Promoting the use of potassium-enriched salt substitutes to improve cardiovascular health in the United Kingdom
Author(s)
Pineda, Ana
Pineda, Elisa
Type
Report
Abstract
Executive Summary
Promoting Low Sodium Salt Substitutes (LSSS) for Cardiovascular Health in the United Kingdom (UK)
A strategic win-win opportunity to revitalise salt reduction and combat cardiovascular disease
Priority Public Health Challenge in the UK
Cardiovascular disease (CVD) is the leading cause of mortality in the UK, responsible for approximately 1 in every 4 premature deaths. High blood pressure (hypertension), often driven by excessive sodium intake, affects around 14.4 million people in the UK and more than one in four adults and is a primary risk factor for heart attack, stroke, and kidney disease. Despite early progress, the UK’s salt reduction efforts have plateaued, with average daily salt intake of 8.4g in men and 6.8g in women—well above the recommended 6g/day.
What are Potassium-Enriched Salt Substitutes?
Potassium-enriched salt substitutes—also known as low sodium salt substitutes (LSSS)—are modified salts that replace a portion of sodium chloride with potassium chloride. This simple substitution does not alter the flavour, while reducing harmful sodium intake and increasing potassium intake, which helps lower blood pressure. Several LSSS products are already available on the UK market, offering a consumer-ready intervention for better heart health.
Proven Benefits and Growing Global Support
There is now strong international evidence supporting the switch from regular salt to LSSS:
• The Salt Substitute and Stroke Study (SSaSS) in China found a 12% reduction in all-cause mortality, 13% reduction in cardiovascular events, and a 7% reduction in stroke with LSSS use.
• A 2022 Cochrane Review concluded that LSSS likely reduces blood pressure and cardiovascular risk in adults, with no evidence of serious harm.
• The World Health Organization (WHO) recommends the use of potassium-enriched salt substitutes as a cost-effective, scalable strategy to reduce hypertension and cardiovascular risk globally.
• The European Society of Cardiology (ESC) hypertension guidelines also endorse LSSS as a viable intervention to help lower blood pressure at the population level.
Potential Risk of Hyperkalaemia: Limited and Manageable
Clinical trial data show that potassium-enriched salts modestly increase serum potassium levels, but do not cause clinical harm in the general population. The potential risk of high potassium (hyperkalaemia) is limited to a small group of individuals with advanced chronic kidney disease (CKD) or those on potassium-sparing medications, which is manageable through:
• Appropriate labelling and public health messaging
• Education of consumers and healthcare professionals
• Targeted advice for individuals at risk
Example statement for consumer-facing messaging:
‘Potassium-enriched salt substitutes are safe for most people but should not be used by individuals with serious kidney problems or those on certain medications without consulting a doctor.’
NICE Position Statement and UK Scientific Guidance
The UK’s Scientific Advisory Committee on Nutrition (SACN) and the Committee on Toxicity (COT) jointly concluded in their 2013 report that potassium-based sodium replacers offer public health benefits and are safe for most of the population.
Building on this, a NICE position statement from 2019 affirms support for the use of potassium-enriched salt substitutes as part of a broader strategy to reduce population-level sodium intake and improve cardiovascular health outcomes.
Policy Recommendation
The UK has a renewed opportunity to lead globally on salt reduction by adopting and promoting the use of LSSS. NICE is encouraged to:
• Publicly endorse potassium-enriched salt substitutes as safe and effective for most people
• Promote LSSS use among consumers, food manufacturers, and restaurants
• Ensure clear labelling and educational outreach, particularly for at-risk groups (e.g., individuals with chronic kidney disease, older adults, and those taking potassium-sparing medications).
• Support public procurement and industry incentives to increase LSSS availability
By shifting the national approach from ‘cutting’ to ‘switching’ salt, the UK can deliver a lifesaving, low-cost, and scalable intervention to reduce cardiovascular disease and improve public health. The UK’s leadership in addressing the largely preventable health crisis of early death due to NCDs - including by scaling up the use of LSSS can serve as a model for other countries, and we have an important opportunity to learn from sodium reduction efforts elsewhere to strengthen our own response in the UK.
Reversing stalled progress to reduce salt intake in the UK
The UK has historically been a global leader in salt reduction, achieving significant early successes—primarily through food reformulation. However, over the past decade, progress has stalled. Reducing salt intake remains challenging for consumers, food manufacturers, and restaurants, and this difficulty is shared across many countries.
