Salt Substitutes Cut Risk for Stroke Recurrence, Death

 

Lots more information here which your competent? doctor has already given you, right?

Has your competent? doctor instructed the dietician to ensure that all hospital meals fall within the limit? NO? So, you don't have a functioning stroke doctor, do you? 

You'll want your competent? doctor to explain all these and give you an EXACT PROTOCOL ON SALT! Noting how much salt your brain needs to function properly! If your doctor doesn't know that, how much else doesn't s/he know? And you're being treated for a brain injury by them?

But this:

 

Review finds no proven clinical benefit to strict salt restriction for patients with heart failure

And this:

In many high income countries, approximately 75% of salt in the diet comes from processed foods and meals prepared outside the home.  So, this China study may not have much relevance in your country.

Intake of potassium- and magnesium-enriched salt improves functional outcome after stroke: a randomized, multicenter, double-blind controlled trial January 2018

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds. June 2011 

The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease December 2014

Why Everything We Know About Salt May Be Wrong May 2017 

Researchers reveal surprising findings on how salt affects blood flow in the brain

November 2021 

You'll want your competent? doctor to explain these and give you an EXACT PROTOCOL ON SALT!

 

 The latest here:

Salt Substitutes Cut Risk for Stroke Recurrence, Death

Marcia Frellick

February 05, 2025

0153

Add to Email Alerts

Switching to a salt substitute from regular sodium chloride significantly reduced the risks for stroke recurrence and death, offering patients a practical, low-cost therapeutic option, according to new data released today from a prespecified subgroup analysis of data from the Salt Substitute and Stroke Study(SSaSS) trial.

The open-label, cluster-randomized clinical trial was conducted in 600 northern villages in China. The subgroup analysis consisted of patients who self-reported a hospital diagnosis of stroke. 

In the trial, which assessed 15,249 patients with stroke, the use of a salt substitute cut the risk for recurrent stroke by 14% (relative risk [RR], 0.86; 95% CI, 0.77-0.95, P = .005). 

Reductions in the risk for hemorrhagic stroke were larger (relative reduction, 30%; P = .002). Risk for death was reduced by 12% (95% CI, 4%-18%; P = .003), with larger effects on stroke-related death (relative reduction, 21%; P = .01) over a mean follow-up period of 61.2 months.

The risk reductions were consistent across subgroups and sensitivity analyses, and the increased risk for hyperkalemia was not significant (RR, 1.01; 95% CI, 0.74-1.38; P = .96).

No Increased Risk for Hyperkalemia

In the sensitivity analyses, participants with repeated recurrent strokes during the follow-up period were excluded, imbalances in baseline characteristics were adjusted, and "possible" and "probable” and “definite" were added to the definition of primary outcome events.

Of the 20,995 people enrolled in the trial, only patients with a history of stroke were assessed in the prespecified subgroup analysis of 7703 in the salt-substitute group and 7546 in the regular-salt group. Mean age was 64 years, and 54% of participants were male. The salt substitute consisted of 75% sodium chloride and 25% potassium chloride by mass.

Concerns about hyperkalemia in the trial have been raised often, Daniel W. Jones, MD, from the Department of Medicine at the University of Mississippi Medical Center, Jackson, and colleagues point out in an accompanying editorial. They note that this subgroup analysis used common manifestations to evaluate the presence of hyperkalemia, including hospitalization and death related to arrythmia; neither increased in the salt-substitute group.

Caution in Some Groups

Concerns about the use of salt substitutes by patients with stage 3 or 4 chronic kidney disease and patients taking a potassium-sparing diuretic are "based on strong evidence," the editorialists add.

"The debate about the importance of increased potassium or reduced sodium as the primary driver of the benefit of the potassium-based salt substitute will continue but should not delay use of this strategy," they add, "as it is proven to be effective and safe for most people."

This analysis and other studies may prove to be the tipping point for the move toward mandatory sodium limits on food, and "should convince clinicians to increase attention to a low-sodium diet" that includes "a potassium-based salt substitute in most patients," Jones and colleagues note.

