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. 2022 Aug 10;8(8):CD015207.
doi: 10.1002/14651858.CD015207.

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

Amanda Brand  1 , Marianne E Visser  1 , Anel Schoonees  1 , Celeste E Naude  1
Affiliations

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

Amanda Brand et al. Cochrane Database Syst Rev. .

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 additionally assessed as primary effectiveness outcomes in adults. Primary safety outcomes were change in blood potassium, hyperkalaemia and hypokalaemia.

Main results: We included 26 RCTs, 16 randomising individual participants and 10 randomising clusters (families, households or villages). A total of 34,961 adult participants and 92 children were randomised to either LSSS or regular salt, with the smallest trial including 10 and the largest including 20,995 participants. No studies in pregnant women were identified. Studies included only participants with hypertension (11/26), normal blood pressure (1/26), pre-hypertension (1/26), or participants with and without hypertension (11/26). This was unknown in the remaining studies. The largest study included only participants with an elevated risk of stroke at baseline. Seven studies included adult participants possibly at risk of hyperkalaemia. All 26 trials specifically excluded participants in whom an increased potassium intake is known to be potentially harmful. The majority of trials were conducted in rural or suburban settings, with more than half (14/26) conducted in low- and middle-income countries. The proportion of sodium chloride replacement in the LSSS interventions varied from approximately 3% to 77%. The majority of trials (23/26) investigated LSSS where potassium-containing salts were used to substitute sodium. In most trials, LSSS implementation was discretionary (22/26). Trial duration ranged from two months to nearly five years. We assessed the overall risk of bias as high in six trials and unclear in 12 trials. LSSS compared to regular salt in adults: LSSS compared to regular salt probably reduce DBP on average (mean difference (MD) -2.43 mmHg, 95% confidence interval (CI) -3.50 to -1.36; 20,830 participants, 19 RCTs, moderate-certainty evidence) and SBP (MD -4.76 mmHg, 95% CI -6.01 to -3.50; 21,414 participants, 20 RCTs, moderate-certainty evidence) slightly. On average, LSSS probably reduce non-fatal stroke (absolute effect (AE) 20 fewer/100,000 person-years, 95% CI -40 to 2; 21,250 participants, 3 RCTs, moderate-certainty evidence), non-fatal acute coronary syndrome (AE 150 fewer/100,000 person-years, 95% CI -250 to -30; 20,995 participants, 1 RCT, moderate-certainty evidence) and cardiovascular mortality (AE 180 fewer/100,000 person-years, 95% CI -310 to 0; 23,200 participants, 3 RCTs, moderate-certainty evidence) slightly, and probably increase blood potassium slightly (MD 0.12 mmol/L, 95% CI 0.07 to 0.18; 784 participants, 6 RCTs, moderate-certainty evidence), compared to regular salt. LSSS may result in little to no difference, on average, in hypertension (AE 17 fewer/1000, 95% CI -58 to 17; 2566 participants, 1 RCT, low-certainty evidence) and hyperkalaemia (AE 4 more/100,000, 95% CI -47 to 121; 22,849 participants, 5 RCTs, moderate-certainty evidence) compared to regular salt. The evidence is very uncertain about the effects of LSSS on blood pressure control, various cardiovascular events, stroke mortality, hypokalaemia, and other adverse events (very-low certainty evidence). LSSS compared to regular salt in children: The evidence is very uncertain about the effects of LSSS on DBP and SBP in children. We found no evidence about the effects of LSSS on hypertension, blood pressure control, blood potassium, hyperkalaemia and hypokalaemia in children.

Authors' conclusions: When compared to regular salt, LSSS probably reduce blood pressure, non-fatal cardiovascular events and cardiovascular mortality slightly in adults. However, LSSS also probably increase blood potassium slightly in adults. These small effects may be important when LSSS interventions are implemented at the population level. Evidence is limited for adults without elevated blood pressure, and there is a lack of evidence in pregnant women and people in whom an increased potassium intake is known to be potentially harmful, limiting conclusions on the safety of LSSS in the general population. We also cannot draw firm conclusions about effects of non-discretionary LSSS implementations. The evidence is very uncertain about the effects of LSSS on blood pressure in children.

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Conflict of interest statement

AB: partly supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies; partial support paid to my institution for a scoping review on total fat intake and health outcomes other than measures of unhealthy weight gain (2020); a systematic review on low sodium salt substitutes and cardiovascular health (2020‐2021); rapid scoping reviews on coconut and palm oil intake and cardiovascular health (2021); a scoping review on the health effects of tropical oil consumption (2022).

MV: partly supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies; partial support paid to my institution for a scoping review on total fat intake and health outcomes other than measures of unhealthy weight gain (2020); a systematic review on low sodium salt substitutes and cardiovascular health (2020‐2021); rapid scoping reviews on coconut and palm oil intake and cardiovascular health (2021); a scoping review on health effects of tropical oil consumption (2022).

AS: partly supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies.

CN: partly supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies; partial support paid to my institution for a scoping review on total fat intake and health outcomes other than measures of unhealthy weight gain; a systematic review on low sodium salt substitutes and cardiovascular health; rapid scoping reviews on coconut and palm oil intake and cardiovascular health; a scoping review on the health effects of tropical oil consumption.

*CN is Co‐director of Cochrane Nutrition, and AB and MV are members of the Cochrane Nutrition local coordination team. These authors had no involvement in the editorial process for this review.

