Science Talk: 1 in 3 Singaporeans has hypertension. Can cutting salt reverse the trend?

Singaporeans will soon be hearing more about their salt intake.

Mandated Nutri-Grade labels are set to appear on pre-packed salt, sauces, seasonings, instant noodles and cooking oil, with advertising prohibited for Grade D products which carry the highest levels of sodium or saturated fat. The move is part of an effort to tackle the high prevalence of hypertension, which affects one in three Singaporeans aged 18 to 74.

But addressing our salt habit is only one part of a broader journey in helping Singapore tackle hypertension rates. As well as understanding why salt is so ingrained in our lives, we also need to recognise why “slightly high” blood pressure should not be dismissed, what practical actions can be taken to manage it, and why even the most health-conscious may have underlying conditions that make them susceptible to hypertension.

Cutting salt is not as easy as it sounds

From a nutritionist’s point of view, Nutri-Grade labels are a welcome step – the vast majority of Singaporeans exceed the recommended daily sodium consumption limit of 2,000mg.

Part of the challenge is that salt, sauces and seasonings are woven into the fabric of how Singaporeans eat, defining the taste of our hawker favourites and home-cooked meals. Most of our sodium comes from salt and sauces added during cooking and from meals eaten outside the home, often in amounts we do not see or measure.

Many end up living with a salt-heavy diet, with their taste buds growing accustomed to a greater level of intensity over time. But while our tastes adapt, doctors caution that the same cannot be said for our bodies, and that persistently elevated blood pressure does not come without consequences.

A doctor’s perspective on the realities of ‘slightly high’ blood pressure

Many patients share that they are not too worried because their blood pressure is only “slightly high”. However, any increase in blood pressure, 24 hours a day, 7 days a week, puts unnecessary stress on the body. Elevated pressure damages the arteries and increases the demand on the heart as it is forced to work harder to pump blood efficiently – ultimately increasing the chance of a heart attack.

Similarly, those with elevated blood pressure face a higher risk of stroke, as sustained pressure can damage or block the brain’s arteries.

Chronic kidney disease is another condition triggered by high blood pressure. Even slightly raised readings, if sustained, can injure the kidneys’ delicate blood vessels, impairing their ability to filter waste and remove excess fluid. The resulting fluid retention can push blood pressure higher, creating a vicious circle that accelerates kidney damage and may progress to end-stage kidney disease requiring dialysis.

As most individuals are asymptomatic, even when blood pressure reaches very high levels, hypertension is often dubbed by healthcare practitioners as the “silent killer”. It damages blood vessels, the heart, brain and kidneys over many years, with symptoms often appearing after significant harm is already done.

Hypertension may not just be about lifestyle

Many high blood pressure cases are related to lifestyle and genetics. But in some cases, despite doing everything “right” – from diet to exercise and regular health checks – patients find that their blood pressure remains stubbornly high despite being on medication. This is a crucial moment to ask: Could there be an underlying medical condition?

One important example is aldosterone dysregulation. Aldosterone is a hormone that controls the sodium and potassium levels in the body. When the body produces too much aldosterone, excess salt is retained, even when dietary salt intake is moderate. This form of hypertension is more harmful than the usual and more common than previously thought, especially among people with resistant or difficult-to-control blood pressure, or those with low potassium levels. The good news is that it is often treatable with the right medication, and sometimes curable, in selected cases, with keyhole surgery.

When blood pressure remains high despite lifestyle changes and multiple medications, it is time to look deeper. Patients should feel empowered to ask their doctors whether other underlying causes, including hormone-related conditions like aldosterone excess, should be considered.

Taking ownership of personal health

Taking control of your blood pressure levels does not require waiting for a confirmed diagnosis or making sweeping lifestyle changes overnight.

Practical steps and accessible resources are readily available to help Singaporeans understand their numbers, have more informed conversations with their doctors, and act before a manageable concern becomes a more serious health problem.

• Know your numbers: In general, the lower the better. Ask your doctor: “What is my personal blood pressure target, and why?” Knowing what is normal for you is the first step towards knowing when something needs attention. In general, risks of heart disease and stroke are lower with lower blood pressure levels.

• Make monitoring a routine, not a reaction. A home blood pressure monitor can make it easy for you to track your readings over time without needing to visit the doctor. Build a habit of measuring your blood pressure: once every two years if it is within the normal range (<130 over 85 mmHg), annually if it is borderline high (130-139 over 85-89 mmHg), or weekly if it is high (>140 over 90 mmHg).

• Make healthy habits part of daily life. Exercise regularly, manage stress levels and follow a balanced, heart-healthy diet with more fruits, vegetables, whole grains and lean protein, while limiting salt, sugar and foods high in saturated and trans fats. Instead of trying to overhaul every single aspect of your diet at once, focus on implementing small, sustainable changes.

• Retrain your taste preferences. If you are accustomed to saltier food, gradually reduce the salt, sauces and seasonings in your meals. Over time, your palate will be able to adjust and less salty food can become more enjoyable.

• Use resources that are already available. The Singapore Heart Foundation’s Blood Pressure Awareness Kiosks offer convenient checks and information to help people make sense of their readings. These touchpoints can be especially useful for those who may not otherwise think to monitor their blood pressure.

• Have an honest conversation about medication. For those taking blood pressure medications, having side effects or difficulty following a regimen should not be reasons to stop treatment quietly. Discuss these issues with your doctor; adjustments or a simpler regimen may make it easier to stay on track.

• Look beyond lifestyle when high readings persist. Not every case of hypertension is explained by diet, exercise or stress. If blood pressure remains high despite lifestyle changes or multiple medications, ask whether further assessment for an underlying cause may be appropriate.

• Stay informed with friends and family. Heart-health education should not be reserved for the clinic. Share what you learn about blood pressure with your family, encourage regular blood pressure checks and support healthier habits at home. This awareness can start from young – initiatives such as the Singapore Heart Foundation’s Heart Heroes Programmes help children learn about heart health and bring these lessons home to their families.

The extension of Nutri-Grade is a positive step in the effort to reverse the one-in-three hypertension trend, but ultimately, it is only one part of the story – a broader shift must be catalysed in how we prevent, detect and manage high blood pressure.

The next step is to create an environment in which people are supported to take proactive ownership of their health, instead of passively waiting to see if and when symptoms surface. That culture of prevention will form the foundation for a healthier Singapore, where high blood pressure is identified and addressed before it becomes a lifelong burden.

• Troy Puar is head and senior consultant at Changi General Hospital’s Department of Endocrinology, exco member of the Singapore Hypertension Society, as well as president of the ASEAN Network of Adrenal Hypertension.

• Lim Kiat is a senior nutritionist at the Singapore Heart Foundation. He also serves as its assistant director of strategic partnerships and philanthropy.