BP-Reducing Effects Well Established

Salt substitutes replace a portion of sodium chloride with potassium chloride and combine the blood pressure-lowering effects of reduced dietary sodium with increased dietary potassium.

"Previous studies have clearly demonstrated that sodium reduction and potassium supplementation not only reduce [blood pressure] independently but also have synergistic effects," note the study authors, led by Xiong Ding, MPH, with the School of Public Health at Wuhan University, China.

Among the trial limitations is its open-label design and the fact that concealing the intervention was not feasible. "However, outcomes were ascertained through standardized methods for all participants and verified by an independent end point adjudication committee blinded to trial-group assignment," Ding and colleagues explain.

The findings provide the evidence to "shape public health strategies worldwide, especially among populations who rely on home cooking with salt," they conclude, adding that salt substitutes "could significantly improve secondary prevention of stroke and cardiovascular health on a global scale."

A question commonly asked is what it would take to move from recommendations to reduce sodium intake to governmental requirements, Jones and colleagues write. And the common response is "a clinical trial demonstrating that a reduction in dietary sodium caused a reduction in cardiovascular events." 

"The SSaSS study, including this secondary analysis, provides that," the editorialists conclude.

Study authors Liping Huang, Yanfeng Wu, and Bruce Neal, report receiving grants from the National Health and Medical Research Council of Australia during the conduct of the study.

Americans eat too much sodium. 8 salt substitutes to help you cut back — and protect your heart health.

 Lots more information here which your competent? doctor has already given you, right?

Has your competent? doctor instructed the dietician to ensure that all hospital meals fall within this limit? NO? So, you don't have a functioning stroke doctor, do you? 

You'll want your competent? doctor to explain all these and give you an EXACT PROTOCOL ON SALT! Noting how much salt your brain needs to function properly! If your doctor doesn't know that, how much else doesn't s/he know? And you're being treated for a brain injury by them?

But this:

 

Review finds no proven clinical benefit to strict salt restriction for patients with heart failure

And this:

In many high income countries, approximately 75% of salt in the diet comes from processed foods and meals prepared outside the home. 

Intake of potassium- and magnesium-enriched salt improves functional outcome after stroke: a randomized, multicenter, double-blind controlled trial January 2018

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds. June 2011 

The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease December 2014

Why Everything We Know About Salt May Be Wrong May 2017 

Researchers reveal surprising findings on how salt affects blood flow in the brain

November 2021 

You'll want your competent? doctor to explain these and give you an EXACT PROTOCOL ON SALT!

 

 The latest here:

Americans eat too much sodium. 8 salt substitutes to help you cut back — and protect your heart health.

Katie Drakeford

Tue, February 11, 2025 at 5:00 AM EST

7 min read

The average American consumes about 3,400 milligrams of sodium per day — well above the recommended limit of 2,300 mg daily. (Getty Images)

Generate Key Takeaways

Americans have a salt problem, consuming much more than the body needs for nerve and muscle function and maintaining a proper balance of fluids. According to the Food and Drug Administration, Americans eat on average 3,400 mg of sodium each day. The Dietary Guidelines for Americans recommends limiting sodium intake to less than 2,300 mg per day, which is about one teaspoon of table salt. The World Health Organization (WHO) recommends slightly less, at just 2,000 mg daily. That’s because too much sodium can lead to a variety of health problems, including heart disease, hypertension, stroke, vision loss and osteoporosis.

The WHO recently published guidelines on using lower-sodium salt substitutes to help reach this goal for disease prevention, stating the global effort to reduce sodium intake demands urgent action.

Cardiac and pulmonary wellness dietitian Sheri Gaw tells Yahoo LIfe that “salt alternatives are especially helpful for people who are at risk for heart disease, stroke or kidney disease.” But given the average American intake of 3,400 mg of sodium, “anyone can benefit from salt alternatives,” she says.

