Review Article

Sudip Bhattacharya1,
“Taste Modification” - A New Strategy for
Amarjeet Singh2 Reduction of Salt Intake among Indian
1
Junior Resident, Population
Department of
Community Medicine,
School of Public Health, Abstract
PGIMER, Chandigarh,
India. Hypertension is an important modifiable risk factor for cardiovascular disease (CVDs).
Excess dietary salt intake is responsible for 17-30% of hypertension. Thus, salt increases
2
Professor, Department of the risk of blood pressure‐related CVD events in normotensives. In spite of such
Community Medicine, conclusive evidence, we have not been able to devise a fruitful/ effective strategy to
School of Public Health,
PGIMER, Chandigarh-
combat this. Changing human behavior is a complex process. Rather than just simply
160012. advising patients to reduce salt intake, we need to provide alternate strategy by
creating an enabling environment for people to adopt this behavior change. In this
Correspondence to:
article, we have proposed two alternate salt-reduction strategies: cross-sectional
Dr. Sudip Bhattacharya,
School of Public Health, strategy (control)/ hospital approach and a long-term/ community (preventive)
PGIMER, Chandigarh, strategy.
India.
A strategy proposed in this article is pre-conditioning the child with low-salt diet right
E-mail Id:
drsudip81@gmail.com
from the weaning period. If the child will be offered a low-salt diet from the very
beginning of life, i.e., preconditioning, this habit is likely to continue and run in
generations, because their taste buds would be physiologically conditioned to low-salt
diet.

Our second strategy is that we may add a counseling room for hypertensive patients;
they may be referred from the hypertension clinic after initial work up. They may be
told that addition of spices/ herbs like ginger, black pepper, etc., in their food will help
in changing their dietary behavior. Over a period of time, gradual reduction in salt in
diet can help in control of hypertension. The idea is to gradually replace salt by these
spices. Thus, effective salt reduction will take place.

Keywords: Hypertension, Taste modification, Salt intake.

Introduction
Hypertension or high blood pressure (HBP) is an important modifiable risk factor for
cardiovascular disease (CVDs). It currently accounts for about 7.6 million (13.5%) of
annual global deaths.1 Hypertension is directly responsible for 54% of all strokes and
47% of all coronary heart diseases worldwide.1 Low- and middle‐income countries bear
a disproportionate burden of hypertension-related risk of death, which is double that of
high‐income countries. There has been plenty of research on finding out the best
strategy to reduce the risk factors for development of high blood pressure. Changing
How to cite this article:
human behavior is a complex process. It is not easy. Rather than just simply advising
Bhattacharya S, Singh A.
“Taste Modification” - A patients to reduce salt intake, we need to provide alternate strategy by creating an
New Strategy for enabling environment for people to adopt this behavior change.
Reduction of Salt Intake
among Indian Population. Over the past few decades, numerous investigations spanning animal, epidemiological
Epidem Int 2016; 1(2): 44- and population intervention studies conducted worldwide have found excess dietary
50. salt or sodium intake to be associated with increased risk of high blood pressure (HBP).1
Other studies (INTERSALT) also have confirmed the harmful health effect of excess salt
ISSN: 2455-7048
consumption, particularly on cardiovascular health. Excess dietary salt intake is
responsible for 17-30% of hypertension.2

© ADR Journals 2016. All Rights Reserved.