Figures

1
1
PRISMA flow diagram
2
2
Summary of the risk of bias judgements for each included study
3
3
Summary of the judgements per risk of bias domain
4
4
Funnel plot for change in DBP (Analysis 1.1) in comparison 1
5
5
Funnel plot for change in SBP (Analysis 1.14) in comparison 1
1.1
1.1. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 1: Change in DBP (mmHg)
1.2
1.2. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 2: Change in DBP (mmHg); subgroup study duration
1.3
1.3. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 3: Change in DBP (mmHg); subgroup age
1.4
1.4. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 4: Change in DBP (mmHg); subgroup gender
1.5
1.5. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 5: Change in DBP (mmHg); subgroup ethnicity
1.6
1.6. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 6: Change in DBP (mmHg); subgroup BMI
1.7
1.7. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 7: Change in DBP (mmHg); subgroup blood pressure status
1.8
1.8. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 8: Change in DBP (mmHg); subgroup LSSS implementation
1.9
1.9. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 9: Change in DBP (mmHg); subgroup type of LSSS
1.10
1.10. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 10: Change in DBP (mmHg); subgroup baseline sodium excretion (mmol/24‐h)
1.11
1.11. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 11: Change in DBP (mmHg); subgroup baseline potassium excretion (mmol/24‐h)
1.12
1.12. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 12: Change in DBP (mmHg); sensitivity analysis: study quality
1.13
1.13. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 13: Change in DBP (mmHg); sensitivity analysis: study design
1.14
1.14. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 14: Change in DBP (mmHg) stepped‐wedge trial
1.15
1.15. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 15: Change in SBP (mmHg)
1.16
1.16. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 16: Change in SBP (mmHg); subgroup study duration
1.17
1.17. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 17: Change in SBP (mmHg); subgroup age
1.18
1.18. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 18: Change in SBP (mmHg); subgroup gender
1.19
1.19. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 19: Change in SBP (mmHg); subgroup ethnicity
1.20
1.20. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 20: Change in SBP (mmHg); subgroup BMI
1.21
1.21. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 21: Change in SBP (mmHg); subgroup blood pressure status
1.22
1.22. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 22: Change in SBP (mmHg); subgroup LSSS implementation
1.23
1.23. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 23: Change in SBP (mmHg); subgroup type of LSSS
1.24
1.24. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 24: Change in SBP (mmHg); subgroup baseline sodium excretion (mmol/24‐h)
1.25
1.25. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 25: Change in SBP (mmHg); subgroup baseline potassium excretion (mmol/24‐h)
1.26
1.26. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 26: Change in SBP (mmHg); sensitivity analysis: study quality
1.27
1.27. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 27: Change in SBP (mmHg); sensitivity analysis: study design
1.28
1.28. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 28: Change in SBP (mmHg), stepped‐wedge trial
1.29
1.29. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 29: Hypertension (as reported, or SBP > 140 mmHg or DBP > 85 mmHg)
1.30
1.30. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 30: Hypertension (as reported, or SBP > 140 mmHg or DBP > 85 mmHg), stepped‐wedge trial
1.31
1.31. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 31: Blood pressure control (achieving blood pressure threshold or 'control' as prespecified)
1.32
1.32. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 32: Cardiovascular events: various events
1.33
1.33. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 33: Cardiovascular events: non‐fatal stroke
1.34
1.34. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 34: Cardiovascular events: non‐fatal stroke; sensitivity analysis: study quality
1.35
1.35. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 35: Cardiovascular events: non‐fatal stroke; sensitivity analysis: study design
1.36
1.36. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 36: Cardiovascular events: non‐fatal acute coronary syndrome
1.37
1.37. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 37: Cardiovascular mortality
1.38
1.38. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 38: Cardiovascular mortality; sensitivity analysis: study quality
1.39
1.39. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 39: Stroke mortality
1.40
1.40. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 40: Change in blood potassium (mmol/L)
1.41
1.41. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 41: Change in blood potassium (mmol/L); subgroup risk of hyperkalaemia
1.42
1.42. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 42: Change in blood potassium (mmol/L); sensitivity analysis: study quality
1.43
1.43. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 43: Change in blood potassium (mmol/L); sensitivity analysis: study design
1.44
1.44. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 44: Hyperkalaemia (> 5.5 mmol/L, or as reported by study authors)
1.45
1.45. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 45: Hyperkalaemia (> 5.5 mmol/L, or as reported by study authors); subgroup risk of hyperkalaemia
1.46
1.46. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 46: Hyperkalaemia (> 5.5 mmol/L, or as reported by study authors); sensitivity analysis: study quality
1.47
1.47. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 47: Hyperkalaemia (> 5.5 mmol/L, or as reported by study authors); sensitivity analysis: study design
1.48
1.48. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 48: Hypokalaemia (< 3.5 mmol/L, or as reported by study authors)
1.49
1.49. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 49: All‐cause mortality
1.50
1.50. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 50: Adverse events: other
1.51
1.51. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 51: Adverse events: other; subgroup risk of hyperkalaemia
1.52
1.52. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 52: Antihypertensive medication use
1.53
1.53. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 53: Antihypertensive medication use; subgroup study duration
1.54
1.54. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 54: Antihypertensive medication use; subgroup age
1.55
1.55. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 55: Antihypertensive medication use; subgroup gender
1.56
1.56. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 56: Antihypertensive medication use; subgroup BMI
1.57
1.57. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 57: Antihypertensive medication use; subgroup blood pressure status
1.58
1.58. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 58: Change in BMI (kg/m2)
1.59
1.59. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 59: Change in serum creatinine (µmol/L)
1.60
1.60. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 60: Change in serum creatinine (µmol/L); subgroup risk of hyperkalaemia
1.61
1.61. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 61: Microalbuminuria
1.62
1.62. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 62: Macroalbuminuria
1.63
1.63. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 63: Change in urinary albumin‐to‐creatinine ratio (uACR)
1.64
1.64. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 64: Change in fasting blood glucose (mmol/L)
1.65
1.65. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 65: Change in blood triglycerides (mmol/L)
1.66
1.66. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 66: Change in blood triglycerides (mmol/L); subgroup study duration
1.67
1.67. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 67: Change in blood triglycerides (mmol/L); subgroup age
1.68
1.68. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 68: Change in blood triglycerides (mmol/L); subgroup ethnicity
1.69
1.69. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 69: Change in blood triglycerides (mmol/L); subgroup BMI
1.70
1.70. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 70: Change in blood triglycerides (mmol/L); subgroup blood pressure status
1.71
1.71. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 71: Change in blood triglycerides (mmol/L); subgroup LSSS implementation
1.72
1.72. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 72: Change in blood triglycerides (mmol/L); subgroup type of LSSS
1.73
1.73. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 73: Change in blood triglycerides (mmol/L); subgroup baseline sodium excretion (mmol/24‐h)
1.74
1.74. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 74: Change in blood triglycerides (mmol/L); subgroup baseline potassium excretion (mmol/24‐h)
1.75
1.75. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 75: Change in total blood cholesterol (mmol/L)
1.76
1.76. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 76: Change in total blood cholesterol (mmol/L); subgroup study duration
1.77
1.77. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 77: Change in total blood cholesterol (mmol/L); subgroup age
1.78
1.78. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 78: Change in total blood cholesterol (mmol/L); subgroup ethnicity
1.79
1.79. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 79: Change in total blood cholesterol (mmol/L); subgroup BMI
1.80
1.80. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 80: Change in total blood cholesterol (mmol/L); subgroup blood pressure status
1.81
1.81. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 81: Change in total blood cholesterol (mmol/L); subgroup LSSS implementation
1.82
1.82. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 82: Change in total blood cholesterol (mmol/L); subgroup type of LSSS
1.83
1.83. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 83: Change in total blood cholesterol (mmol/L); subgroup baseline sodium excretion (mmol/24‐h)
1.84
1.84. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 84: Change in total blood cholesterol (mmol/L); subgroup baseline potassium excretion (mmol/24‐h)
1.85
1.85. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 85: Change in 24‐h urinary sodium excretion (mmol/24‐h)
1.86
1.86. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 86: Change in 24‐h urinary sodium excretion (mmol/24‐h) stepped‐wedge trial
1.87
1.87. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 87: Change in 24‐h urinary potassium excretion (mmol/24‐h)
1.88
1.88. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 88: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup study duration
1.89
1.89. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 89: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup age
1.90
1.90. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 90: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup gender
1.91
1.91. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 91: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup ethnicity
1.92
1.92. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 92: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup BMI
1.93
1.93. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 93: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup blood pressure status
1.94
1.94. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 94: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup LSSS implementation
1.95
1.95. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 95: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup type of LSSS
1.96
1.96. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 96: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup baseline sodium excretion (mmol/24‐h)
1.97
1.97. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 97: Change in 24‐h urinary potassium excretion (mmol/24‐h); subgroup baseline potassium excretion (mmol/24‐h)
1.98
1.98. Analysis
Comparison 1: Low‐sodium salt substitutes versus regular salt or no active intervention in adults, Outcome 98: Change in 24‐h urinary potassium excretion (mmol/24‐h) stepped‐wedge trial
2.1
2.1. Analysis
Comparison 2: Low‐sodium salt substitutes versus regular salt or no active intervention in children, Outcome 1: Change in DBP (mmHg) at > 3 to 12 months
2.2
2.2. Analysis
Comparison 2: Low‐sodium salt substitutes versus regular salt or no active intervention in children, Outcome 2: Change in SBP (mmHg) at > 3 to 12 months
2.3
2.3. Analysis
Comparison 2: Low‐sodium salt substitutes versus regular salt or no active intervention in children, Outcome 3: Change in BMI (kg/m2) at > 3 to 12 months
2.4
2.4. Analysis
Comparison 2: Low‐sodium salt substitutes versus regular salt or no active intervention in children, Outcome 4: Change in 24‐h urinary sodium (mmol/24‐h)
2.5
2.5. Analysis
Comparison 2: Low‐sodium salt substitutes versus regular salt or no active intervention in children, Outcome 5: Change in 24‐h urinary potassium (mmol/24‐h)
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References

