World Stroke Organization The Paper of The Month – February
12 Feb 2025Paving the Way for Sodium Reduction Through Lower-Sodium Salt Substitutes
Paving the Way for Sodium Reduction Through Lower-Sodium Salt Substitutes
By Prof. Octavio Marques Pontes-Neto, MD, PHD – WSA Editor-in-Chief
This article is a commentary on the following: Use of lower-sodium salt substitutes: WHO guideline, ISBN 978-92-4-010559-1 (electronic version), ISBN 978-92-4-010560-7 (print version)
Commentary:
In an era where cardiovascular disease (CVD) continues to be a leading cause of mortality worldwide, innovative strategies to mitigate risk factors are essential. The World Health Organization’s (WHO) recent guideline on the use of lower-sodium salt substitutes (LSSS) marks a critical step forward in global public health policy. The evidence it presents has implications for clinical practice, policy, and future research, particularly in the context of stroke prevention and cardiovascular outcomes.
Stroke prevention remains a priority within public health strategies due to its devastating impact on morbidity and mortality. The WHO guideline recommends the use of LSSS containing potassium chloride (KCl) as a replacement for regular sodium chloride (NaCl) in table salt. This recommendation is based on moderate-certainty evidence demonstrating significant reductions in systolic and diastolic blood pressure—key risk factors for CVD and stroke—when LSSS is used. The WHO’s evidence synthesis highlights that LSSS use is associated with a 4.76 mmHg reduction in systolic blood pressure and a 2.43 mmHg reduction in diastolic blood pressure, both of which are meaningful from a clinical perspective. These reductions translate into decreased risks of non-fatal stroke, non-fatal acute coronary syndrome, and cardiovascular death. Although the magnitude of risk reduction in stroke outcomes did not reach conventional statistical significance, the trends suggest potential benefits that warrant further investigation.
A critical aspect of the guideline is its emphasis on safety, particularly concerning hyperkalemia. The guideline excludes individuals with conditions that could impair potassium excretion, such as chronic kidney disease or those on potassium-sparing diuretics. While the evidence suggests little to no difference in hyperkalemia incidence between LSSS and regular salt users, the overall certainty regarding potassium-related adverse events remains moderate. Consequently, implementation strategies must incorporate mechanisms for identifying and monitoring high-risk populations.
The guideline also recognizes socioeconomic disparities in LSSS accessibility, especially in low- and middle-income countries. The higher cost of LSSS compared to regular salt and limited consumer awareness present barriers to widespread adoption. WHO’s conditional recommendation acknowledges the need for context-specific adaptations. For example, national health authorities could consider subsidies, public education campaigns, and regulations to promote LSSS uptake while ensuring safety monitoring in at-risk populations.
Implementing the WHO guideline offers an opportunity to address the persistent challenge of excessive sodium intake. National health systems must align LSSS policies with broader sodium reduction strategies, such as food reformulation and public education. Moreover, future research is needed to fill key knowledge gaps, particularly in children, pregnant women, and individuals with comorbid conditions. Further longitudinal studies and real-world implementation research can provide insights into the long-term efficacy and safety of LSSS at the population level. Implementation of lower-sodium salt substitutes must be in line with country iodisation programs, and iodisation of lower-sodium salt substitutes should continue in the same way as regular salt. Monitoring systems should be established to track sodium and potassium intake and evaluate the impact of LSSS interventions on cardiovascular outcomes.
In conclusion, the WHO’s guideline on LSSS represents an important step forward in addressing one of the most modifiable risk factors for CVD and stroke. It is essential to recognize the potential of LSSS as part of an integrated approach to reduce hypertension and prevent stroke. However, the conditional nature of the recommendation underscores the importance of tailored implementation strategies and ongoing research. By fomenting collaboration among policymakers, clinicians, and researchers, we can optimize the full potential of LSSS to improve global cardiovascular health and reduce the burden of stroke.
References:
Use of lower-sodium salt substitutes: WHO guideline
ISBN 978-92-4-010559-1 (electronic version)
ISBN 978-92-4-010560-7 (print version)
Use of lower-sodium salt substitutes: WHO guideline
Additional Resources:
- Salt Substitution and Recurrent Stroke and Death – A Randomized Clinical Trial: Ding X, Zhang X, Huang L, Xiong S, Li Z, Zhao Y, Zhou B, Yin X, Xu B, Wu Y, Neal B, Tian M, Yan LL. Salt Substitution and Recurrent Stroke and Death: A Randomized Clinical Trial. JAMA Cardiol. 2025 Feb 5:e245417. doi: 10.1001/jamacardio.2024.5417.
- TGI resources for clinicians and product finder: https://www.georgeinstitute.org.au/switchthesalt
- Prof. Bruce Neal’s bio: Bruce Neal | The George Institute for Global Health
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