Epidem. Int. 2016; 1(2)
Thus, salt substantially increases the risk of blood
pressure‐related CVD events in normotensives. A dose-
response relationship between the reduction in salt
intake and the decrease in blood pressure has also been
documented in the literature. It is estimated that a
reduction of salt by 6 g/d would lower blood pressure
by 4-7 mmHg in individuals with high blood pressure
and 2-4 mmHg in those with normal blood pressure.2
For the last 3-4 decades, there is enough evidence in the
literature to prove that salt is one of the main etiological
factor for hypertension. In spite of such conclusive
evidence, we have not been able to devise a fruitful/
effective strategy to combat this.
This is because of the fact that only medical approach
has been tried so far for this purpose (Fig. 1). As doctors,
we have always tried to use a paternalistic (parent-child)
approach to counsel the patients to reduce dietary salt
intake. It is usually done in a clinic setting. Community
Parent (Doctor)
Adult
Child
*Transaction in a clinic setting between a doctor and a patient (conventional approach)
**Transaction in the proposed approach
Figure 1.Transactional Analysis Model of Communication: A Comparison of Two Approaches
In this article, we have proposed two alternate salt-
reduction strategies: cross-sectional strategy (control)
and a long-term (preventive) strategy.
Long-Term Preventive Strategy (“Catch Them
Young-Target the Children”)
A strategy proposed in this article (Fig. 3) is pre-
conditioning the child with low-salt diet right from the
weaning period when he/ she starts taking feeds other
than breast milk. This requires counseling of the mother
and the general public by healthcare personnel during
their interactions with patients/ people in home or
hospital or any contact point in the community,
regarding relation of high salt intake in diet and chances
of development of high blood pressure in future.
Mother would be taught that following a simple advice
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Bhattacharya S et al.
or family level contact between doctor and patient is
missing. The approach has always been to create a fear
among the public regarding various risk factors, e.g., salt
intake. In other words, we are trying to impose a
behavior change on the people. Actually, we have failed
to effectively design and implement behavior change-
based salt-reduction strategy through active
involvement of patients or their families. For this
reason, the response has not been up to the desired
extent. Changing human behavior is a complex process.
It is not easy. Rather than just simply advising patients
to reduce salt intake, we need to provide alternate
strategy by creating an enabling environment for people
to adopt this behavior change. It is much more than an
OPD-based doctor-patient interaction. We need to
consider family also while devising such strategies. This
is because patient’s behavior may be influenced by
“significant others.”
Parent
Adult
Child
(Patient)
(adding less salt in diet) can benefit their child in future.
As it is seen that a better understanding is present
between these healthcare providers and the mothers
due to regular interaction in the community or since
often they belong from the same community. This
communication process is likely to be more successful
than simply advice giving by a doctor in a clinical setting.
This way the message of long-term benefits of the
strategy will be conveyed effectively to the target
population. If they understand the benefit then they will
try to change their behavior and the child will be offered
a low-salt diet from the very beginning of life. Thus the
child will be preconditioned with this type of diet. This
habit is likely to continue and run in generations,
because their taste buds would be physiologically
conditioned to low-salt diet. In future, they would not
prefer high-salt diet in their routine lives.
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Bhattacharya S et al. Epidem. Int. 2016; 1(2)

Approach for salt

reduction

Usual Our
approach to strategy

HTN patients

By doctors
Involve family and patient
and health workers

Counsel
Drugs Dietary salt
reduction

Problem of Only advice For adults

For children
compliance
No strategy for HTN/Normal B.P.
Cost factors inducing behavior
change
Side effects
Preconditioning
Conditioning
with low salt
with low salt
diet
+spices/herbs

