The Proportion of Dietary Salt Replaced With Potassium-Enriched Salt in the SSaSS: Implications for Scale-Up

Abstract

BACKGROUND: The SSaSS (Salt Substitute and Stroke Study) recently reported definitive effects of a potassium-enriched salt on cardiovascular outcomes and death. Quantifying the amount of potassium-enriched salt used by trial participants is important for understanding the magnitude of the effect of potassium-enriched salt on risk reduction and how population-wide scale-up might be achieved. METHODS: Baseline and annual 24-hour urine samples were collected from subgroups of participants in SSaSS throughout the 5-year follow-up. The mean difference in 24-hour potassium excretion between the 2 groups was used to estimate the quantity of potassium-enriched salt consumed in the intervention group. The corresponding projected difference in sodium intake between groups was calculated and compared with the observed difference. RESULTS: The potassium-enriched salt group, compared to the regular salt group, had a mean increase in 24-hour urinary potassium excretion of 0.80 g/d (95% CI, 0.71–0.90), which equates to consumption of 8.8 g/d (95% CI, 7.8–9.9) of potassium-enriched salt. Based on 8.8 g/d potassium-enriched salt consumption, the projected difference in 24-hour urinary sodium excretion was −0.79 g/d. This compares to an observed difference of −0.35 g/d (95% CI, −0.55 to −0.15) and suggests that 72% of baseline regular salt intake was replaced by potassium-enriched salt. CONCLUSIONS: The smaller than anticipated between-group difference in sodium excretion likely results from the joint use of regular salt and potassium-enriched salt in the intervention group. Our findings suggest that even an incomplete replacement of regular salt with potassium-enriched salt can deliver significant health gains. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02092090.

Potassium: To Add or to Replace…That Is the Question

“…In summary, this report by Yin et al 7 addresses an important question of why urine sodium reduction was not commensurate with increases in urine potassium and the potential implications for potassium as the primary driver of the cardiovascular health benefits found in SSaSS. This study offers crucial insights for shaping public health policies and dietary guidelines aimed at reducing BP and improving cardiovascular health, especially in countries where discretionary salt is widely used.…”

“…6 The modeling study mentioned above also estimated that a China nationwide potassium-enriched salt substitution program could result in ≈11 000 hyperkalemia-related deaths in people with chronic kidney diseases (although the net benefit prevents ≈450 000 deaths). 10 Yin et al 7 stated that individuals at a higher risk for hyperkalemia are already recommended to avoid any dietary salt, but it is uncertain if this applies to the population level due to the under-diagnosis of chronic kidney diseases in China and a potential lack of understanding of potassium-related risks among those susceptible to hyperkalemia. In one small feeding study of higher dietary potassium among adults with chronic kidney diseases, there were more cases of hyperkalemia from the high potassium assignment short-term, but no adverse events.…”

“…Rather than substitute salt, an alternate solution may be to simply increase potassium intake. Yin et al 7 found that even partial replacement of regular salt with potassium-enriched salt yielded substantial benefits. Consistent with these findings, Messerli et al 11 compared the 24-hour sodium and potassium excretion in SSaSS to the US National Health and Nutrition Examination Survey data and found that most benefits observed in SSaSS were likely due to the increase in potassium intake.…”

“…In this issue of Hypertension , Yin et al 7 determined that the health benefits of SSaSS were achieved by consuming 8.8 g/d of potassium-enriched salt, which was equivalent to replacing 72% of the 12.2 g/d of regular salt consumption at baseline. These numbers were estimated using the stored 24-hour urine samples from a subset of SSaSS participants (n=4366) and were robust under varying assumptions about the proportions of urine potassium and sodium excretion.…”

Global cardiovascular diseases burden attributable to high sodium intake from 1990 to 2019

“…However, at present, few countries specifically mention CVD care in their health benefits packages, and there is still limited information to guide policy around CVD and UHC 33 . Previous studies provided some cost‐effective clinical services, which may serve as a starting point to improve the inclusion of CVD into UHC 34,35 . A call for future work from policy‐makers to raise the profile of CVD on the UHC agenda to reach the target of a 25% reduction in NCDs by 2025.…”