Researchers call for formal guidance on salt substitute use for people with hypertension
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Key takeaways:
- A new review recommends most people with hypertension use potassium-enriched salt.
- Researchers called for formal clinical guidance regarding salt substitute use.
Salt substitutes enriched with potassium are a feasible way for people with hypertension to reduce sodium intake long term, yet clinical guidance regarding salt substitute use is lacking, according to a review published in Hypertension.
“There is strong evidence for benefits of potassium-enriched salts but they are very infrequently used,” Bruce Neal, MB, ChB, PhD, FRCP, FAHA, professor of medicine and executive director at The George Institute for Global Health Australia, told Healio. “The absence of recommendations to patients made by clinicians is a key part of the uptake problem. The rationale for the review was that it would provide a summary of current guideline advice to clinicians, identify how the advice needs to be updated, enable us to formulate standard recommended wording for guideline updates, and provide us with an opportunity to highlight the potential for potassium-enriched salts to the clinical community.”
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A simple switch for hypertension
Potassium-enriched, sodium-reduced salt substitutes, or potassium-enriched salts, are products that can be used as a direct switch for regular salt for seasoning, preserving and manufacturing foods. Potassium-enriched salts are made by replacing a proportion of the sodium chloride in regular salt with potassium chloride.
“Sometimes, other nonpotassium substitutes, such as magnesium sulfate, may also be added,” the researchers wrote in Hypertension. “The sodium content of potassium-enriched salts ranges from zero to 100%.”
The researchers noted that evidence supports the replacement of regular salt with potassium-enriched salt in patients with hypertension and that “there is also a case” for recommending salt substitutes for the general population where risks of misuse can be managed.
Current clinical guidelines offer incomplete and inconsistent recommendations about the use of potassium-enriched salt substitutes, as well as reducing dietary sodium intake and increasing dietary potassium intake, according to the review.
“Most cardiology patients would benefit from consuming less sodium,” Neal told Healio. “Many will be given advice to eat less sodium but cardiologists know that very few will achieve a reduction because they find it too difficult to cut salt from their diet. Because it requires changes in cooking, purchasing and dining habits as well as acceptance of a less salty taste. Potassium-enriched salt is a feasible way for patients to reduce sodium intake and can be sustained in the long term because it requires only a switch in the type of salt that is purchased. Patients can use the same quantity, in the same way and it looks just the same. Most people will notice no difference in taste as well.
For the first time, cardiologists have a sodium reduction intervention that it is likely their patients will be able to adhere to, that is likely to reduce their blood pressure and that will lower future cardiovascular risk,” Neal told Healio.
Salt substitute not for everyone
Neal cautioned that cardiologists should not recommend potassium-enriched salt to patients with advanced kidney disease or to those using other medications that elevate blood potassium, where the BP-lowering benefits of potassium-enriched salt might be offset by an increased risk from hyperkalemia.
In the review, the researchers provide “recommended standard wording” for guidance regarding the use of salt substitutes in the diet. It states: “Potassium-enriched salt with a composition of 75% sodium chloride and 25% potassium chloride should be recommended to all patients with hypertension, unless they have advanced kidney disease, are using a potassium supplement, are using a potassium-sparing diuretic, or have another contraindication.”
Neal said the effects of potassium-enriched salt on BP and hard clinical outcomes are “largely proven,” with tens of thousands of people already included in completed large-scale trials.
“The primary research challenges now relate to how to achieve translation of the research into practice and uptake at scale, all around the world,” Neal told Healio. “Research that defines how to address safety concerns related to hyperkalemia risks in general populations will also be helpful for scaling use of potassium-enriched salts to general populations, where reduced sodium intake is likely to attenuate the rise in BP with age and provide protection against the development of high BP in non-hypertensive patients.”
As Healio previously reported, data from the Salt Substitute and Stroke Study (SaSS) presented at the European Society of Cardiology Congress in 2021 demonstrated that switching from regular salt to a salt substitute reduced the risk for stroke, major CV events and death in a large trial of adults in rural China with a history of stroke or high risk for stroke. Among nearly 21,000 adults and over a mean follow-up of 4.74 years, the rate of stroke was 14% lower with use of a salt substitute compared with regular salt.
For more information:
Bruce Neal, MB, ChB, PhD, FRCP, FAHA, can be reached at bneal@georgeinstitute.org.au.
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