Continue
medicines

Taste
modification

Reduced incidence and prevalence of HTN

Maintenance of controlled
BP

Figure 2.Proposed and Usual Strategy for Dietary Salt Reduction

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Epidem. Int. 2016; 1(2)
Cooking with low Low salt
salt diet to child
Food acceptance Taste modification
after some time
Figure 3.Proposed Strategy for Child (Preventive strategy)
Cross-Sectional-Control Strategy (“Better Late
than Never-Tackling the Adults”)
With rising incidence and prevalence of NCDs, the
problem of hypertension is present everywhere
whether in urban or rural clinic. When we talk about
hypertension management in clinic setting in urban
area, a physician usually encounters adults who are pre-
conditioned with high-salt content in their diet since
their childhood. It is difficult to convince them to change
their dietary salt intake overnight from high salt to low
or no salt simply by giving advice in a short span of 5-7
minutes in OPD setting, where scores of patients are
waiting. We need to offer a feasible alternative to them.
We may add a counseling room approach. Here, high
blood pressure patients may be referred from the main
OPD after initial work up. In that room, the message can
be given at a leisurely pace. They may be told about
addition of spices/ herbs like ginger, black pepper, etc.,
in their food. Over a period of time, gradual reduction in
salt in diet can help in control of hypertension (Fig. 4).
This approach has been successfully tried in a DBT
project on multi-purpose behavior therapy in
hypertension clinic in PGIMER, Chandigarh. The room
may have add-on features like posters, displays, live
demonstration/ training of exercises, laptop-based
education, etc. Discussion may be held between patient
and counselor across the table in a congenial set up.
Even their family members would be actively involved in
the counseling session in a friendly atmosphere. It will
save time of the patient as well as of the doctors. It will
also enhance patient satisfaction.
The idea is to gradually replace salt by these spices. The
altered taste may not be acceptable to people in the
early phase. But gradually, their taste buds would be
conditioned to the new taste. Eventually, these spices
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Bhattacharya S et al.
Persist; no
pampering
Food refusal Taste bud
conditioning
Runs into generation
may become acceptable to them. This way salt intake
will be reduced. Another aspect which is often ignored
by us is that when we educate a patient regarding salt
reduction in diet, we do not involve the family especially
the lady of the house. As a matter of fact, we know that
they play an important role in salt reduction. The
proposed strategy (Fig. 2) will target the family/ women,
especially one who is responsible for cooking. So it is
important to consider family as an integral part of salt-
reduction strategy. This approach is quite feasible
because there will be no extra burden to the food
maker in terms of money or labor. This is in contrast to
the usual strategy (Fig. 2) where only the patient is
targeted for advice on salt-restriction who virtually has
no control over the amount of salt in the food.
Figure 2 compares two communication models: the
conventional clinic approach and the proposed
approach.
Transactional analysis (Fig. 1) (TA to its adherents), has
an origin in as a discipline. As per this framework,
humans are social creatures and that a person is a multi-
faceted being that changes when in contact with
another person in their world. Typically, according to
TA, there are three ego states that people consistently
use:
Parent (exteropsyche): A state in which people behave,
feel, and think in response to an unconscious mimicking
of how their parents (or other parental figures) acted, or
how they interpreted their parent’s actions.
Adult (neopsyche): Our adult ego state is our thinking,
feeling and behaving in here and now appropriately to
any stimulus. When we are in our Adult ego state, we
are in full contact with and are responding to the here
and now.
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Bhattacharya S et al.
Cooking soup Low salt+ Taste of the
with low salt increase
+herbs/spices spices in diet
altered
for adults
Acceptance Taste
modification
Figure 4.Proposed Strategy for Adults (Cross sectional strategy)
Child (archaeopsyche): A state in which people behave,
feel and think similarly to how they did in childhood.
Kinds of Transactions
There are basically three kinds of transactions:
1. Reciprocal/ Complementary (the simplest)
2. Crossed
3. Ulterior-Duplex/ Angular (the most complex)
Reciprocal or Complementary Transactions
A simple, reciprocal transaction occurs when both
partners are addressing the ego state the other is in.
These are also called complementary transactions.
Crossed Transactions
Communication failures are typically caused by a
'crossed transaction,' where partners address ego states
other than that their partner is in. Consider the above