Health benefits of lowering sodium intake

Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention and New York City Health Commissioner, commented online on the WHO’s executive summary to raise awareness about this public health concern. The WHO paper states that 1.9 million people die each year from heart attack or stroke directly linked to excessive sodium consumption. According to one of his recent posts on Threads, Frieden says that switching to a salt alternative could prevent nearly 7 million deaths worldwide by 2030.

Adding to that is a new study, published in JAMA Cardiology and involving more than 15,000 patients, that found switching to salt substitutes led to a 14% reduction in the risk of recurrent stroke and a 12% lower risk of death.

“Reducing salt can help lower high blood pressure, reduce your risk of heart disease and potentially prevent kidney problems,” dietitian Samantha DeVito tells Yahoo Life. “When we eat too much sodium, the body holds onto extra water, which puts more strain on the heart and blood vessels. By lowering your salt intake, you're giving your heart a little break.” Consuming less sodium can also help reduce the risk of stroke and even improve bone health over time, “as high sodium levels can lead to calcium loss, which is bad for bones,” she says.

Toning down the saltiness of your food may have benefits beyond your physical health. “When you cut back on salt, you start to appreciate the natural flavors of food more, which can lead to a healthier relationship with eating,” DeVito notes.

People with heart disease, hypertension, kidney disease or fluid retention may benefit the most from salt reduction by switching to salt alternatives. However, since many Americans are guilty of overindulging in salt, it’s not a bad idea for most people to cut back. Dietitian Terry Brown says that “even ‘healthy’ people can benefit from a lower salt diet and the use of salt alternatives for overall chronic disease prevention.”

Here are 8 salt alternatives worth trying:

Traditional salt substitutes

Traditional salt substitutes swap out all or some of the sodium chloride for potassium chloride, which tastes almost identical to salt for most people.

Since low potassium levels can also lead to hypertension, getting a little boost in the form of a salt substitute is a win-win. The WHO recommends increasing potassium intake from food sources (like salt substitutes) to reduce blood pressure. This makes traditional salt substitutes like LoSalt, Nu-Salt or Morton Lite Salt an easy switch for those looking to reduce their sodium intake. Most salt substitute products are used in a 1 to 1 ratio with salt.

However, it’s important to keep in mind that these salt alternatives are not ideal for people with chronic kidney disease, as it may cause increased potassium levels in the blood, which is harder to regulate for those with the condition.

Citrus

Citrus, such as lemon or lime juice and zest, is another popular pick to amp up a dish’s flavor without adding any sodium.

“Lemon juice and zest offer an acidic kick that can mimic the taste of salt,” Gaw says. “I like the versatility of lemon juice as it can be used to flavor fish, meats, cooked vegetables, whole grains, salad dressings, soups, sauces and desserts.”

If you don’t typically have fresh citrus on hand, consider stocking up on crystallized citrus products from the TruCitrus line. They are budget-friendly and pantry stable so you don’t have to worry about spoilage.

Vinegar

Swapping salt for a small splash of flavorful vinegar when finishing a dish can wake up your taste buds and cancel out any bitterness in the same way salt does. DeVito says vinegar can enhance the taste of many dishes. “They bring acidity and brightness, helping balance flavors without salt,” she says.

DeVito recommends choosing a quality vinegar product and using it sparingly. A little goes a long way here.

Onion

Adding a bit of onion to your dish boosts flavor and adds a touch of sweetness. Dietitian Angie Konegi recommends shredding fresh onion, which releases more flavor and natural sugars, giving you a stronger onion flavor with enhanced sweetness when cooked.

If you don’t have fresh onion on hand, onion powder and dried onion work well too.

Smoked paprika

Smoked paprika is a great salt alternative that packs flavor and a little heat. “Smoked paprika is one of my favorite salt alternatives that provides a rich, smoky taste with a touch of spice,” says Gaw. “Instead of using salt or high-sodium seasoning packets, I like to use smoked paprika in taco meat, chili, stews or homemade hummus.”

The spice provides a gentle warmth to dishes so don’t be afraid to add a generous amount — start with a tablespoon or so — to take your dish to the next level.

