|Year : 2013 | Volume
| Issue : 1 | Page : 12-14
Usage of non-iodized salt in North West India
Sanjay Kalra1, Bharti Kalra2, Kanishka Sawhney3
1 Department of Endocrinology, Bharti Hospital, Karnal, India
2 Department of Obstetrics, Bharti Hospital, Karnal, India
3 Medical Student, Subharti Medical College, Meerut, India
|Date of Web Publication||10-Jan-2013|
Department of Endocrinology, Bharti Hospital, Karnal - 132 001
Source of Support: None, Conflict of Interest: The authors report "minimal" personal consumption of black salt
Background: Though the sale of non-iodized salt is banned by law, it is still available in, and used in, North West India. Aims: This study aimed to assess the patterns of sale and consumptions of non-iodized salt, and explore the reasons behind its continued use. Materials and Methods: A cross-sectional survey was conducted using a semi-structured questionnaire, administered to 16 wholesalers, and 32 retailers, spread over eight districts of three states, and to 100 hypothyroid patients, attending an endocrine clinic. Results: Non-iodized salt was available at all 16 wholesale shops, and 30 out of 32 retail shops. The self-reported sale of non-iodized salt, as a percentage of total salt sold, was 10-20% at wholesale and 0-5% at retail counters. All (100%) of the patients consumed non-iodized salt, reporting this as 2-10% of their total consumption. Common reasons for use were religious necessity, better flavor, and perceived medicinal property (88%, 77%, 62% respectively). Conclusion: Use of non-iodized salt is still prevalent in North West India. Concerted and sustained public awareness campaigns are needed to ensure optimal consumption of iodized salt.
Keywords: Haryana, iodine deficiency disorder, prevention, Punjab, rock salt, thyroid, Western Uttar Pradesh
|How to cite this article:|
Kalra S, Kalra B, Sawhney K. Usage of non-iodized salt in North West India. Thyroid Res Pract 2013;10:12-4
| Introduction|| |
According to law, only iodized salt is allowed to be sold, bought and used in India. This is a central pillar of the National Iodine Deficiency Disorders Control Programme, which seeks to eliminate iodine deficiency disorders from the country.  On the ground, however, the reality is different. Extensive research has been carried out during the past decade, and prior to that, to determine the status of iodization in India.  The data obtained from some studies focuses on the availability of iodized salt on households, and does not attempt to explore the reasons behind use of non-iodized salt.  Available literature does not define the types of, and uses of, various traditional alternatives to common salt. No recent figures are available for the use of non-iodized salt in the districts of northern Haryana, Punjab and western Uttar Pradesh.
To achieve a meaningful change in the patterns of salt usage, the aforementioned factors are important. An in-depth understanding, and documentation of the current trends in sale and consumption of non-iodized salt, along with the reasons behind them, is necessary.
Uniodized salt, or rock salt, is available in north-west India in different forms, which can be classified into two categories:
Rock salt is a mineral form of sodium chloride, which contains impurities such as sulfate, halide, and borate salts of calcium, and potassium. It is imported from Pakistan, where it is mined principally at the Khewra rock salt mine in Jhelum, and sold as big chunks of rock. It does not contain any traces of iodine. It is used as part of animal feed, and helps in melting ice. Black salt is a ground form of volcanic halite, which contains traces of sodium sulphate, iron sulphide. It has a pungent smell (due to hydrogen sulphide) which adds flavour to cooking.
- Halite, syn rock salt, vern sendha namak, Pakistani namak, Lahori namak
- Volcanic halite, syn black salt, vern kala namak.
| Materials and Methods|| |
We explored the sale and consumption of various forms of non-iodized salt in 16 towns, and cities, covering eight districts of Haryana, western Uttar Pradesh, and Punjab, viz, Sonepat, Panipat, Kurushetra, Shamli, Saharanpur, and Ludhiana.
A semi-structured questionnaire was distributed to 16 wholesalers, and 32 retailers of salt, chosen by convenience sampling, to assess the magnitude, scale, and details of consumptions of uniodized salt. Open-ended interventions of 100 patients with hypothyroidism were conducted with a view to assess the knowledge, attitudes, and practice related to non-iodized, and iodized salt consumption. The study was conducted in August, and September, 2012. Detailed literature search was performed on the topic, but no recent online publications from North West India related to this field could be identified. The results of our interviews are summarized below.
| Results|| |
For every 100 kg of iodized salt sold at wholesale counters, about 10-20 kg of non-iodized salt is bought by consumers. This proportion varied in different towns: It was highest (25%), in markets catering to rural customers, and lowest (10%), in urban areas. At retail shops, the percentage of non-iodized salt sold varied from 0% to 5%. Grocery chains such as easyday and More did not stock non-iodized salt, while small retail shops had varying quantities (2-5%) of rock salt on their shelves. The proportion of rock salt vs. black salt varied from 50:50 in urban areas to 90:10 in rural areas.
