Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study

Abstract

Background: Salt substitution (ie, replacement of table and cooking salt with potassium-enriched salt substitutes) is a promising strategy to reduce blood pressure and prevent cardiovascular disease, particularly in countries like India where there is high sodium intake, mainly from discretionary salt, and low potassium intake. Life-threatening hyperkalemia from increased potassium intake is a postulated concern for individuals with chronic kidney disease. methods: We used comparative risk assessment models to estimate the number of (1) cardiovascular deaths averted due to blood pressure reductions; (2) potential hyperkalemia-related deaths from increased potassium intake in individuals with advanced chronic kidney disease; and (3) net averted deaths from nationwide salt substitution in India. We evaluated a conservative scenario, based on a large, long-term pragmatic trial in rural China; and an optimistic scenario informed by our recent trial in India. Sensitivity analyses were conducted to assess the robustness of the findings. Results: In the conservative scenario, a nationwide salt substitution intervention was estimated to result in ≈214 000 (95% uncertainty interval, 92 764–353 054) averted deaths from blood pressure reduction in the total population and ≈52 000 (22 961–80 211) in 28 million individuals with advanced chronic kidney disease, while ≈22 000 (15 221–31 840) hyperkalemia-deaths might be caused by the intervention. The corresponding estimates for the optimistic scenario were ≈351 000 (130 470–546 255), ≈66 000 (24 925–105 851), and ≈9000 (4251–14 599). Net benefits were consistent across sensitivity analyses. Conclusions: Modeling nationwide salt substitution in India consistently estimated substantial net benefits, preventing around 8% to 14% of annual cardiovascular deaths. Even allowing for potential hyperkalemia risks there were net benefits estimated for individuals with chronic kidney disease.

Dietary sodium/potassium intake and cognitive impairment in older patients with hypertension: Data from NHANES 2011–2014

“…[5][6][7] Additionally, potassium-containing salts have been used as substitutes for sodium. [8][9][10] Many studies have shown that high potassium intake may lower blood pressure and CVD risk partly, [11][12][13] and high potassium intake may mitigate the negative impacts of high sodium intake. 14 Cognitive impairment is linked to cardiovascular risk factors in the general population, 15 and diet is considered an important factor in cognitive function.…”

Potassium-Enriched Salt Substitution as a Population Strategy to Prevent Cardiovascular Disease

“…A second pivotal study is reported in this issue of Hypertension. 2 The researchers modeled the effects of a population-wide intervention in India replacing salt with a potassium enriched salt substitute as used in the China study. The modeling study evaluated the impact of this intervention on cardiovascular disease morbidity and mortality as well as adverse effects from hyperkalemia both in the general population and in those with undiagnosed chronic kidney disease.…”

Knowledge, attitudes, and behaviors related to dietary salt intake and the acceptability of salt substitute among the Australian culturally and linguistically diverse community: An online survey

“…23 Importantly, the nationwide implementation of salt substitution could lead to potential benefits, such as the prevention of approximately one in nine cardiovascular deaths in China, 44 and avoid 8%-14% of annual cardiovascular deaths in India. 45 These findings are relevant to the Australian CALD community, where Australians born overseas in India and China make-up 5% of the total population. 46 Notably, over 40% of our survey respondents had previously heard of or had used a salt substitute, which was higher than the 5.9% of participants in the SSaSS 23 and none in the SSiIS study.…”

“…The China Salt Substitute and Stroke Study (SSaSS) demonstrated that using potassium‐enriched salt substitute significantly lowers the risk of stroke by 14% and death by 12% among 20 995 Chinese individuals 23 . Importantly, the nationwide implementation of salt substitution could lead to potential benefits, such as the prevention of approximately one in nine cardiovascular deaths in China, 44 and avoid 8%–14% of annual cardiovascular deaths in India 45 . These findings are relevant to the Australian CALD community, where Australians born overseas in India and China make‐up 5% of the total population 46 .…”