Swapping table salt for potassium-enriched salt could save millions of lives each year

Replacing ordinary salt with potassium-enriched salt worldwide could prevent nearly three million deaths and more than ten million new cases of cardiovascular disease and chronic kidney disease every year, according to a modelling analysis published in Nature Health. The study, led by researchers including Liping Huang and Bruce Neal of The George Institute for Global Health, is the first to project the effects of such a switch across 193 separate countries and territories, and its headline numbers represent roughly 14.6 percent of annual deaths, 13.1 percent of new cases and 16.5 percent of disability-adjusted life years attributable to these conditions globally.

The analysis used a comparative risk assessment framework, the same modelling approach the authors had refined in earlier work, to translate changes in salt consumption into changes in blood pressure and then into changes in disease risk. For every scenario, the composition of the potassium-enriched salt was fixed at 75 percent sodium chloride and 25 percent potassium chloride, the ratio for which the best evidence of clinical benefit and acceptability exists. The model estimated how replacing regular salt would alter dietary sodium and potassium intake in each country, how those changes would shift systolic blood pressure, and how the shifted blood pressure distribution would change the risks of cardiovascular disease and chronic kidney disease.

The adult population of each of the 193 jurisdictions, aged 25 years and older, was divided into five-year age intervals and analysed separately for women and men before the results were combined. Country-specific estimates of sodium intake came from the 2021 Global Burden of Disease Study, as did country-, age- and sex-specific blood pressure figures. Hypertension prevalence and treatment proportions were drawn from the 2019 Non-Communicable Disease Risk Factor Collaboration. The effect of sodium reduction on systolic blood pressure was estimated from a meta-regression of trials, while the effect of increased potassium intake came from a meta-analysis of randomized controlled trials, with the two effects assumed to be additive. Uncertainty was quantified through 1,000 Monte Carlo simulations, with central estimates taken from the 50th percentile and 95 percent uncertainty intervals from the 2.5th and 97.5th centiles of those runs.

Under the most ambitious scenario, in which all added salt, both the discretionary salt people add during home cooking and seasoning and the non-discretionary salt embedded in processed and restaurant foods, is replaced, the model projected 2.96 million deaths averted each year, with a 95 percent uncertainty interval of 2.81 to 3.12 million. New cases prevented numbered 10.17 million, and disability-adjusted life years averted totalled 69.43 million. The greatest burden averted fell on ischaemic heart disease, hypertensive heart disease, stroke and chronic kidney disease. The largest absolute benefits accrued to China and India, which combine enormous populations with high levels of salt consumption, yet in 133 of 193 countries, roughly 69 percent and concentrated in Asia, North America and Latin America, at least 10 percent of cardiovascular deaths would be prevented by the switch. About 40 percent of the benefit would accrue to women, a proportion broadly consistent across intervention strategies.

Because replacing the entire global salt supply would be a decades-long undertaking, the researchers also modelled narrower strategies. Switching only discretionary salt, the salt added at home, would avert 1.85 million deaths annually, about 63 percent of the benefit of the full switch and 9.2 percent of annual deaths attributable to cardiovascular disease and kidney disease. Switching only non-discretionary salt, the salt already in processed and restaurant foods, would prevent 1.56 million deaths, or 53 percent of the full benefit, equivalent to 7.7 percent of annual deaths from these conditions. The geographic patterns differed sharply: discretionary salt replacement in China, India, Indonesia and Russia alone would deliver over 60 percent of total global benefits, but only 58 countries would see 10 percent or more of cardiovascular deaths prevented, whereas the United States displaces Russia among the top beneficiaries of the non-discretionary strategy, reflecting the predominance of processed and restaurant food in the American diet. Only 20 countries would achieve a 10 percent or greater reduction in cardiovascular deaths under that narrower approach.

Targeting people already under clinical care produced smaller but still substantial gains. Replacing discretionary salt for the 658 million people with diagnosed hypertension would prevent 0.59 million deaths a year, and doing so for the 523 million people with treated hypertension would prevent 0.48 million. The authors note these targeted strategies achieve only about one-fifth of the potential benefit but may be more immediately achievable because they reach populations already in contact with health services and should minimize the risk of hyperkalaemia, the dangerous elevation of blood potassium that is the central safety concern of any potassium-based salt substitute.