All 16 wholesalers, and 32 retailers, were aware that it is illegal to sell non-iodized salt. They felt that rock salt and black salt are a part of traditional Indian diet, with medicinal and religious value, and hence selling them was not "wrong". Some shopkeepers justified themselves by informing the investigators that they sold only branded iodized salt, while their competitors stocked "cheap" iodized salt. Rock salt was cheaper than iodized salt (` 10/kg vs. ` 15/kg at current prices, August 2012), while black salt was more expensive (` 20/kg).
No special precautions were taken by any of the shopkeepers for storage of rock-salt: It was kept on the floor, in the open, or in gunny bags of coarse jute. Black salt was packed in small polythene bags and stored on the shop shelves, along with other spices.
Of the 100 patients with hypothyroidism (88 female, 12 male, and mean age 42.14 ± 13.14 years) who were assessed, all (100%) admitted to consuming non-iodized salt in the diet. As a proportion of total salt the intake of non-iodized salt varied from 2% to 10%. No obvious difference was noted in the response of patients, based on gender, age, religion, or place of residence.
The common reasons put forward by patients for talking uniodized salt were:
Many rural patients revealed that most of the rock salt bought by them was consumed by their dairy animals, who need it for strength and vitality.
- Religious sanction for use during fasts such as navratras (88%)
- Better flavor (77%)
- Perceived medicinal property (62%)
- Perceived benefit in blood pressure (38%)
- Perceived laxative effect (14%)
- Perceived "tonic" or strengthening "effect" (10%)
- Less expensive (2%)
Of the 100 patients, none had obvious symptoms or signs of iodine deficiency disorders. All but three (all elderly rural women) were aware that buying and selling uniodized salt was illegal. They justified their consumption of rock salt by pointing out that it was a minimal part of their total salt intake, it has medicinal properties which cannot be ignored, and that religious fasts like navratras cannot be observed without its use.
| Discussion|| |
This simple study reveals that consumption of non-iodized salt is widely prevalent (100%) in the selected districts of North West India. The self-reported intake of this salt is low (2-10% of total salt usage), and these figures seems to be concordant with self-reported sales figures at retail shops (0-5%). The higher proportion of non-iodized at wholesale markets (25%), can be explained by the fact that farmers who need rock salt in large quantities for animal husbandry tend to buy it from these counters directly.
The study highlights the near-universal awareness of laws making its mandatory to iodinate salt (100% in shopkeepers, 97% in patients of hypothyroidism). At the same time, it highlights the universal disregard for this legislation, with respondents justifying the use of rock salt and black salt by different explanations. The commonest reasons for use of non-iodized are religious (88%), culinary (77%), and medicinal (62%), with economic factors being cited by only 2%.
The findings of this study is important from a thyroidology point of view. The alarmingly high acceptance of non-iodized salt as a medicinal or curative agent, and a preventive strategy for hypertension, is surprising as well as disconcerting. Contrary to popular perception, rock salt does not have less sodium or less vasculotropic effect. Neither does it have an anabolic effect, though it may help manage mild dyselectrolytemia, which is common in Indian summers. While religious issues cannot be tackled head on, there is a multitude of spices and condiments available in Indian cuisine to replace table salt for a short period of time. Research has shown that continued efforts are needed to ensure that iodine deficiency disorders do not reappear. 
On the other hand, experts have recommended a re-examination of the universal salt iodization strategy and proposed a "safer, people-centered, eco-social epidemiological approach" rather than a universal legal ban.  Perhaps the results of this study support such a suggestion. Does it make sense to have a law if it is universally flouted, citing sociocultural and religious reasons? One cannot predict, however, what the pattern of usage of non-iodized salt will be if the law on mandatory salt iodization is repealed. 
This study admits to some limitations. No attempt was made in this study to compare non-iodized salt consumption in hypothyroid, hyperthyroid and euthyroid subjects. Neither did we try to assess iodization status in the population. The aim of this study was not to be document the relationship of salt intake with thyroid function or adequacy of iodization; rather, it aimed to record the current usage pattern of non-iodized salt in the community. No attempt was made to study statistical significance of any clinical, demographic, social or biochemical parameters in relation to salt usage, because of the surprisingly one-sided and homogenous answers obtained from respondents. Though the authors belong to the same community that was studied, they were unprepared for the high prevalence and acceptance of non-iodized salt usage that was observed.
In spite of these limitations, this study has major strengths, which warrant its publication and publicity. The study respondents were from eight contiguous districts of Haryana, western Uttar Pradesh and Punjab, thus representing three large states of North West India. Wholesalers, retailers and customers were covered in this study, thus covering the complete marketing chain of salt. Honest answers were obtained from all participants after promising confidentiality, and assuring them that no "governmental action" would be taken, and that data would not be shared with civic authorities.
| Conclusion|| |
The sale of non-iodized salt is banned in India since 2006. However, 6 years later, it continues to be accepted, sold, and used in India for a variety of reasons, both 'actual' and 'perceived'. This paper reveals current trends in consumption of non-iodized salt, and stimulates all concerned stakeholders not to ignore this potential threat to public health. We should not forget the grim picture of iodine deficiency and goiter prevalent in our country just two generations ago. 
The continued use of rock salt in India deserves attention, and should be accepted as one of the public health challenges faced by thyroidology. 
| Acknowledgments|| |
We acknowledge, with gratitude, the cooperation of all participants and patients.
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