Is advising no added salt sufficient for managing sodium intake in patients with hypertension or cardiovascular disease?

No Added Salt Advice is Insufficient for Managing Sodium Intake in Hypertension and Cardiovascular Disease

Simply advising patients to avoid adding salt at the table is inadequate because the vast majority (75-80%) of dietary sodium comes from processed and restaurant foods, not from the salt shaker. 1, 2 To achieve meaningful blood pressure reduction and cardiovascular risk reduction, patients require specific quantitative sodium targets and education about hidden sodium sources in their diet.

Why "No Added Salt" Falls Short

The Primary Source Problem

• Most dietary sodium intake occurs through sodium already contained in processed foods, not from salt added during cooking or at the table. 1
• Any meaningful strategy to reduce salt intake must rely on food manufacturers reducing the amount added during food processing, as individual table salt avoidance addresses only a small fraction of total intake. 2
• The average sodium intake among U.S. adults is approximately 3,266 mg/day (excluding table salt), far exceeding recommended levels. 3

Evidence-Based Sodium Targets

For patients with hypertension or cardiovascular disease, the 2024 European Society of Cardiology guidelines recommend restricting total dietary sodium intake to approximately 2 g/day or less (equivalent to approximately 5 g or about a teaspoon of salt per day), including both added salt and salt already contained in food. 1

Alternative guideline recommendations include:

• The American Heart Association recommends sodium intake <1,500 mg/day for the entire U.S. population, though this target is acknowledged as challenging to achieve. 1
• The 2010 U.S. Dietary Guidelines call for no more than 1,500 mg/day in African Americans, people >51 years of age, and people with hypertension, diabetes, or chronic kidney disease. 1
• For patients with non-elevated blood pressure, a more feasible compromise might be a target sodium intake range of 2-4 g/day. 1

Blood Pressure Reduction Benefits

The evidence for quantified sodium reduction is compelling:

• Meta-analyses demonstrate that reducing sodium intake by approximately 1,800 mg/day lowers systolic blood pressure by approximately 4 mmHg and diastolic blood pressure by 2 mmHg in hypertensive patients. 1, 2
• A dose-response relationship exists: a reduction of 2,300 mg/day in urinary sodium predicts a 7.11 mmHg decrease in systolic blood pressure for patients with hypertension. 1
• Sodium reduction produces a 20% reduction in cardiovascular disease and stroke events when trials in both hypertensive and normotensive populations are pooled. 1

Practical Implementation Strategy

Step 1: Provide Specific Quantitative Targets

Rather than vague "no added salt" advice, give patients:

• A specific daily sodium target (ideally ≤2,000 mg/day for hypertension/CVD). 1, 2
• Education that this includes ALL sodium sources, not just the salt shaker. 1

Step 2: Address Hidden Sodium Sources

• Educate patients that processed foods, canned goods, restaurant meals, and packaged foods contain the majority of dietary sodium. 1, 2
• Teach patients to read nutrition labels and identify high-sodium products. 2
• Recommend choosing fresh, unprocessed foods whenever possible. 2

Step 3: Consider Potassium-Enriched Salt Substitutes

For patients with normal renal function, potassium-enriched salt substitutes (75% sodium chloride and 25% potassium chloride) should be recommended, as they provide dual benefits of sodium reduction and potassium supplementation. 1

• The Salt Substitute and Stroke Study (SSaSS) demonstrated compelling causal evidence for reduced cardiovascular disease with sodium restriction using potassium-enriched salt substitutes. 1
• This approach achieves a favorable sodium-to-potassium ratio of 1.5-2.0, which is associated with greater blood pressure reduction. 1

Step 4: Increase Dietary Potassium

In addition to sodium reduction, increased potassium intake provides additive blood pressure benefits:

• Target potassium intake of 3,000-4,700 mg/day through fruits, vegetables, and low-fat dairy products. 2
• Good sources include bananas (450 mg per medium banana), unsalted boiled spinach (840 mg/cup), and mashed avocado (710 mg/cup). 1

Important Caveats and Contraindications

Chronic Kidney Disease

• Patients with advanced chronic kidney disease (CKD) should avoid potassium-enriched salt substitutes and excessive potassium supplementation. 1
• The Canadian Society of Nephrology suggests that for CKD patients, those with mean urinary sodium excretion corresponding to intakes of 2.7-3.3 g/day had the fewest adverse outcomes, and does not support recommendations <2 g/day due to absence of evidence for this threshold. 1

Severe Heart Failure

• In patients with severe heart failure requiring aggressive diuretic therapy, very low sodium restriction may be harmful and requires careful clinical judgment. 1

Monitoring Considerations

• Patients taking potassium-sparing diuretics, ACE inhibitors, or angiotensin receptor blockers require serum potassium monitoring when using potassium-enriched salt substitutes. 1

Addressing Feasibility Concerns

While some observational research suggests a J-shaped relationship between sodium intake and cardiovascular outcomes 1, 4, 5, the guideline task forces have determined that such J-curve data are often due to reverse causality or confounding, and that the relationship between dietary sodium and stroke is typically linear without a J-curve. 1 The causal trial evidence from SSaSS demonstrating reduced cardiovascular disease with sodium restriction was compelling, even though sodium restriction in these trials was not below 2 g/day. 1

The bottom line: "No added salt" advice addresses only a minor component of total sodium intake and provides no quantitative target for patients to achieve meaningful blood pressure and cardiovascular risk reduction. Effective sodium management requires specific numerical targets, education about processed food sources, and consideration of potassium-enriched salt substitutes for appropriate patients. 1, 2