References to studies included in this review

Allaert 2013 {published data only}
    1. Allaert FA. Double-blind, randomized, crossover, controlled clinical trial of NaCl + Chitosan 3% versus NaCl on mild or moderate high blood pressure during the diet and lifestyle improvement period before possible prescription of an antihypertensive treatment. International Angiology 2013;32(1):94-101. - PubMed
Allaert 2017 {published data only}
    1. Allaert FA. Double blind, randomized, controlled clinical trial of NaCl + Chitosan 3% vs. NaCl on the decrease of blood pressure induced by a low salt diet in healthy prehypertensive volunteers. Archives of Cardiovascular Diseases Supplements 2019;11(Suppl.3):e372. [DOI: 10.1016/j.acvdsp.2019.05.098] - DOI
    1. Allaert FA. Effect of NaCl + Chitosan 3% vs. NaCl on high blood pressure parameters of healthy volunteers with prehypertension. Minerva Cardioangiologica 2017;65(6):563-76. [DOI: 10.23736/S0026-4725.17.04451-6] - DOI - PubMed
Arzilli 1986 {published data only}
    1. Arzilli F, Taddei S, Graziadei L, Bichisao E, Giovannetti R, Salvetti A. Potassium-rich and sodium-poor salt reduces blood pressure in hospitalized patients. Journal of Hypertension 1986;4(5 Suppl 1):S347-50. - PubMed
Bernabe‐Ortiz 2014 {published data only}
    1. Bernabe-Ortiz A, Diez-Canseco F, Gilman RH, Cárdenas MK, Sacksteder KA, Miranda JJ. Launching a salt substitute to reduce blood pressure at the population level: a cluster randomized stepped wedge trial in Peru. Trials 2014;15:93. [DOI: 10.1186/1745-6215-15-93] - DOI - PMC - PubMed
    1. Bernabe-Ortiz A, Sal y Rosas VG, Ponce-Lucero V, Cárdenas MK, Carrillo-Larco RM, Diez-Canseco F, et al. Effect of salt substitution on community-wide blood pressure and hypertension incidence. Nature Medicine 2020;26:374-8. [DOI: 10.1038/s41591-020-0754-2] - DOI - PMC - PubMed
    1. NCT01960972. Launching a salt substitute to reduce blood pressure at the population level in Peru. clinicaltrials.gov/ct2/show/NCT01960972 (first received 11 October 2013).
Chang 2006 {published data only}
    1. Chang H-Y, Hu Y-W, Yue C-S, Wen Y-W, Yeh W-T, Hsu L-S, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. American Journal of Clinical Nutrition 2006;83(6):1289-96. [DOI: 10.1093/ajcn/83.6.1289] - DOI - PubMed
    1. Chang H-Y, Pan W-H. Reply to CK Chow. American Journal of Clinical Nutrition 2006;84(6):1553-4. [DOI: 10.1093/ajcn/84.6.1553] - DOI - PubMed
    1. Chow CK. Does potassium-enriched salt or sodium reduction reduce cardiovascular mortality and medical expenses? American Journal of Clinical Nutrition 2006;84(6):1552-3. [DOI: 10.1093/ajcn/84.6.1552] - DOI - PubMed
CSSS Collaborative Group 2007 {published data only}
    1. China Salt Substitute Study Collaborative Group. Salt substitution: a low-cost strategy for blood pressure control among rural Chinese. A randomized, controlled trial. Journal of Hypertension 2007;25(10):2011-8. [DOI: 10.1097/HJH.0b013e3282b9714b] - DOI - PubMed
    1. He FJ, MacGregor GA. Can a low-sodium, high-potassium salt substitute reduce blood pressure in rural Chinese people? Nature Reviews Cardiology 2008;5(4):186-7. [DOI: 10.1038/ncpcardio1122] - DOI - PubMed
    1. Hu J, Jiang X, Li N, Yu X, Perkovic V, Chen B, et al. Effects of salt substitute on pulse wave analysis among individuals at high cardiovascular risk in rural China: a randomized controlled trial. Hypertension Research 2009;32(4):282-8. [DOI: 10.1038/hr.2009.7] - DOI - PubMed
    1. Jiang X, Hu J, Li N, Wu Y. Effects of a reduced sodium increased potassium salt substitute on periphral and central blood pressure among high risk individuals in rural China: a randomised controlled trial. Journal of Hypertension 2009;27 Suppl 4:S276.
    1. Li N, Prescott J, Wu Y, Barzi F, Yu X, Zhao L, et al, China Salt Substitute Study Collaborative Group. The effects of a reduced-sodium, high-potassium salt substitute on food taste and acceptability in rural northern China. British Journal of Nutrition 2009;101(7):1088-93. [DOI: 10.1017/S0007114508042360] - DOI - PubMed
Geleijnse 1994 {published data only}
    1. Geleijnse JM, Witteman JC, Bak AA, Den Breeijen JH, Grobbee DE. Long-term moderate sodium restriction does not adversely affect the serum HDL/total cholesterol ratio. Journal of Human Hypertension 1995;9(12):975-9. - PubMed
    1. Geleijnse JM, Witteman JC, Bak AA, Den Breeijen JH, Grobbee DE. Reducing blood pressure by use of a low sodium high potassium, high magnesium mineral salt in older persons with mild to moderate hypertension [Verlaging van de bloeddruk door gebruik van een mineraalzout met een verlaagd natriumgehalte en een verhoogd kalium- en magnesiumgehalte bij ouderen met milde tot matige hypertensie]. Nederlands Tijdschrift voor Geneeskunde 1995;139:512-8.
    1. Geleijnse JM, Witteman JC, Bak AA, Den Breeijen JH, Grobbee DE. Reduction in blood pressure with a low sodium, high potassium, high magnesium salt in older subjects with mild to moderate hypertension. BMJ (Clinical research ed.) 1994;309(6952):436-40. [DOI: 10.1136/bmj.309.6952.436.] - DOI - PMC - PubMed
Gilleran 1996 {published data only}
    1. Gilleran G, O'Leary M, Bartlett WA, Vinall H, Jones AF, Dodson PM. Effects of dietary sodium substitution with potassium and magnesium in hypertensive type II diabetics: a randomised blind controlled parallel study. Journal of Human Hypertension 1996;10(8):517-21. - PubMed
Hu 2018 {published and unpublished data}
    1. Hu J, Zhao L, Thompson B, Zhang Y, Wu Y. Effects of salt substitute on home blood pressure differs according to age and degree of blood pressure in hypertensive patients and their families. Clinical and Experimental Hypertension 2018;40(7):664-72. [DOI: 10.1080/10641963.2018.1425415] - DOI - PubMed
    1. Hu J-H, Zhao L-C, Li X, Wu Y-F. Effects of salt substitution on blood pressure using home measurements in essential hypertensive patients: a double-blinded, randomized controlled trial. Chinese Journal of Hypertension 2014;22(1):42-6.
    1. Visser ME. Low sodium salt Substitutes (LSSS) systematic review: request for outcome data [personal communication]. Email to: J Hu 10 July 2020.
Kawasaki 1998 {published data only}
