Salt-Sodium

09 Feb JAMA Cardiology Stroke Study Finds Salt Substitute a Simple Effective Strategy to Reduce Recurrence and Mortality

Posted at 15:14h in Author Interviews, JAMA, Salt-Sodium, Stroke by

MedicalResearch.com Interview with:
Xiong Ding, MPH
School of Public Health
Wuhan University
Wuhan, China

MedicalResearch.com: What is the background for this study?

Response: Stroke is one of the leading causes of death and long-term disability worldwide, particularly in low- and middle-income countries. Patients who have previously experienced a stroke are at high risk of recurrence, and in China, this risk is even higher than the global average. It is well established that high blood pressure is a major risk factor for stroke recurrence, and lowering blood pressure is an effective preventive strategy.

Salt substitutes, which replace part of sodium chloride with potassium chloride, have been shown to lower blood pressure by reducing sodium intake and increasing potassium intake. However, before our study, there was limited direct evidence demonstrating whether salt substitutes could reduce the risk of stroke recurrence and death. Therefore, we conducted this research as part of the Salt Substitute and Stroke Study (SSaSS), specifically focusing on stroke survivors to determine the long-term health effects of salt substitution in this high-risk population.

MedicalResearch.com: What are the main findings?

Response:  We conducted a large-scale randomized controlled trial in 600 rural villages in northern China, involving 15,249 stroke patients. Participants were assigned to use either a salt substitute (75% sodium chloride + 25% potassium chloride) or regular salt (100% sodium chloride), and they were followed for five years. Our main findings include:

  • A 14% reduction in the risk of recurrent stroke among those using salt substitutes (Relative Risk [RR] = 0.86, P = 0.005).
  • A 12% reduction in overall mortality, with a particularly 21% lower risk of stroke-related death (P = 0.01).
  • A modest reduction in systolic blood pressure (~2 mmHg), which is clinically meaningful.
  • No increased risk of hyperkalemia in the salt substitute group (P = 0.96), indicating that it is safe for stroke patients.

Overall, this study provides strong evidence that salt substitution is a safe, low-cost dietary intervention that can significantly reduce stroke recurrence and mortality.

MedicalResearch.com: What should readers take away from your report?

Response: The key takeaway is that salt substitution is a simple, safe, and effective strategy to significantly reduce stroke recurrence and mortality. For individuals with a history of stroke, reducing sodium intake and increasing potassium intake through salt substitutes is a practical and effective way to prevent future strokes.

Importantly, our study shows that salt substitutes can deliver significant health benefits without compromising taste. This makes them an easy and sustainable dietary change for many people. We also demonstrated that even a modest reduction in blood pressure (2 mm Hg) can lead to substantial health improvements at the population level.

Additionally, for those concerned about safety, our findings confirm that salt substitutes are well-tolerated and do not increase the risk of hyperkalaemia in the general population, including those with moderate cardiovascular risk.

MedicalResearch.com: What recommendations do you have for future research as a results of this study?

1. Effects on early-stage chronic kidney disease (CKD): Modeling studies have suggested that salt substitutes may provide net benefits even for CKD patients, and the DECIDE-SALT trial did not exclude CKD patients. However, there is a lack of direct clinical evidence on the benefits and risks of salt substitutes in this population. Since current guidelines advise against salt substitutes only for those with advanced CKD, more research is needed to clarify their safety and effectiveness in patients with early-stage CKD.

2. Implementation research: It is essential to move from evidence to action by exploring how to translate these findings into real-world practice. Implementation research can help identify effective strategies to promote salt substitution on a large scale, addressing challenges such as accessibility, affordability, and public awareness. This research should also examine the roles of policy, healthcare systems, and community engagement in facilitating widespread adoption.

3. Salt substitution in processed and packaged foods: Most current research focuses on discretionary salt use, i.e., salt added during home cooking or at the table. However, in many countries, a significant portion of sodium intake comes from processed and packaged foods. Future studies should investigate the feasibility and health impact of reformulating processed foods with lower-sodium, potassium-enriched alternatives. This would require collaboration with the food industry and policymakers to set and implement sodium reduction targets for commercially processed foods.

MedicalResearch.com: Is there anything else you would like to add? Any disclosures?

Response: Our study highlights that salt substitution is a cost-effective, practical intervention that can save lives by reducing stroke recurrence and mortality. However, achieving widespread adoption will require a multisectoral approach involving government policymakers, healthcare professionals, the food industry, and consumers.

Policymakers can play a crucial role by implementing regulations to encourage the production and use of salt substitutes, supporting public awareness campaigns, and integrating salt substitution into broader sodium reduction strategies. Healthcare professionals should be empowered to recommend salt substitutes to their patients, especially those at high risk of stroke or cardiovascular disease.

Finally, the food industry can contribute by reformulating processed foods with potassium-enriched salt substitutes, helping to reduce hidden sodium in the food supply. Together, these efforts can help more people benefit from this simple yet powerful intervention and move us closer to achieving global sodium reduction targets.

 

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Last Updated on February 9, 2025 by Marie Benz MD FAAD

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