High blood pressure is one of the clearest dietary drivers of cardiovascular disease. For decades, public-health messages have emphasised the same simple advice: eat less salt. But “less salt” is easier said than done — sodium is everywhere, baked into processed foods and hidden in restaurant meals.
Over the last decade an alternative strategy has gained momentum: not only reduce sodium, but replace some of it with potassium. These products — broadly called low sodium substitutes or potassium-enriched salt substitutes — have now been investigated.
This article reviews the clinical research and also answers the following questions:
- Does adding salt to Your meals increase Your risk of heart attack and heart failure?
- How SALT affects Your BLOOD PRESSURE?
- What are the effects of SALT Substitutes on Heart Health?
Take home messages:
- Replacing ordinary salt (sodium chloride) with potassium-enriched salt substitutes lowers blood pressure and — in large randomized trials — reduced stroke, major cardiovascular events and all-cause mortality.
https://www.nejm.org/doi/full/10.1056/NEJMoa2105675?utm
- A major cluster randomized trial (the SSaSS study) in China found a salt substitute (≈25% potassium chloride) reduced cardiovascular events.
https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.123.22410
- Much of the effect appears driven by increased potassium intake rather than sodium reduction alone. That is, potassium salt benefits extend beyond simply cutting sodium.
https://www.nature.com/articles/s41371-024-00896-4?utm_
- Patients with advanced kidney disease, those taking potassium-sparing medicines, or those on high-dose potassium supplements need caution — potassium excess (hyperkalemia) is the major safety concern.
https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.119.13241
- Global health organisations (including WHO) now support replacing regular table salt with lower-sodium, potassium-enriched alternatives as a population strategy — but implementation should include warnings for at-risk groups.
https://www.who.int/news-room/fact-sheets/detail/sodium-reduction?utm_
Why replace salt instead of just eating less of it?
Sodium (Na⁺) raises blood pressure by increasing fluid retention and altering vascular function; high BP is a leading risk factor for stroke, coronary heart disease and heart failure. Public health campaigns and reformulation efforts have had some success in reducing sodium intake in places where processed food producers cooperate, but globally average intake remains well above recommended levels.
A high proportion of sodium in our diet comes from processed foods and restaurants, not the saltshaker.
A complementary, pragmatic strategy is to swap regular table salt for low sodium substitutes — blends where a portion of sodium chloride is replaced with potassium chloride.
Why potassium? As an electrolyte, potassium opposes many of sodium’s harmful cardiovascular effects. In the case of salt substitutes, the benefit comes from both lowering sodium and increasing potassium.
Research Evidence
The Salt Substitute and Stroke Study (SSaSS) (NEJM, 2021)
The most influential randomized evidence is the Salt Substitute and Stroke Study (SSaSS), a cluster-randomized trial that enrolled about 21,000 adults in rural China and followed them for ~5 years. Households were randomized to receive a salt substitute (about 75% sodium chloride + 25% potassium chloride) or continue with regular salt. The trial found that the salt substitute group had a significant reduction in stroke, major cardiovascular events and all-cause mortality compared with regular salt. Crucially, the trial also demonstrated systolic BP reductions, and the investigators reported no overall increase in clinically detected hyperkalemia events in the population they studied (people with severe kidney disease were largely excluded).
https://www.nejm.org/doi/full/10.1056/NEJMoa2105675?utm_
Meta-analyse and systematic review
Published in 2022 concluded, that the use of a salt substitute significantly lowers blood pressure and reduces all-cause mortality. Incorporating salt substitutes into the daily diet offers an effective, non-pharmacological approach to improving blood pressure control.
https://pubmed.ncbi.nlm.nih.gov/36196475/
Recent secondary and subgroup analyses
Secondary analyses of SSaSS and related studies have explored whether the benefit differs by age, baseline blood pressure, or medication use; several analyses suggest the greatest absolute benefit is in higher-risk groups (older adults, people with hypertension). Analyses attempting to separate the sodium-reduction effect from the potassium-increase effect suggest a substantial portion of the BP and outcome benefit is driven by the potassium component. In other words, potassium salt benefits are not just theoretical — they appear to be major contributors to improved outcomes.
https://www.nature.com/articles/s41371-024-00896-4?utm_
Mechanisms: how does a salt substitute improve heart health?
