels are linked with the development of hypertension and cardiovascular disease risk.3 While this fact is well known, both health care professionals, and the public at large, tend to ignore recommendations for optimal sodium intake. This is unfortunate, as sodium imbalance leads to a unique type of malnutrition. Just as obesity and protein energy insufficiency are considered a form of malnutrition, micronutrient over usage and insufficiency both represent unhealthy dietary intake. Keeping this in mind, sodium intake must be targetted as a part of balanced nutrition.


Recommendations And Reality


The World Health Organization suggests 5 grams of salt, or 2 g of sodium per person, as the recommended daily allowance.4 It must be noted that this includes both visible, or table, salt and invisible salt, which is present in many foodstuffs, especially meats. The maximum limit also includes non-salt sources of sodium, such as sodium monoglutamate (ajinomoto)

In reality, however, sodium intake is much higher than this. Studies from South Asia suggest a daily consumption of salt intake that goes up to over 13 grams.5 This may be associated with adverse cardiovascular health, as reported by various researchers. A sustained campaign on sodium literacy, amongst health care providers, as well as the general public is necessary to tackle this issue


Sodium Literacy


Literacy is defined as the ability to read and write. Sodium literacy, therefore, can be described as the ability to read and understand the sodium content in various foodstuffs. A more comprehensive (and idealistic) explanation may be as follows: sodium literacy is the ability to read and understand the sodium content in various foods and food ingredients and act upon this information to ensure optimal dietary sodium intake. Sodium literacy is dependent upon multiple factors, as listed in Table 1.



Simple Suggestions


Most (nearly 90%) of the sodium in South Asian cuisine comes from table salt.6 This means that a sodium literacy campaign on low salt cooking is required. High sodium containing foods should also be avoided in large quantities.7 The dangerous Ps-papads, pakoras, pickles, pizzas and potato chips, as well as the equally salt-laden Ks-ketchup, kadhi, karela, kathal (jackfruit), and kurkure (salted fritters), are a simple, yet effective, way of reminding patients about high salt-containing preparation that should be avoided. A movement on accurate food labelling, with “red flag” warnings for high sodium foods, should be initiated.  South Asian cuisine is blessed with a wide variety of spices that can be used as alternatives to salt. Their usage should be promoted, as part of a discussion on functional foods.




Sodium literacy should be highlighted as an integral part of health literacy, and diabetes literacy. Focusing on this will help reduce sodium intakes to optimal levels, and improve cardiovascular health.




1.      Liu C, Wang D, Liu C, Jiang J, Wang X, Chen H, Ju X, Zhang X. What is the meaning of health literacy? A systematic review and qualitative synthesis. Family medicine and community health. 2020;8: e000351

2.      Gödecke T, Stein AJ, Qaim M. The global burden of chronic and hidden hunger: trends and determinants. Global food security. 2018; 17:21-9.

3.      Cappuccio FP, Campbell NR, He FJ, Jacobson MF, MacGregor GA, Antman E, Appel LJ, Arcand J, Blanco-Metzler A, Cook NR, Guichon JR. Sodium and health: old myths and a controversy based on denial. Current Nutrition Reports. 2022 Feb 14:1-3.

4.      World Health Organization. Guideline: Sodium intake for adults and children. World Health Organization; 2012. Available at: Last accessed on 1 October 2022.

5.      Mohan S, Prabhakaran D, Krishnan A. Promoting population wide salt reduction in the South-East Asia Region: current status and future directions. Reg Heal Forum 2013;17:72-79.

6.      Johnson C, Santos JA, Sparks E, Raj TS, Mohan S, Garg V, Rogers K, Maulik PK, Prabhakaran D, Neal B, Webster J. Sources of dietary salt in north and south India estimated from 24-hour dietary recall. Nutrients. 2019;11:318.

7.      Kalra S, Kumar KH. Seven sinful sisters: seven smart solutions to stop diabetes. J Pak Med Assoc. 2018;68:1727-8.

8.      Kalra S, Choubey N. Low salt South Asian diet. J Pak Med Assoc. 2017; 67:1628-9.

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