Swapping table salt for a potassium-enriched substitute worldwide could prevent about 2.96m deaths a year, a modelling study in Nature Health says. The study covers 193 countries, and the figure is a calculation, not something observed in real life.
The study was carried out by researchers at the George Institute for Global Health. It replaces ordinary salt with a mix of 75% sodium chloride and 25% potassium chloride. The model covers about 4.63bn adults over 25. It also estimates about 10.17m cases of cardiovascular and chronic kidney disease a year.
Four scenarios for the switch
The biggest effect comes from a full switch, including salt in processed food and in restaurants. The figure is a net one, after deaths from high potassium are subtracted. It equals about 15% of deaths from cardiovascular and kidney disease.
If people swap only the salt they cook with and add at home, the figure falls to 1.85m deaths and 6.19m cases of disease. Changing only the salt in factory-made and restaurant food gives 1.56m deaths and 5.46m cases.
The third option covers only people with high blood pressure and only home salt. About 660 million people have a diagnosis, and the model assumes 80% of them would use the product. That would prevent about 590,000 deaths and 1.72m cases of disease. Among treated people with high blood pressure, about 520 million, the figures are 480,000 deaths and 1.41m cases.
The gaps between countries are large. For China, the model gives more than 1.08m deaths prevented a year, for India about 400,000, for the US about 105,000 and for the UK about 13,000. In Europe and North America, more than 70% of salt comes from processed and restaurant food, so the benefit there depends on the food industry. The authors of the model give no figures for Bulgaria.
Assumptions about potassium and the kidneys
The result rests on several assumptions. The effect on blood pressure is cut to 80% of the calculated figure. When a robustness check treats potassium as weaker, the net result stays between 2.02m and 2.72m lives saved. The model also assumes the switch is complete, and its data on sodium intake come from the Global Burden of Disease study for 2021.
The assumption about people with advanced kidney disease, stages G3–G5, is the most sensitive. Their kidneys struggle to clear potassium. The model assumes that in a full switch they are not barred from using the product. Among them, 0.75m cardiovascular deaths are prevented, but 0.10m deaths from high potassium are added.
The authors admit that higher deaths from high potassium have not been shown in clinical trials, and the model may overstate them. In the scenarios for people with high blood pressure, the model assumes a clinical check, so only the blood pressure benefits are counted.
Kidney specialist Vivek Jha of the institute says the risk for this group "can be managed effectively through patient education, product labelling and clinical supervision". The authors say people with severe kidney disease, or those taking drugs that raise potassium, need safeguards.
Chinese trial and WHO advice
The only large trial with firm results is China's SSaSS, from 2021. It involved 20,995 adults from about 600 villages, all with a past stroke or high blood pressure. The villages were picked at random, and people were followed for 4.74 years on average. People with poor kidney function were excluded.
Strokes among users of the substitute were 29.14 per 1,000 person-years, against 33.65 with ordinary salt, or 14% fewer. Overall deaths were 12% lower. Serious cases of high potassium did not differ between the two groups.
An editorial in the journal warns that "wider effectiveness is hard to predict" because of limited applicability. People in the villages rarely eat processed food, so the result may not hold for a Western diet.
The trial measured real strokes in a set group. The model carries similar effects over to whole populations and adds assumptions about salt intake and blood pressure. Cases of disease in the model are counted only through the blood pressure benefit.
The World Health Organization issued its first guidance on substitutes on 27 January 2025. It conditionally recommends potassium substitutes for people who use table salt. It covers adults in the general population, but not pregnant women, children and people whose bodies clear potassium poorly. If a member of a household is at risk from high potassium, the substitute should not be used for shared meals. The product should be introduced only where health services can spot such conditions.
The advice rests on 26 trials with adults, in which people were assigned at random. They show an average drop in systolic blood pressure of about 4.76 mmHg, while blood potassium rises by 0.12 mmol/L. People with kidney disease did not take part. The WHO advice covers only table salt, while the model also counts factory-made food.
The researchers admit that a rollout worldwide could take decades, and that cost, supply and acceptance by the food industry stand in the way. Prof Bruce Neal of the University of Sydney and the George Institute calls the global shift "ambitious" and a "starting point". He says output of potassium chloride must rise for the full effect.