Nutritional yeast

Nutritional yeast is a deactivated form of yeast, which is traditionally used for brewing beer and baking bread, but it’s often fortified with vitamins and lends a cheesy, umami flavor to a variety of dishes.

“Nutritional yeast is a great flavor enhancer that offers a cheesy-like taste with very little sodium and fat, unlike cheese,” Gaw says, adding that it contains beneficial nutrients and vitamins such as protein, fiber, folate, B12 and iron.

Sprinkle a small amount into soups and sauces or use it as a Parmesan-like garnish on top of dishes such as pasta or popcorn to add an extra boost of flavor.

Garlic powder

Garlic powder adds a subtly savory, sweet and slightly bitter flavor to foods. Dietitian Juliana Crimi often recommends garlic powder as it “adds bold flavor without the need for extra sodium.”

Search for a high-quality variety that uses just the garlic cloves instead of the paper and stems if your budget allows. It has more depth than inexpensive products, allowing you to use less, and it has a much longer shelf life than fresh garlic.

Other herbs and spices

When flavoring dishes without salt, it’s smart to experiment with the different herbs and spices in your fridge or pantry to find out what you like.

“Things like garlic, onion powder, basil, thyme, oregano and rosemary can add a ton of flavor,” DeVito says. “Fresh herbs, like cilantro or parsley, are great too. They’re packed with antioxidants and nutrients, and they don’t come with the health risks of too much salt.”

Adapting to a lower-sodium diet can take time, but eventually your tastes will adjust to lower amounts of salt. Konegni says it can take about two or three months for your taste buds to get used to using less salt.

Crimi adds: “By experimenting with different seasonings, you’ll be less likely to miss the salt while still enjoying delicious, flavorful meals.”

Katie Drakeford is a registered dietitian and freelance nutrition writer based in Oklahoma City, Okla.

Salt Substitution and Recurrent Stroke and DeathA Randomized Clinical Trial

 

Ask your doctor to clarify if this substitute would help for the amount of salt you are using at home.

In many high income countries, approximately 75% of salt in the diet comes from processed foods and meals prepared outside the home. This research in China might not be transferable to your needs.

 But this:

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds. June 2011 

Researchers reveal surprising findings on how salt affects blood flow in the brain

November 2021 

You'll want your competent? doctor to explain these and give you an EXACT PROTOCOL ON SALT! Noting how much salt your brain needs to function properly! If your doctor doesn't know that, how much else doesn't s/he know? And you're being treated for a brain injury by them?

 

The latest here: 

Salt Substitution and Recurrent Stroke and DeathA Randomized Clinical Trial

Xiong Ding, MPH^1,2; Xinyi Zhang, MPH³; Liping Huang, PhD⁴; et al Shangzhi Xiong, PhD⁴; Zhifang Li, PhD⁵; Yi Zhao, PhD⁶; Bo Zhou, PhD⁷; Xuejun Yin, PhD⁴; Bingqing Xu, MD⁸; Yanfeng Wu, PhD⁹; Bruce Neal, PhD^4,10; Maoyi Tian, PhD^3,4,11; Lijing L. Yan, PhD^1,2

Author Affiliations

JAMA Cardiol. Published online February 5, 2025. doi:10.1001/jamacardio.2024.5417

editorial comment icon

Editorial

Comment

related articles icon

Related

Articles

• Editorial
  Dietary Sodium- and Potassium-Enriched Salt Substitutes—The Tipping Point?
  Daniel W. Jones, MD; Brent M. Egan, MD; Daniel Thomas Lackland, DrPH
  JAMA Cardiology

• Original Investigation
  Sodium Reduction Legislation and Urinary Sodium and Blood Pressure in South Africa
  Thomas Gaziano, MD; David Kapaon, MA, MS; Jacques D. du Toit, MBBCh, MSc; Nigel J. Crowther, PhD; Alisha N. Wade, MBBS, DPhil; June Fabian, MD, PhD; Carlos Riumallo-Herl, PhD; F. Carla Roberts-Toler, MSc; Xavier Gómez-Olivé, MD, PhD; Stephen Tollman, MMed, PhD
  JAMA Cardiology

Key Points

Question  Does the use of a reduced-sodium, added-potassium salt substitute vs regular salt decrease the risk of stroke recurrence and death in patients with a history of stroke?