That safety concern is most acute for people with advanced chronic kidney disease, whose kidneys cannot excrete potassium efficiently. Among the 239 million adults worldwide with stage G3 to G5 kidney disease, the model projected that replacing all salt would prevent 0.75 million cardiovascular deaths through blood pressure lowering but could cause 0.10 million deaths from hyperkalaemia, meaning more than seven deaths prevented for every one potentially caused. The authors emphasize that this harm estimate is likely substantially overstated because the population-wide scenarios assumed no capacity to keep people with advanced kidney disease from using the product; in practice such patients are more likely to be diagnosed, advised to limit salt, and steered away from high-potassium products. For the targeted hypertension scenarios, the model assumed that 20 percent of diagnosed or treated hypertensive adults would be advised against using potassium-enriched salt because of possible stage 3 to 5 kidney disease or hyperkalaemia risk, an assumption the authors deem conservative given that measured prevalence of stage 3 to 5 kidney disease among US adults with hypertension was 8.9 percent in 2015 to 2018.

The findings were robust across a battery of sensitivity analyses. Halving the replacement of all regular salt in all adults would still avert 1.72 million deaths, and one-fifth replacement would avert 0.7 million. Seven further analyses tested attenuated dose-response relationships between sodium reduction and blood pressure, reduced additive effects of sodium and potassium, halved potassium effects, no potassium effect in people without hypertension, a salt substitute containing only 15 percent potassium chloride, and plateaus in the blood pressure effect at sodium intakes of 2.5 and 3.0 grams per day; across these, averted deaths ranged from 2.02 to 2.72 million. An alternative method for estimating the proportion of discretionary salt shifted some benefit between the two salt sources but had little impact on the overall total.

The projected benefits substantially exceed what sodium reduction alone could achieve, reflecting the combined effect of lower sodium exposure and higher potassium intake, and a previous analysis of data from the Salt Substitute and Stroke Study showed that the potassium increase contributed a substantial portion of the effect. The work complements a recently launched World Health Organization guideline on lower-sodium salt substitutes with added potassium. Yet the authors are candid about limitations: the underlying data are a few years old, the split between discretionary and non-discretionary salt is poorly documented in many countries, the evidence for potassium’s blood pressure effect is sparser than that for sodium, and the model captures a single point in time without accounting for future demographic change. Full implementation would probably take decades, echoing the near-century-long global transition to iodized salt, and would require raising awareness among clinicians and consumers, expanding retail availability, and cutting the price of potassium-enriched salt, which currently averages double that of regular salt, though economies of scale in potassium chloride production are expected to reduce unit costs.

The practical challenges are considerable but the authors argue they are surmountable: updating clinical guidelines for hypertension management, as recently done in Europe and the United States, standardizing warning labels on products, listing potassium-enriched salt as an ingredient in foods, and reporting potassium content on nutrient panels would all support safe adoption. The UK Committee on Toxicity has judged that replacing up to 25 to 30 percent of sodium chloride with potassium chloride in most food categories is feasible and safe, which matters because in regions such as Europe and the United States over 70 percent of salt intake comes from processed and restaurant foods. The study identifies the countries where a switch might be prioritized and quantifies the likely balance of risks and benefits for each, but the authors stress that a translational research agenda showing how implementation can be achieved in diverse settings is now required, and that none of the modelled scenarios represents immediately achievable health gains.

Subject of Research: Modelling the global cardiovascular and kidney disease impact of replacing dietary sodium chloride with potassium-enriched salt

Article Title: Global health outcomes from replacing dietary sodium chloride with potassium-enriched salt

Article References: Huang, L., Xu, X., Matsushita, K., Brady, T. M., Appel, L. J., Hoorn, E. J., Schutte, A. E., Wu, J. H. Y., Tian, M., Aminde, L. N., Trieu, K., Neal, B., & Marklund, M. (2026). Global health outcomes from replacing dietary sodium chloride with potassium-enriched salt. Nature Health. https://doi.org/10.1038/s44360-026-00216-9

Image Credits: AI Generated

DOI: 10.1038/s44360-026-00216-9

Keywords: potassium-enriched salt, salt substitute, cardiovascular disease, chronic kidney disease, blood pressure, comparative risk assessment, Global Burden of Disease, hypertension, hyperkalaemia, disability-adjusted life years, WHO guideline, global health modelling