    1. Kawasaki T, Itoh K, Kawasaki M. Reduction in blood pressure with a sodium-reduced, potassium- and magnesium-enriched mineral salt in subjects with mild essential hypertension. Hypertension Research 1998;21(4):235-43. [DOI: 10.1291/hypres.21.235] - DOI - PubMed
Li 2014 {published data only}
    1. Li Z, Feng X, Wu T, Yan L, Elliott P, Wu Y. Randomised trial on effect of involving media reporters in salt reduction programme to increase media reports and the public's knowledge, belief and behaviors on salt and health: Changzhi reporters trial. PLoS One 2021;16(7):e0252989. [DOI: 10.1371/journal.pone.0252989] - DOI - PMC - PubMed
    1. Li Z, Yang H, Wu Y, Elliott P, Du S, X Feng, et al. Relationship of the dietary sodium substitution with low sodium and high potassium salt with the blood pressure among middle aged and elderly people: a randomized controlled study [低钠富钾替代盐与中老年人群血压关系的 随机对照研究]. Chinese Journal of Geriatrics 2014;33(4):365-7.
Li 2016 {published data only}
    1. Chu H, Zhang J, Fetters MD, Niu W, Li H, Li N, et al. A mixed methods process evaluation of a clustered-randomized controlled trial to determine the effects of community-based dietary sodium reduction in rural China. Frontiers in Medicine 2021;8:646576. [DOI: 10.3389/fmed.2021.646576] - DOI - PMC - PubMed
    1. Jardine M, Li N, Ninomiya T, Feng X, Zhang J, Shi J, et al. Dietary sodium reduction reduced albuminuria in 1,903 rural Chinese: a cluster randomised trial. Nephrology 2014;19 Suppl 4:28.
    1. Jardine M, Li N, Ninomiya T, Feng X, Zhang J, Shi J, et al. Dietary sodium reduction reduces albuminuria: a cluster randomized trial. Journal of Renal Nutrition 2019;29(4):276-84. [DOI: 10.1053/j.jrn.2018.10.009] - DOI - PubMed
    1. Li N, Yan L, Niu W, Yao C, Feng X, Zhang J, et al. China Rural Health Initiative - Sodium Reduction Study: the effects of a community-based sodium reduction program on 24hr urinary sodium and blood pressure in rural China. Circulation 2013;128(24):2707.
    1. Li N, Yan LL, Niu W, Labarthe D, Feng X, Shi J. A large-scale cluster randomized trial to determine the effects of community-based dietary sodium reduction - the China Rural Health Initiative Sodium Reduction Study. American Heart Journal 2013;166(5):815-22. [DOI: 10.1016/j.ahj.2013.07.009] - DOI - PMC - PubMed
Mu 2003 {published data only}
    1. Mu J-J, Liu Z-Q, Yang J, Liang Y-M, Zhy D-J, Wang Y-X, et al. Long term observation in effects of potassium and calcium supplementation on arterial blood pressure and sodium metabolism in adolescents with higher blood pressure. Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine] 2003;37(2):90-2. - PubMed
Mu 2009 {published data only}
    1. Mu J, Liu Z, Liu F, Xu X, Liang Y, Zhu D. Family-based randomized trial to detect effects on blood pressure of a salt substitute containing potassium and calcium in hypertensive adolescents. American Journal of Hypertension 2009;22(9):943-7. [DOI: 10.1038/ajh.2009.136] - DOI - PubMed
Neal 2021 {published data only}
    1. Huang L, Tian M, Li N, Elliott P, Yan L, Labarthe D, et al. Interim effects of salt substitution on urinary electrolytes and blood pressure in the China Salt Substitute and Stroke Study (SSaSS). Journal of Hypertension 2018;36(Suppl.3):e279. [DOI: 10.1097/01.hjh.0000549138.27560.0d] - DOI - PubMed
    1. Huang L, Tian M, Yu J, Li Q, Liu Y, Yin X, et al. Interim effects of salt substitution on urinary electrolytes and blood pressure in the China Salt Substitute and Stroke Study (SSaSS). American Heart Journal 2020;221:136-45. [DOI: 10.1016/j.ahj.2019.12.020] - DOI - PubMed
    1. Huang L, Woodward M, Stepien S, Tian M, Yin X, Hao Z, et al. Spot urine samples compared with 24-h urine samples for estimating changes in urinary sodium and potassium excretion in the China Salt Substitute and Stroke Study. International Journal of Epidemiology 2018;47(6):1811-20. [DOI: 10.1093/ije/dyy206] - DOI - PubMed
    1. Ingelfinger JR. Can salt substitution save at-risk persons from stroke? New England Journal of Medicine 2021;385(12):1137-8. [DOI: 10.1056/NEJMe2112857] - DOI - PubMed
    1. NCT02092090. China Salt Substitute and Stroke Study (SSaSS) [A large-scale cluster randomized trial to determine the effects of sodium reduction on stroke: the China Salt Substitute and Stroke Study (SSaSS)]. clinicaltrials.gov/ct2/show/NCT02092090 (first received 19 March 2014).
Omvik 1995 {published data only}
    1. Omvik P, Myking OL. Unchanged central hemodynamics after six months of moderate sodium restriction with or without potassium supplement in essential hypertension. Blood Pressure 1995;4(1):32-41. [DOI: 10.3109/08037059509077565] - DOI - PubMed
Pan 2017 {published data only}
    1. Lai YH, Chen JR, Jeng JS, Chen CM, Bai CH, Lin RT, et al. The effect of intervention with potassium and magnesium-enriched salt on neurological performance in stroke patients. Cerebrovascular Diseases 2014;38(Suppl.1):98. [DOI: 10.1159/000367674] - DOI
    1. NCT02910427. The effect of intervention with potassium and/or magnesium-enriched salt on neurological performance of stroke patients. https://clinicaltrials.gov/ct2/show/NCT02910427 (first received 22 September 2016).
    1. Pan W-H, Lai Y-H, Yeh W-T, Chen J-R, Jeng J-S, Bai C-H, et al. Intake of potassium- and magnesium-enriched salt improves functional outcome after stroke: a randomized, multicenter, double-blind controlled trial. American Journal of Clinical Nutrition 2017;106(5):1267-73. [DOI: 10.3945/ajcn.116.148536] - DOI - PubMed
Pereira 2005 {published data only}
    1. Pereira MA, Galvão R, Zanella MT. Effects of potassium supplementation by salt on arterial blood pressure and insulin resistance in hypertensive obese patients on diuretic therapy [Efeitos da suplementação de potássio via sal de cozinha sobre a pressão arterial e a resistência à insulina em pacientes obesos hipertensos em uso de diuréticos]. Revista de Nutrição [Brazilian Journal of Nutrition] 2005;18(1):5-17. [DOI: 10.1590/S1415-52732005000100001] - DOI
Sarkkinen 2011 {published data only}
    1. ISRCTN01739816. The effect of replacing regular salt with SmartSalt® mineral salt on blood pressure in middle-aged subjects with high blood pressure or with mild hypertension: a randomised controlled two-arm human study. doi.org/10.1186/ISRCTN01739816 (first received 11 November 2009).
    1. Sarkkinen ES, Kastarinen MJ, Niskanen TH, Karjalainen PH, Venäläinen TM, Udani JK, et al. Feasibility and antihypertensive effect of replacing regular salt with mineral salt - rich in magnesium and potassium - in subjects with mildly elevated blood pressure . Nutrition Journal 2011;10(1):88. [DOI: 10.1186/1475-2891-10-88] - DOI - PMC - PubMed
Suppa 1988 {published data only}
    1. Suppa G, Pollavini G, Alberti D, Savonitto S. Effects of a low-sodium high-potassium salt in hypertensive patients treated with metoprolol: a multicentre study. Journal of Hypertension 1988;6(10):787-90. - PubMed
Toft 2020 {published data only}
    1. Bjoernsbo KS, Riis NL, Andreasen AH, Petersen J, Lassen AD, Trolle E, et al. Salt reduction intervention in families investigating metabolic, behavioral and health effects of targeted intake reductions: study protocol for a four months three-armed, randomized, controlled “real-life” trial. International Journal of Environmental Research and Public Health 2019;16(19):3532. [DOI: 10.3390/ijerph16193532] - DOI - PMC - PubMed
    1. Riis NL, Bjoernsbo KS, Toft U, Trolle E, Hyldig G, Hartley IE, et al. Impact of salt reduction interventions on salt taste sensitivity and liking, a cluster randomized controlled trial. Food Quality and Preference 2021;87:104059. [DOI: 10.1016/j.foodqual.2020.104059] - DOI
    1. Toft U, Riis NL, Lassen AD, Trolle E, Andreasen AH, Frederiksen AK, et al. The effects of two intervention strategies to reduce the intake of salt and the sodium-to-potassium ratio on cardiovascular risk factors. A 4-month randomised controlled study among healthy families. Nutrients 2020;12(5):1467. [DOI: 10.3390/nu12051467] - DOI - PMC - PubMed
    1. Visser ME. Request for information on the composition of Viva salt [personal communication]. Email to: A Woitrin 22 September 2021.
Yu 2021 {published data only}
    1. NCT03909659. The effects on blood pressure of salt substitute among adults with hypertension in India [A randomized-controlled trial to determine the effects on blood pressure of a reduced-sodium added-potassium salt substitute among adults with hypertension in India]. https://clinicaltrials.gov/ct2/show/NCT03909659 (first received 10 April 2019).
    1. Thout SR, Yu J, Tian M, Huffman MD, Arnott C, Li Q, et al. Rationale, design, and baseline characteristics of the Salt Substitute in India Study (SSiIS): the protocol for a double-blinded, randomized-controlled trial. Journal of Clinical Hypertension 2020;22(8):1504-12. [DOI: 10.1111/jch.13947] - DOI - PMC - PubMed
    1. Visaria A, Shahani J, Shah M, Modak A, Chilakapati R. Maximizing the potential of the Salt Substitute in India Study. Journal of Clinical Hypertension 2021;23(1):197-8. [DOI: 10.1111/jch.14109] - DOI - PMC - PubMed
    1. Yu J, Thout SR, Li Q, Tian M, Marklund M, Arnott C, et al. Effects of a reduced-sodium added-potassium salt substitute on blood pressure in rural Indian hypertensive patients: a randomized, double-blind, controlled trial. American Journal of Clinical Nutrition 2021;114(1):185-93. [DOI: 10.1093/ajcn/nqab054.] - DOI - PubMed
Zhang 2015 {published data only}
    1. Zhang H, Li DF, Li WW, Wang Q, Brunner HR, Zhang BQ, et al. Safety of long-term enriched potassium salt consumption and effect on blood pressure in Chinese. Journal of Hypertension 2015;33 e-Suppl 1:e148-9.
    1. Zhang H, Wang Q, Brunner HR, Li W, Zhang B, Dong Y, et al. Effects of long-term enriched potassium salt consumption on premature death in Chinese living in nursing houses - preliminary analysis. Journal of Hypertension 2018;36 e-Suppl 3:e286-7.
    1. Zhang H, Wang Q, Guo Y, Li D, Zhang B, Dong Y, et al. Effect of long-term enriched potassium salt consumption on all causes mortality in Chinese living in nursing houses - a preliminary analysis. Journal of Hypertension 2016;34 e-Suppl 1:e52-3.
Zhao 2014 {published data only}
    1. NCT01429246. China Salt Substitute Study in Tibet (CSSS-Tibet) [China Salt Substitute Study in Tibet: efficacy of salt substitute in reducing blood pressure in hypertensive adults]. clinicaltrials.gov/ct2/show/NCT01429246 (first received 7 September 2011).
    1. Zhao X, Ke L, Li S, Li N, Yan LL, Ba S, et al. Effects on blood pressure of a low-sodium, high-potassium salt substitute among Tibetan Chinese: a randomized controlled trial. Circulation 2010;122(2):e353.
    1. Zhao X, Yin X, Li X, Yan LL, Lam CT, Li S, et al. Using a low-sodium, high-potassium salt substitute to reduce blood pressure among Tibetans with high blood pressure: a patient-blinded randomized controlled trial. PLOS One 2014;9(10):e110131. [DOI: 10.1371/journal.pone.0110131] - DOI - PMC - PubMed
Zhou 2009 {published data only}
    1. Yang G-H, Zhou X, Ji W-J, Liu J-X, Sun J, Shi R, et al. Effects of a low salt diet on isolated systolic hypertension: a community-based population study. Medicine 2018;97(14):e0342. [DOI: 10.1097/MD.0000000000010342] - DOI - PMC - PubMed
    1. Yang GH, Zhou X, Ji W-J, Liu J-X, Sun J, Shi R, et al. Effects of low salt diet on isolated systolic hypertension: a community-based population study. Journal of Hypertension 2018;36 e-Suppl 3:e298. - PMC - PubMed
    1. Zhou X, Liu J-X, Shi R, Yang N, Song D-L, Pang W, et al. Compound ion salt, a novel low-sodium salt substitute: from animal study to community-based population trial. American Journal of Hypertension 2009;22(9):934-42. [DOI: 10.1038/ajh.2009.135] - DOI - PubMed
Zhou 2013 {published data only}
    1. Sun H, Ma B, Wu X, Wang H, Zhou B. Long-term effect of salt substitute on all-cause and cardiovascular disease mortality: an exploratory follow-up of a randomized controlled trial. Frontiers in Cardiovascular Medicine 2021;8:645902. [DOI: 10.3389/fcvm.2021.645902] - DOI - PMC - PubMed
    1. Zhou B, Wang H-L, Wang W-L, Wu X-M, Fu L-Y, Shi J-P. Long-term effects of salt substitution on blood pressure in a rural north Chinese population. Journal of Human Hypertension 2013;27(7):427-33. [DOI: 10.1038/jhh.2012.63.] - DOI - PubMed
    1. Zhou B, Webster J, Fu L-Y, Wang H-L, Wu X-M, Wang W-L, et al. Intake of low sodium salt substitute for 3 years attenuates the increase in blood pressure in a rural population of North China - a randomized controlled trial. International Journal of Cardiology 2016;215:377-82. [DOI: 10.1016/j.ijcard.2016.04.073] - DOI - PubMed

References to studies excluded from this review

Allaert 2015 {published data only}
    1. Allaert F, Melero C. CO-42: Observational study of the effect of substituting NaCl with NaCl+ chitosan 3% (Symbiosal®) in the diet of elderly subjects on their blood pressure values [Étude observationnelle de l‘effet d‘une substitution du NaCl par du NaCl + chitosan 3% (Symbiosal®) dans l‘alimentation des personnes âgées sur leurs paramètres tensionnels]. Annales de Cardiologie et d'Angéiologie 2015;64(Supplement 1):S19.
    1. Allaert FA. Observational study of the effect of substituting NaCl with NaCl+Chitosan 3% (Symbiosal) in the diet of elderly subjects on their blood pressure values. Minerva Cardioangiologica 2015;63(6):515-23. - PubMed
Baek 2015 {published data only}
    1. Baek SH, Ahn JW, Lee HR, Cho SH, Kim JH. Anti-hypertensive effect of a solar salt diet in elderly hypertensive patients: a preliminary randomized, double-blind clinical trial. Korean Journal of Health Promotion 2015;15(3):98-107.
Barros 2013 {published data only}
    1. Barros CL. Substitution of Regular Salt with Light Salt: Impact on Blood Pressure of Hypertensive Patients (Impacto da Substituição do Sal Convencional Pelo Sal Light sobre a Pressão Arterial de Hipertensos [Master's thesis]. Goiânia (Brazil): Universidade Federal de Goiás Faculdade de Nutrição Programa de Pós-Graduação em Nutrição e Saúde, 2013.
Barros 2015 {published data only}
    1. Barros CL, Sousa AL, Chinem BM, Rodrigues RB, Jardim TS, Carneiro SB, et al. Impact of light salt substitution for regular salt on blood pressure of hypertensive patients. Arquivos Brasileiros de Cardiologia 2015;104(2):128-35. - PMC - PubMed
ChiCTR1800016804 {unpublished data only}
    1. ChiCTR1800016804. Home cook intervention to reduce salt intake: in China - a cluster randomized controlled trial. www.chictr.org.cn/showprojen.aspx?proj=25400 (first received 25 June 2018).
ChiCTR1800018119 {published data only}
    1. ChiCTR1800018119. A community-based comprehensive intervention to reduce salt intake in the Chinese population: a cluster randomized controlled trial. www.chictr.org.cn/com/25/showproj.aspx?proj=30631 (first received 31 August 2018).
ChiCTR1800019727 {published data only}
    1. ChiCTR1800019727. Effects of salt substitution on blood pressure using home blood pressure, ambulatory blood pressure and clinical blood pressure in essential hypertensive patients: a randomized controlled trial. www.chictr.org.cn/showprojen.aspx?proj=31036 (first received 25 November 2018).
ChiCTR2000033349 {published data only}
    1. ChiCTR2000033349. Zhejiang province pilot of intervention evaluation project of salt reduction and prevention and control of hypertension: a cluster randomized controlled trial. www.chictr.org.cn/hvshowproject.aspx?id=36685 (first received 29 May 2020).
Dent 2011 {published data only}
    1. Dent A, Walmsley D, Dhandapani S. Hyperkalaemia is a risk with low sodium salt in vulnerable patients. British Medical Journal 2011;343:2. - PubMed
Doorenbos 2003 {published data only}
    1. Doorenbos CJ, Vermeij CG. Lesson of the week: danger of salt substitutes that contain potassium in patients with renal failure. British Medical Journal (International Edition) 2003;326(7379):35-6. - PMC - PubMed
Farrand 2019 {published data only}
    1. Farrand C, MacGregor G, Campbell NR, Webster J. Potential use of salt substitutes to reduce blood pressure. Journal of Clinical Hypertension 2019;21(3):350-4. - PMC - PubMed
He 2020 {published data only}
    1. He FJ, Tan MN, Song J, MacGregor GA. Salt substitution to lower population blood pressure. Nature Medicine 2020;26(3):313-4. - PubMed
Hueston 1989 {published data only}
    1. Hueston WJ. Use of salt substitutes in the treatment of diuretic-induced hypokalemia. Journal of Family Practice 1989;29(6):623-6. - PubMed
Itoh 1997 {published data only}
    1. Itoh K, Kawasaki T. Clinical and nutritional study of low sodium, high potassium and high magnesium salt on sensory test and electrolyte balance. Japanese Journal of Nutrition 1997;55:263-72.
Janda 2017 {published data only}
    1. Janda J, Veleminsky M, Sulakova T, Prochazka B, Eliasek J, Stransky P, et al. Effect of the DASH-diet and salt Kardisal on blood pressure in adolescents with prehypertension (cooperative multicentre interventional study). Neuroendocrinology Letters 2017;38(8):544-8. - PubMed
Jeffrey 1984 {published data only}
    1. Jeffery RW, Pirie PL, Elmer PJ, Bjornson-Benson WM, Mullenbach VA, Kurth CL, et al. Low-sodium, high-potassium diet: feasibility and acceptability in a normotensive population. American Journal of Public Health 1984;74(5):492-4. - PMC - PubMed
JPRN‐UMIN000012560 {published data only}
    1. JPRN-UMIN000012560. Effect of using low sodium seasonings (miso and soy sauce) or monitoring salt concentration of dishes prepared at home for 12 weeks on the reduction of sodium intake among healthy middle-aged Japanese individuals: a randomized, controlled, crossover trial. upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_his_list.cgi?recptno=R000013246 (first received 12 December 2013).
Karppanen 1984 {published data only}
    1. Karppanen H, Tanskanen A, Tuomilehto J, Puska P, Vuori J, Jantti V, et al. Safety and effects of potassium-containing and magnesium-containing low sodium-salt mixtures . Journal of Cardiovascular Pharmacology 1984;6:S236-43. - PubMed
Katz 1999 {published data only}
    1. Katz A, Rosenthal T, Maoz C, Peleg E, Zeidenstein R, Levi Y. Effect of a mineral salt diet on 24-h blood pressure monitoring in elderly hypertensive patients. Journal of Human Hypertension 1999;13(11):777-80. - PubMed
Lambert 2019 {published data only}
    1. Lambert K, Conley M, Dumont R, Montgomery R, Noble S, Notaras S, et al. Letter to the editor on "Potential use of salt substitutes to reduce blood pressure". Journal of Clinical Hypertension 2019;21(10):1609-10. - PMC - PubMed
Little 2004 {published data only}
    1. Little P, Kelly J, Barnett J, Dorward M, Margetts B, Warm D. Randomised controlled factorial trial of dietary advice for patients with a single high blood pressure reading in primary care. BMJ 2004;328(7447):1054. - PMC - PubMed
    1. Visser ME. Request for study data [personal communication]. Email to: P Little 10 September 2021.
Maleki 2016 {published data only}
    1. Maleki A, Soltanian AR, Zeraati F, Sheikh V, Poorolajal J. The flavor and acceptability of six different potassium-enriched (sodium reduced) iodized salts: a single-blind, randomized, crossover design. Clinical Hypertension 2016;22(18):eCollection 2016. [DOI: 10.1186/s40885-016-0054-9] - DOI - PMC - PubMed
Maruya 2020 {published data only}
    1. Maruya S, Takachi R, Kanda M, Nakadate M, Ishihara J. Short-term effects of salt restriction via home dishes do not persist in the long term: a randomized control study. Nutrients 2020;12(10):3034. [DOI: 10.3390/nu12103034] - DOI - PMC - PubMed
Matlou 1986 {published data only}
    1. Matlou SM, Isles CG, Higgs A, Milne FJ, Murray GD, Schultz E, et al. Potassium supplementation in blacks with mild to moderate essential hypertension. Journal of Hypertension 1986;4(1):61-4. - PubMed
Mu 2020 {published data only}
    1. Mu L, Li C, Liu T, Xie W, Li G, Wang M, et al. A pilot study on efficacy and safety of a new salt substitute with very low sodium among hypertension patients on regular treatment. Medicine 2020;99(8):e19263. - PMC - PubMed
Nakano 2016 {published data only}
    1. Nakano M, Eguchi K, Sato T, Onoguchi A, Hoshide S, Kario K. Effect of intensive salt-restriction education on clinic, home, and ambulatory blood pressure levels in treated hypertensive patients during a 3-month education period. Journal of Clinical Hypertension 2016;18(5):385-92. - PMC - PubMed
NCT02105727 {published data only}
    1. NCT02105727. Changing population salt consumption in Lithgow, Australia [A before after comparison of the effectiveness of a community-based salt reduction program done in Lithgow, Australia]. clinicaltrials.gov/ct2/show/NCT02105727 (first received 7 April 2014).
Pietinen 1981 {published data only}
    1. Pietinen P, Ruotsalainen P, Tanskanen A, Puska P. Sodium intake reduction in volunteer families by using a salt substitute and nutrition counselling. Annals of Nutrition & Metabolism 1981;25(6):371-80. - PubMed
Robare 2010 {published data only}
    1. Robare JF, Milas NC, Bayles CM, Williams K, Newman AB, Lovalekar MT, et al. The key to life nutrition program: results from a community-based dietary sodium reduction trial. Public Health Nutrition 2010;13(5):606-14. - PMC - PubMed
Salvetti 1988 {published data only}
    1. Salvetti A, Bichisao E, Caiazza A, Bartolomei G, Cagianelli MA, Federighi G, et al. The combination of a low-Na/high-K salt with metoprolol in the treatment of mild-moderate hypertension. A multicenter study. American Journal of Hypertension 1988;1(3 Pt 3):201s-5s. - PubMed
Sciarrone 1992 {published data only}
    1. Sciarrone SE, Beilin LJ, Rouse IL, Rogers PB. A factorial study of salt restriction and a low-fat/high-fibre diet in hypertensive subjects. Journal of Hypertension 1992;10(3):287-98. - PubMed
Zoccali 1985 {published data only}
    1. Zoccali C, Cumming AM, Hutcheson MJ, Barnett P, Semple PF. Effects of potassium on sodium balance, renin, noradrenaline and arterial pressure. Journal of Hypertension 1985;3(1):67-72. - PubMed

References to studies awaiting assessment

Jones 2019 {published data only}
    1. Jones D. Dietary sodium and potassium intake: an event-based randomized clinical trial. Journal of Hypertension 2019;37(Supplement 1):e252.
Neutel 1996 {published data only}
    1. Neutel J. Replacing regular salt with sodium-reduced, potassium- and magnesium-enriched mineral salt may offer non-pharmacological approach to lowering blood pressure. American Journal of Hypertension 1996;9:94A.
Voloshyna 2017 {published data only}
    1. Voloshyna I, Vizir VA, Voloshyn MA, Krivenko VI, Ponomarenko VI. Effect of potassium/magnesium enriched salt on functional capacity and quality of life in symptomatic patients with chronic heart failure. European Journal of Heart Failure 2017;19(Supplement 1):53.

References to ongoing studies

ACTRN12619000352101 {published data only}
    1. ACTRN12619000352101. Salt ALTernatives Study (SALTS): a smartphone app and dietary alternative salt to lower blood pressure for adults with high blood pressure. trialsearch.who.int/?TrialID=ACTRN12619000352101 (first received 06 March 2019).
ChiCTR08000296 {published data only}
    1. ChiCTR-TRC-08000296. China Salt trial. www.chictr.org.cn/showproj.aspx?proj=9234 (first received 30 December 2008).
ChiCTR09000538 {published data only}
    1. ChiCTR-TRC-09000538. The study on pathogeny of hypertension and the salt intervention on diet in the population of Zhangwu County. www.chictr.org.cn/showproj.aspx?proj=8997 (first received 11 September 2009).
ChiCTR2000029017 {published data only}
    1. ChiCTR2000029017. Study on the application of low-sodium formula salt in hypertensive patients with diabetes. www.chictr.org.cn/showproj.aspx?proj=47080 (first received 01 November 2020).
IRCT2016103130572N1 {published data only}
    1. IRCT2016103130572N1. The effects of a salt substitute on an Iranian population. trialsearch.who.int/?TrialID=IRCT2016103130572N1 (first received 08 December 2016).
NCT02016404 {published data only}
    1. NCT02016404. The effect of a low sodium-high potassium salt on blood pressure in Vietnamese adults. clinicaltrials.gov/ct2/show/NCT02016404?term=NCT+02016404&draw=2&amp... (first received 20 December 2013).
NCT02021435 {published data only}
    1. NCT02021435. Tibet salt reduction study. clinicaltrials.gov/ct2/show/NCT02021435?term=NCT02021435&draw=2&... (first received 27 December 2013).
NCT03290716 {published data only}
    1. Jin A, Liu K, Labarthe DR, Feng X, Zhang R, Wang H, et al. Impact of salt substitute and stepwise reduction of salt supply on blood pressure in residents in senior residential facilities: design and rationale of the DECIDE-Salt trial. American Heart Journal 2020;226:198-205. [DOI: 10.1016/j.ahj.2020.05.013] - DOI - PubMed
    1. NCT03290716. Diet, exercise and cardiovascular health - effect of salt substitute and stepwise salt supply control in reducing blood pressure in the elderly in nursing homes in China. clinicaltrials.gov/ct2/show/NCT03290716?term=NCT03290716&draw=2&... (first received 25 September 2017).

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