There are two complementary mechanisms:
- Lower sodium intake — reduces fluid retention and lowers blood pressure, which in turn reduces the risk of stroke and heart disease. Even modest average reductions in systolic BP at the population level translate into meaningful declines in stroke and heart attack rates.
- Higher potassium intake — potassium directly affects vascular tone, sodium excretion, and counteracts sodium’s pressor effects.
Physiologically, increased dietary potassium enhances natriuresis (sodium excretion), improves endothelial function, and modulates sympathetic activity — all cardioprotective effects.
Benefits quantified: how big are the effects?
- Blood pressure: Randomized trials and meta-analyses generally find modest but clinically meaningful reductions in systolic BP (commonly a few mmHg on average). Even small average BP reductions across a population materially reduce stroke incidence. PMC
- Stroke and cardiovascular events: The SSaSS trial reported a reduction in stroke incidence and a composite of major cardiovascular events; pooled meta-analyses also show lower rates of total mortality and cardiovascular outcomes in salt-substitute users. Exact effect sizes vary by study and population, but the direction is consistent.
Risks and safety — the hyperkalemia (high potassium levels) question
The major safety concern with potassium-enriched salt is hyperkalemia (dangerously high blood potassium), which can cause cardiac arrhythmias. Several important caveats:
- Trials typically excluded people with advanced chronic kidney disease (CKD) and those taking potassium-sparing agents.
Who should (and should not) use potassium-enriched or low-sodium substitutes?
Good candidates:
- Adults at risk of high blood pressure or cardiovascular disease who do not have advanced kidney disease, and who are not taking potassium-raising medications. These people are most likely to gain net benefit. New England Journal of MedicinePMC
Exercise caution / consult a clinician:
- Patients with Chronic Kidney Disease (moderate to severe), those on ACE inhibitors, ARBs, spironolactone/eplerenone, potassium supplements, or those with other conditions affecting potassium handling. For these patients, a personalized risk assessment is essential before switching.
Practical options: what are the alternatives to regular salt?
When people talk about sodium alternatives, they usually mean one (or more) of the following:
- Potassium-enriched salt substitutes (common composition: ~70–80% NaCl + 20–30% KCl). These are the products tested in trials like SSaSS. They taste similar to salt and can be used in home cooking and at the table. New England Journal of Medicine
- Low-sodium sea salts and “lite” salts — marketing names vary; these may be mostly NaCl but with reduced sodium content or added minerals.
Further useful recommendations can be also found on this WHO website:
https://www.who.int/news-room/fact-sheets/detail/sodium-reduction?utm_
Policy implications: population strategies vs individual risk
Population-level interventions often yield large public health gains even when per-person effects are modest. In that light, replacing regular salt with potassium-enriched salt substitutes may be attractive.
However, implementation must be paired with safety measures: clear labelling, education for clinicians and patients, and targeted screening for people with CKD or on potassium-raising drugs.
Simulation studies indicate the overall population net benefit is large.
https://www.bmj.com/content/369/bmj.m824?utm_
But even small excess harms in vulnerable subgroups should be anticipated and mitigated through careful policy design.
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2825%2900235-9/fulltext?utm_
Frequently asked questions
- Are potassium salts as tasty as regular salt?
A: Many people find potassium-enriched salts close enough in flavour for everyday use; some detect a slight metallic or bitter aftertaste at higher KCl proportions. Manufacturers sometimes add flavour enhancers to improve palatability. Clinical trials used products that participants accepted for household cooking. - What about iodine?