examples jumbled up a bit.
Ulterior Transactions
Another class of transactions is the ulterior transaction,
where the explicit social conversation occurs in parallel
with an implicit psychological transaction.
Problems occur in crossed transactions when the other
person is at a different level. In a conventional clinic
setting, the physician and the patient are at a different
level due to asymmetry of information and the high
pedestal at which the physician is placed in the society.
For this reason, messages are not conveyed in a proper
manner resulting in non-compliance.
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Epidem. Int. 2016; 1(2)
Early refusal Taste bud
soup
Persist conditioning
Maintenance of the
changed behavior
In the proposed approach (OPD consultation integrated
with counseling in separate room), the communication
will improve. In the counseling room, the patient can
relax a bit and there will be enough time for discussion.
This way the child state of the patient can be brought
back to the adult stage. Now the patient will be
confident enough to speak their problems openly. And
then effective (adult to adult) communication will come
to play. Thus barrier to effective communication can be
easily broken by this approach. The family will realize its
role in harm reduction of their loved ones. This effective
communication will lead to proper practice because the
kitchen owner will decide the cooking practices of the
household.
Physiological Basis of the Strategy
Sodium balance in an organism is influenced by a variety
of factors such as diet, disease, and hormonal state. In
human beings, there is some evidence that sodium
depletion also results in altered taste response.3 In
many experiments, it has been shown that after a
certain period of salt depletion from diet, the food
which was considered normal previously was
categorized as salty.3 As an example, if we develop a
habit to eat salad with less salt and mixing more citric
juice on it, our taste will definitely change after a certain
period. After some time, if somebody offers us salad
with high salt, then it will not be acceptable to us. This is
because our taste buds have been conditioned.
This observation has important implications for dietary
salt control. It shows that preferences of food quality
and taste are mostly acquired. Essentially, our taste is a
learned experience rather than genetically determined.
Hence it is quite manipulable.
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Epidem. Int. 2016; 1(2)
We develop different taste as per exposure through our
family kitchen. For example, Hyderabadi food may be
considered too spicy by a North-East person, while
Laddakhi tea may be considered too salty to the Marathi
people. It is called food neophobia. In our lives most of
us have neophobia. Many of us cannot be able to adjust
to life in a foreign country because of food. We feel
comfortable when we are back in our family to enjoy
home food.
A study from China shows that addition of herbs and
spices can enhance the liking of low-salt tomato soup by
the people which was previously unacceptable.4
Reducing salt content and incorporating herbs and
spices into a typical tomato soup led to initial rejection
by the customers. But after some time due to repeated
exposure, it was well accepted by the same customers.4
Decades of research on psychological factor research
consistently show that mere repetition of a simple
action in a consistent context leads, through associative
learning, to the action being activated upon subsequent
exposure to those contextual cues (that is, habitually).4,5
Once initiation of the action is ‘transferred’ to external
cues, dependence on conscious attention or
motivational processes is reduced.4
Therefore habits are likely to persist even after
conscious motivation or interest dissipates. For
example, if we train a person who is responsible for
cooking regarding salt reduction in food, for the first
few days s/ he will consciously do the act but after
repeated practice it will be converted as a reflex action
for him/ herself.
Habit-formation advice, paired with a ‘small changes’
approach, has been tested as a behavior change
strategy. It has been quite successful.5 Similarly, the
cooks have to form a habit of preparing low-salt diet
with a small change in cooking process that is adding of
low salt and incorporating spices. Rest of the cooking
process will remain the same. So, this strategy will be
quite easy and successful.
In India, we have multiple options of altering food taste
by using masala (spices like haldi, pepper, ginger). Spices
(or masalas as it is called in Hindi) are the “heart” of an
Indian kitchen. Thus, we can have multiple
combinations of masalas to add taste to the food while
simultaneously reducing the salt content in our diet.
In the conventional clinic-based approach, we advise
low-salt food for the hypertensive patient only in OPD
setting when they report. This advice is to be