Findings  In this prespecified subgroup analysis of the Salt Substitute and Stroke Study (SSaSS) trial involving 15 249 patients with stroke, the use of a salt substitute led to a 14% reduction in the risk of recurrent stroke and a 12% reduction in mortality.

Meaning  Results suggest that salt substitution significantly reduced the risks of stroke recurrence and death and is a novel and practical therapeutic option for patients with stroke.

Abstract

Importance  The direct effect of consumption of salt substitutes on recurrent stroke and mortality among patients with stroke remains unclear.

Objective  To evaluate the effects of salt substitutes vs regular salt on the incidence of recurrent stroke and mortality among patients with stroke.

Design, Setting, and Participants  The Salt Substitute and Stroke Study (SSaSS), an open-label, cluster randomized clinical trial, was conducted in 600 northern Chinese villages (clusters). Patients who self-reported a hospital diagnosis of stroke were included in this prespecified subgroup analysis. Data were analyzed from November 2023 to August 2024.

Interventions  Participants were assigned to use either a salt substitute, consisting of 75% sodium chloride and 25% potassium chloride by mass, or regular salt.

Main Outcomes and Measures  The primary outcome was recurrent stroke.

Results  After excluding 5746 persons without a baseline history of stroke, 15 249 patients with stroke (mean [SD] age, 64.1 [8.8] years; 6999 [45.9%] female; 8250 male [54.1%]) were included. Over a median (IQR) follow-up of 61.2 (60.9-61.6) months, the mean difference in systolic blood pressure was −2.05 mm Hg (95% CI, −3.03 to −1.08 mm Hg). A total of 2735 recurrent stroke events (691 fatal and 2044 nonfatal) and 3242 deaths were recorded. Recurrent stroke was significantly lower in the salt substitute vs regular salt group (rate ratio [RR], 0.86; 95% CI, 0.77-0.95; P = .005), with larger effects on hemorrhagic stroke (relative reduction, 30%; P = .002). Death rates were also significantly lower (RR, 0.88; 95% CI, 0.82-0.96; P = .003), with larger effects on stroke-related deaths (relative reduction 21%; P = .01). No significant difference was observed for hyperkalemia (RR, 1.01; 95% CI, 0.74-1.38; P = .96).

Conclusions and Relevance  Results of this cluster trial demonstrate that salt substitution was safe, along with reduced risks of stroke recurrence and death, which underscores large health gains from scaling up this low-cost intervention among patients with stroke.

Trial Registration  ClinicalTrials.gov Identifier: NCT02092090

• Editorial
  Dietary Sodium- and Potassium-Enriched Salt Substitutes—The Tipping Point?
  JAMA Cardiology

Full Text

Salt substitution reduces mortality, cardiovascular events, studies suggest

Ask your doctor to clarify if this substitute would help for the amount of salt you are using at home.

In many high income countries, approximately 75% of salt in the diet comes from processed foods and meals prepared outside the home. Taiwan might be considered high income but China is not.

 But this:

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds. June 2011 

Researchers reveal surprising findings on how salt affects blood flow in the brain

November 2021 

You'll want your competent? doctor to explain these and give you an EXACT PROTOCOL ON SALT! Noting how much salt your brain needs to function properly! If your doctor doesn't know that, how much else doesn't s/he know? And you're being treated for a brain injury by them?

 

The latest here:

Salt substitution reduces mortality, cardiovascular events, studies suggest

Key takeaways:

• Salt substitutes reduced all-cause and cardiovascular mortality, as well as cardiovascular events, in eight trials.
• However, the results might be more generalizable to older populations that follow Asian diets.