A promising and more feasible solution is to shift the focus from simply ‘cutting’ salt to ‘switching’ to low sodium salt substitutes (LSSS). These products reduce sodium (Na) intake while increasing potassium (K) intake—offering dual cardiovascular health benefits, as demonstrated by robust randomized controlled trial (RCT) evidence.
However, scaling up the use of LSSS will require coordinated, multisectoral action. Governments must lead by creating enabling environments—using policy levers, public procurement policies, fiscal incentives, and potentially mandating LSSS use in specific settings. The food industry must be engaged to reformulate products and actively promote LSSS. Meanwhile, consumer uptake hinges on awareness, affordability, and cultural acceptance, which can be hindered by established cooking practices and taste preferences. Without alignment across government, industry, and consumers, adoption is likely to remain slow and uneven.
While the health benefits of potassium-enriched salt (LSSS) are substantial—including reductions in blood pressure and cardiovascular risk—the strategy also raises concerns around cost and the potential risk of hyperkalaemia. Hyperkalaemia is a condition where potassium levels in the blood become too high, which can affect heart rhythm and, in severe cases, be life-threatening. This risk is primarily relevant for individuals with impaired potassium excretion, such as those with advanced chronic kidney disease (CKD stages 4–5), or individuals taking potassium-sparing diuretics or potassium supplements.
However, less than 1% of the global population has CKD at a stage where hyperkalaemia becomes a serious risk, and no evidence from large-scale trials suggests increased incidence of clinically significant hyperkalaemia due to LSSS use. Indeed, modelling studies show a favourable benefit-risk profile even among high-risk groups.
To mitigate these risks, we will adopt a tailored rollout strategy that includes:
• Clear front-of-pack labelling with appropriate health warnings.
• Public education campaigns to raise awareness of who should and shouldn’t use LSSS.
• Targeted guidance for at-risk groups, especially those with diagnosed kidney disease or on medications that influence potassium levels.
These safeguards will be developed with regulatory and clinical input during the study, helping ensure both safety and public trust in potassium-enriched salt as a viable public health intervention.
In the UK, implementation would initially focus on discretionary use and collaboration with key stakeholders such as food manufacturers and the hospitality sector. By embracing this innovative approach, the UK can reinvigorate its salt reduction agenda and achieve significant, long-term public health gains.
Promoting Low Sodium Salt Substitutes (LSSS) for Cardiovascular Health in the United Kingdom (UK)
A strategic win-win opportunity to revitalise salt reduction and combat cardiovascular disease
Priority Public Health Challenge in the UK
Cardiovascular disease (CVD) is the leading cause of mortality in the UK, responsible for approximately 1 in every 4 premature deaths. High blood pressure (hypertension), often driven by excessive sodium intake, affects around 14.4 million people in the UK and more than one in four adults and is a primary risk factor for heart attack, stroke, and kidney disease. Despite early progress, the UK’s salt reduction efforts have plateaued, with average daily salt intake of 8.4g in men and 6.8g in women—well above the recommended 6g/day.
What are Potassium-Enriched Salt Substitutes?
Potassium-enriched salt substitutes—also known as low sodium salt substitutes (LSSS)—are modified salts that replace a portion of sodium chloride with potassium chloride. This simple substitution does not alter the flavour, while reducing harmful sodium intake and increasing potassium intake, which helps lower blood pressure. Several LSSS products are already available on the UK market, offering a consumer-ready intervention for better heart health.
Proven Benefits and Growing Global Support
There is now strong international evidence supporting the switch from regular salt to LSSS:
• The Salt Substitute and Stroke Study (SSaSS) in China found a 12% reduction in all-cause mortality, 13% reduction in cardiovascular events, and a 7% reduction in stroke with LSSS use.
• A 2022 Cochrane Review concluded that LSSS likely reduces blood pressure and cardiovascular risk in adults, with no evidence of serious harm.
• The World Health Organization (WHO) recommends the use of potassium-enriched salt substitutes as a cost-effective, scalable strategy to reduce hypertension and cardiovascular risk globally.
• The European Society of Cardiology (ESC) hypertension guidelines also endorse LSSS as a viable intervention to help lower blood pressure at the population level.
Potential Risk of Hyperkalaemia: Limited and Manageable
Clinical trial data show that potassium-enriched salts modestly increase serum potassium levels, but do not cause clinical harm in the general population. The potential risk of high potassium (hyperkalaemia) is limited to a small group of individuals with advanced chronic kidney disease (CKD) or those on potassium-sparing medications, which is manageable through:
• Appropriate labelling and public health messaging
• Education of consumers and healthcare professionals
• Targeted advice for individuals at risk
Example statement for consumer-facing messaging:
‘Potassium-enriched salt substitutes are safe for most people but should not be used by individuals with serious kidney problems or those on certain medications without consulting a doctor.’
