Replacing salt with low-sodium salt substitutes (LSSS) for cardiovascular health in adults, children and pregnant women

Abstract

Background Elevated blood pressure, or hypertension, is the leading cause of preventable deaths globally. Diets high in sodium (predominantly sodium chloride) and low in potassium contribute to elevated blood pressure. The WHO recommends decreasing mean population sodium intake through effective and safe strategies to reduce hypertension and its associated disease burden. Incorporating low‐sodium salt substitutes (LSSS) into population strategies has increasingly been recognised as a possible sodium reduction strategy, particularly in populations where a substantial proportion of overall sodium intake comes from discretionary salt. The LSSS contain lower concentrations of sodium through its displacement with potassium predominantly, or other minerals. Potassium‐containing LSSS can potentially simultaneously decrease sodium intake and increase potassium intake. Benefits of LSSS include their potential blood pressure‐lowering effect and relatively low cost. However, there are concerns about potential adverse effects of LSSS, such as hyperkalaemia, particularly in people at risk, for example, those with chronic kidney disease (CKD) or taking medications that impair potassium excretion. Objectives To assess the effects and safety of replacing salt with LSSS to reduce sodium intake on cardiovascular health in adults, pregnant women and children. Search methods We searched MEDLINE (PubMed), Embase (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection (Clarivate Analytics), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to 18 August 2021, and screened reference lists of included trials and relevant systematic reviews. No language or publication restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and prospective analytical cohort studies in participants of any age in the general population, from any setting in any country. This included participants with non‐communicable diseases and those taking medications that impair potassium excretion. Studies had to compare any type and method of implementation of LSSS with the use of regular salt, or no active intervention, at an individual, household or community level, for any duration. Data collection and analysis Two review authors independently screened titles, abstracts and full‐text articles to determine eligibility; and extracted data, assessed risk of bias (RoB) using the Cochrane RoB tool, and assessed the certainty of the evidence using GRADE. We stratified analyses by adults, children (≤ 18 years) and pregnant women. Primary effectiveness outcomes were change in diastolic and systolic blood pressure (DBP and SBP), hypertension and blood pressure control; cardiovascular events and cardiovascular mortality were additional...

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.…”

“…Properly managing sodium intake is a highly effective way to significantly reduce the risk of cardiovascular disease, and dietary sodium intake has been considered a common modifiable risk factor for hypertension 5–7 . Additionally, potassium‐containing salts have been used as substitutes for sodium 8–10 . Many studies have shown that high potassium intake may lower blood pressure and CVD risk partly, 11–13 and high potassium intake may mitigate the negative impacts of high sodium intake 14 …”

Physical activity and nutrition in chronic kidney disease

“…However, these trials excluded people known to be at high risk of hyperkalaemia, such as people with chronic kidney disease, diabetes or on potassium-sparing medications. Pooled analysis of seven trials included people possibly at risk of hyperkalaemia demonstrated a small increase in serum potassium with a mean difference 0.12 mmol/L higher in those using LSSS [33]. The risk versus benefits of salt substitutes in moderate-to-advanced chronic kidney disease population will need further evaluation.…”

Potassium Intake Linked With Heart Benefits

“…The team published the results in the Cochrane Database of Systematic Reviews in August 2022. 3 On the basis of pooled data from ≈2 dozen randomized controlled trials that enrolled nearly 21 000 people, most of whom had elevated blood pressure, the researchers found an association between the substitutes and reduced blood pressure. They found that using salt substitutes reduced systolic blood pressure by an average of 4.76 mm Hg and diastolic blood pressure by 2.43 mm Hg.…”