Salt substitution may reduce the risk for all-cause and cardiovascular mortality, and it may also reduce the risk for major cardiovascular events, according to a systematic review and meta-analysis of randomized controlled trials.

However, the associations were based on low- or even very low-certainty evidence, and the effect may be stronger in certain populations, researchers said.

Salt substitutes reduced all-cause and cardiovascular mortality, as well as cardiovascular events, in eight trials. Image: Adobe Stock

“We had heard of salt substitutes as a promising method of reducing cardiovascular events and deaths but noticed that previous studies focused on shorter term follow-up, and we were aware that new [randomized controlled trials (RCT)] had been conducted since the last systematic review,” Hannah Greenwood, BPsychSc, a research assistant at Bond University in Australia, told Healio. “We conducted this study as we wanted to examine long-term studies only — that is, follow-up of at least 6 months — and ensure that the evidence was updated with the latest available data.”

In the systematic review and meta-analysis, published in the Annals of Internal Medicine, Greenwood and colleagues assessed 16 RCTs published through Aug. 23, 2023, in which participants (n = 35,251) used regular table salt or salt substitutions for at least 6 months.

The study’s primary outcomes were all-cause and cardiovascular mortality, major cardiovascular events (MACE) — like myocardial infarction or revascularization — and serious adverse events.

Among the RCTs, eight studied the primary outcomes. Of these, seven were conducted in China or Taiwan, three were conducted in residential facilities and seven included populations with an average age of 62 years.

According to the results, salt substitutes may reduce the risk for all-cause mortality (rate ratio [RR] = 0.88; 95% CI, 0.82-0.93) and cardiovascular mortality (RR = 0.83; 95% CI, 0.73-0.95), although both associations were based on low-certainty evidence. The researchers found that salt substitution resulted in an absolute reduction in all-cause mortality of five in 1,000 (95% CI, –3 to –7) and an absolute reduction in CVD mortality of three in 1,000 (95% CI, –1 to –5).

They also found very low-certainty evidence that salt substitution may result in a slight reduction in MACE (RR = 0.85, 95% CI, 0.71-1), and that its use did not increase serious adverse events (RR = 1.04; 95% CI, 0.87-1.25). The absolute reduction in MACE was eight in 1,000 (95% CI, 0 to –15), with one in 1,000 more serious adverse events (95% CI, 4 to –2).

Because most of the evidence was from older populations with an increased risk for CVD that followed an Asian diet, “generalizability to a population with a Western diet and/or with average cardiovascular risk is very limited,” Greenwood and colleagues noted.

According to Greenwood, primary care physicians “should consider suggesting salt substitutes to their patients looking to reduce their cardiovascular risk, especially if they are older or have existing cardiovascular risk factors, like hypertension.”

However, individual circumstances should be considered, as salt substitutes may not be suitable for all patients, "especially those with kidney disease,” she said.

Greenwood added that sodium intake is just one driver of CVD, “so salt substitutes should not be seen as a holy grail that will eliminate CVD.”

“Rather, salt substitutes are another tool to help manage cardiovascular risk, alongside medications and other nondrug approaches, including diet change, smoking cessation and exercise,” she said.

In a related editorial, J. Jaime Miranda, MD, MSc, PhD, FFPH, a professor and head of the Sydney School of Public Health at the University of Sydney, Australia, and colleagues explained that elevated BP is a major global health burden.

Thus, “we must turn our attention to effective evidence-based alternatives, such as the use of potassium-enriched salts,” they wrote. “Potassium-enriched salts are safe, can be incorporated into daily habits, and reduce sodium levels in processed foods.”

They concluded that implementing potassium-enriched salts into diets “holds promise to improve BP control and foster healthier societies on a global scale.”

References:

• Greenwood H, et al. Ann Intern Med. 2024;doi:10.7326/M23-2626
• Miranda J, et al. Ann Intern Med. 2024;doi:10.7326/M24-0860.

Sources/Disclosures

Collapse

Source:

Greenwood H, et al. Ann Intern Med. 2024;doi:10.7326/M23-2626.