A: Many table salts are iodized to prevent iodine deficiency. Some salt substitutes are not iodized. WHO recommends ensuring iodine intake is maintained (either through iodized salt substitutes or other iodine sources).
https://www.who.int/news-room/fact-sheets/detail/sodium-reduction?utm_
Conclusion
Can we reduce cardiovascular risk and prevent `Salt heart disease` by using `Smart Salt`? The clinical evidence — mainly from the SSaSS trial and supported by systematic reviews — says yes: replacing a portion of sodium chloride with potassium chloride in discretionary salt lowers blood pressure and has been associated with reductions in stroke, cardiovascular events and mortality in trial settings. Those findings have pushed global organisations, including WHO, to endorse the use of potassium-enriched, lower-sodium salt substitutes as part of broader sodium-reduction strategies.
However, safety is important. Patients with advanced kidney disease, or those on potassium-raising medications, are at genuine risk of hyperkalemia (high potassium levels), so implementation must be accompanied by targeted screening, blood tests monitoring where appropriate, and clear product labelling. Done thoughtfully, population-level salt substitution promises a low-cost, scalable tool to reduce the burden of salt heart disease across the world; done carelessly, it risks avoidable harms in vulnerable subgroups.
Additional Questions:
Does adding salt to Your meals increase Your risk of heart attack and heart failure?
– This study ⬇️ published in December 2022 in the Journal of the American College of Cardiology showed that the answer is *YES*.
https://www.jacc.org/doi/epdf/10.1016/j.jacc.2022.09.039
– The researchers included 175670 participants who did not have any prior cardiovascular disease diagnosed and followed them up for a median of 11.8 years.
– They recorded 9963 cardiovascular events including:
– 6993 cases of ischaemic heart disease (angina and heart attacks)
– 2269 of the study participants suffered with heart failure
– 2007 had a stroke
– Lower frequency of additional salt was linked to lower incidence of cardiovascular events.
– The recruited individuals were divided into three groups depending on adding salt frequency – usually, sometimes and never/rarely with Hazard Ratio of 0.81, 0.79 and 0.77 respectively (p<0.001).
– Interestingly, additional salt intake had the strongest link to heart failure, followed by coronary heart disease but was not associated with stroke.
How SALT affects Your BLOOD PRESSURE?
– One week of low salt diet caused a decrease of 8mmHg in participants’ Blood Pressure in comparison to high salt intake.
– This is a similar effect to an Antihypertensive medication.
– This was an American study, conducted between April 2021 and February 2023, published in JAMA in November 2023.
– Over 200 participants, aged 50-75 years were included.
– Interestingly, there was a wide variation in individuals enrolled in terms of underlying diagnoses, with 25% having normal blood pressure, 25% unteated hypertension, 20% controlled hypertension and just over 30% poorly controlled hypertension.
– In this study, low-sodium diet = 500mg daily, high-sodium diet = 2200 mg daily.
– The effect of low salt diet was seen in 75% of participants.
– More details in the article below ⬇️:
https://jamanetwork.com/journals/jama/article-abstract/2811931
– The Authors concluded:
‘Dietary sodium reduction significantly lowered BP in the majority of middle-aged to elderly adults. The decline in BP from a high- to low-sodium diet was independent of hypertension status and antihypertensive medication use, was generally consistent across subgroups, and did not result in excess adverse events.’
What are the effects of SALT Substitutes on Heart Health?
Recently (April 2024) published meta-analysis showed that Salt Substitutes:
– may reduce risk of all-cause and cardiovascular mortality (low certainty)
– may cause slight reduction in Major Adverse Cardiovascular Events (very low certainty)
– This data included 16 randomised controlled trials. Of which 8 reported mortality, major adverse cardiovascular events and adverse events at 6 months or more. 7 out of 8 were done in China or Taiwan and included participants with a mean age of 62 years old.
– The authors concluded: ‘Salt substitution may reduce all-cause or cardiovascular mortality, but the evidence for reducing cardiovascular events and for not increasing serious adverse events is uncertain, particularly for a Western population. The certainty if evidence is higher among populations at higher cardiovascular risk and/or following a Chinese diet.’
– Link to the article below:
