Global Drinking Water Standards Lack Clear Health-Based Limits for Sodium

Abstract

Background/objectives: High sodium consumption increases the risk of hypertension and cardiovascular disease. Although food remains the primary source of intake, elevated sodium levels in drinking water can further contribute to excessive intake, particularly in populations already exceeding recommendations. This review examines the extent to which national drinking water standards account for sodium-related health risks and aims to inform discussion on the need for enforceable, health-based sodium limits.

Methods: National standards for unbottled drinking water in 197 countries were searched for using the WHO 2021 review of drinking water guidelines, the FAOLEX database, and targeted internet and AI searches. For each country, data were extracted for the document name, year, regulatory body, regulation type, sodium limit (if stated), and rationale. Socio-geographic data were sourced from World Bank Open Data. A descriptive analysis was conducted using Microsoft Excel.

Results: Standards were identified for 164 countries. Of these, 20% (n = 32), representing 30% of the global population, had no sodium limit. Among the 132 countries with a sodium limit, 92% (n = 121) adopted the WHO's palatability-based guideline of 200 mg/L. Upper limits ranged from 50 to 400 mg/L. Only twelve countries (9%) cited health as a rationale. Three countries-Australia, Canada, and the United States-provided a separate recommendation for at-risk populations to consume water with sodium levels below 20 mg/L.

Conclusions: Globally, drinking water standards give inadequate attention to sodium's health risks. Most either lack sodium limits or rely on palatability thresholds that are too high to protect health. Updating national and international standards to reflect current evidence is essential to support sodium reduction efforts. Health-based sodium limits would empower communities to better advocate for safe water. Amid rising water salinity, such reforms must be part of a broader global strategy to ensure universal and equitable access to safe, affordable drinking water as a basic human right.

Keywords: cardiovascular disease; drinking water; guidelines; health-based targets; salinity; sodium; standards.

Figure 1

Flowchart of search methods used to identify national drinking water standards for 197 countries.

Figure 2

Global map of sodium limits in national drinking water standards.

Figure 3

Comparison of sodium limits in national drinking water standards across 197 countries by geographical region.

Figure 4

Sodium limits in national drinking water standards by country income level (n = 197).