NICE Position Statement and UK Scientific Guidance
The UK’s Scientific Advisory Committee on Nutrition (SACN) and the Committee on Toxicity (COT) jointly concluded in their 2013 report that potassium-based sodium replacers offer public health benefits and are safe for most of the population.
Building on this, a NICE position statement from 2019 affirms support for the use of potassium-enriched salt substitutes as part of a broader strategy to reduce population-level sodium intake and improve cardiovascular health outcomes.
Policy Recommendation
The UK has a renewed opportunity to lead globally on salt reduction by adopting and promoting the use of LSSS. NICE is encouraged to:
• Publicly endorse potassium-enriched salt substitutes as safe and effective for most people
• Promote LSSS use among consumers, food manufacturers, and restaurants
• Ensure clear labelling and educational outreach, particularly for at-risk groups (e.g., individuals with chronic kidney disease, older adults, and those taking potassium-sparing medications).
• Support public procurement and industry incentives to increase LSSS availability
By shifting the national approach from ‘cutting’ to ‘switching’ salt, the UK can deliver a lifesaving, low-cost, and scalable intervention to reduce cardiovascular disease and improve public health. The UK’s leadership in addressing the largely preventable health crisis of early death due to NCDs - including by scaling up the use of LSSS can serve as a model for other countries, and we have an important opportunity to learn from sodium reduction efforts elsewhere to strengthen our own response in the UK.
Reversing stalled progress to reduce salt intake in the UK
The UK has historically been a global leader in salt reduction, achieving significant early successes—primarily through food reformulation. However, over the past decade, progress has stalled. Reducing salt intake remains challenging for consumers, food manufacturers, and restaurants, and this difficulty is shared across many countries.
A promising and more feasible solution is to shift the focus from simply ‘cutting’ salt to ‘switching’ to low sodium salt substitutes (LSSS). These products reduce sodium (Na) intake while increasing potassium (K) intake—offering dual cardiovascular health benefits, as demonstrated by robust randomized controlled trial (RCT) evidence.
However, scaling up the use of LSSS will require coordinated, multisectoral action. Governments must lead by creating enabling environments—using policy levers, public procurement policies, fiscal incentives, and potentially mandating LSSS use in specific settings. The food industry must be engaged to reformulate products and actively promote LSSS. Meanwhile, consumer uptake hinges on awareness, affordability, and cultural acceptance, which can be hindered by established cooking practices and taste preferences. Without alignment across government, industry, and consumers, adoption is likely to remain slow and uneven.
While the health benefits of potassium-enriched salt (LSSS) are substantial—including reductions in blood pressure and cardiovascular risk—the strategy also raises concerns around cost and the potential risk of hyperkalaemia. Hyperkalaemia is a condition where potassium levels in the blood become too high, which can affect heart rhythm and, in severe cases, be life-threatening. This risk is primarily relevant for individuals with impaired potassium excretion, such as those with advanced chronic kidney disease (CKD stages 4–5), or individuals taking potassium-sparing diuretics or potassium supplements.
However, less than 1% of the global population has CKD at a stage where hyperkalaemia becomes a serious risk, and no evidence from large-scale trials suggests increased incidence of clinically significant hyperkalaemia due to LSSS use. Indeed, modelling studies show a favourable benefit-risk profile even among high-risk groups.
To mitigate these risks, we will adopt a tailored rollout strategy that includes:
• Clear front-of-pack labelling with appropriate health warnings.
• Public education campaigns to raise awareness of who should and shouldn’t use LSSS.
• Targeted guidance for at-risk groups, especially those with diagnosed kidney disease or on medications that influence potassium levels.
These safeguards will be developed with regulatory and clinical input during the study, helping ensure both safety and public trust in potassium-enriched salt as a viable public health intervention.
In the UK, implementation would initially focus on discretionary use and collaboration with key stakeholders such as food manufacturers and the hospitality sector. By embracing this innovative approach, the UK can reinvigorate its salt reduction agenda and achieve significant, long-term public health gains.
Date Issued
2025-05-19
Citation
2025
Publisher
The George Institute for Global Health UK
Copyright Statement
Copyright © 2025 The Author(s).
Identifier
https://profiles.imperial.ac.uk/e.pineda
Place of Publication
UK
Publication Status
Published