implemented at home. However, preparing low-salt
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Bhattacharya S et al.
food separately for a hypertensive patient in a family is
burdensome and time consuming for the homemaker or
the cook. Affordability is also a concern due to fuel
consumption. So hypertensive patients are compelled to
eat the food prepared for the whole family.
Another issue is the compliance of the patient to the
low-salt dietary advice. A person who is habituated to
take high-salt diet right from the weaning period is
physiologically pre-conditioned with high salt content in
the diet. A sudden prescription of low-salt or no-salt
diet will create phobia in him. It usually results in non-
compliance.
As a physician in clinic, we think that hypertensive
patients are the only target group for advice. We do not
take into consideration the family, the setting in which
they live. We never give advice to the women who are
actually responsible for cooking whether it is mother,
sister or wife. They are the main controllers of salt in the
diet. Thus, setting-based approach of health promotion
should be used.
Here it is an opportunity to use psychological theory
related to habit formation to formulate simple and
sustainable behaviour change advice. In a family if we
have to modify the salt intake of member we have to
target the children. If a mother cooks food with less salt,
there may be initial rejection. But after some time the
child will get used to take low-salt diet.
Moreover, children can learn quickly as they usually
follow their parents. Once the child is preconditioned
with low-salt diet and the habit is properly maintained,
there would be an opportunity to relay this behavior
from generation to generation. So, this is a sustainable
option for reducing salt in diet of the family.
Discussion
Thus, we have discussed two novel strategies. One is a
long-term (preventive) strategy and the other one is
cross-sectional (control) strategy. The first strategy
relates to preliminary conditioning or habit formation
with low-salt diet from childhood. The other one entails
taste modification or habit change by using spices/
herbs. The two approaches may be applicable to
different segments of the population concurrently.
First one shall be applicable to young children in a family
right from the weaning period when the child starts
taking complementary feeds. The second strategy is
applicable to all sections of the population. Above
mentioned methods are mainly dependent on behavior
change or habit change or habit formation.
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Bhattacharya S et al.
This behavior-change strategy (taste modification)
seems to be a new approach for reduction in salt intake.
The approach is easy because we are involving not only
patient but also the family members, who are
responsible for kitchen. In the proposed strategy, no
extra effort will be needed (training) on the part of the
home-maker, easy to follow (place of intervention is
kitchen) and there will be no extra financial burden
(same masala or spices will be used). And it will be
culturally appropriate for Indians.
As we know taste plays an important role regarding salt
intake, we have to condition our taste buds, first by
behavior change or habit change (taste modification).
Taste modification may be a new approach for the
Indian population. So food can be made with reduced
salt and adding spices or herbs to it. Result may not
come very quickly, it will take time. This approach is
applicable to all. This novel idea can be further explored
by trials. And it can be pilot-tested first in urban areas,
due to feasibility concern.
If this strategy is combined with enabling factors/
supportive environment like government regulation
(e.g., ban on sale of fast food in school canteens) and
subjective norms (encouragement for home tiffin and
avoidance of market food), we can control hypertension
in population level, effectively.
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Epidem. Int. 2016; 1(2)
Acknowledgment
We are thankful to the colleagues of School of Public
Health, PGIMER, for motivating us to prepare this
manuscript.
Conflict of Interest: None
References
1. Lawes CM, Vander Hoorn S, Rodgers A et al. Global
burden of blood‐pressure‐related disease. Lancet
2008; 371: 1513‐38.
2. Salt and Hypertension (Professional Paper).
Available from: www.heartfoundation.com.au.
Accessed on: Dec 12, 2014.
3. Mary B, Gary K, Karl E et al. Long term reduction in
dietary sodium alters the taste of salt. The American
J of Clinical Nutrition 1982; 36: 1134-44.
4. Khalil GS, Rowland I, Methven L. Enhancing
consumer liking of low salt tomato soup over
repeated exposure by herb and spice seasonings.
Appetite 2014; 81: 20-29.
5. Benzamin G, Phillippa L, Jane W et al. The
psychology of ‘habit-formation’ and general
practice. Br J of Gen Pract Dec 2012; 62: 664-66.
Date of Submission: 01st Jul. 2016
Date of Acceptance: 03rd Jul. 2016
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