Low-sodium salt prevents stroke

Date:
August 30, 2021
Source:
European Society of Cardiology
Summary:
Replacing salt with a low-sodium alternative lowers the risk
of stroke in people with high blood pressure or prior stroke,
according to recent research.



FULL STORY ========================================================================== Replacing salt with a low-sodium alternative lowers the risk of stroke
in people with high blood pressure or prior stroke, according to late
breaking research presented in a Hot Line session today at ESC Congress 20211and published in the New England Journal of Medicine2.


==========================================================================
Both elevated sodium intake and low potassium intake are associated with
high blood pressure and an increased risk of cardiovascular disease and premature death.3,4 Salt substitutes, which replace part of the sodium
chloride in regular salt with potassium chloride, have been shown to
lower blood pressure5 but their effects on heart disease, stroke, and
death had been uncertain. In addition, there had been concerns about
causing hyperkalaemia in people with chronic kidney disease leading to
cardiac arrhythmias and sudden death.

The Salt Substitute and Stroke Study (SSaSS) compared the effect
of reduced sodium salt substitute versus regular salt on stroke,
cardiovascular events, mortality and clinical hyperkalaemia.6 SSaSS was
an open, cluster-randomised, trial that enrolled participants between
April 2014 and January 2015.

Participants were adults with either previous stroke or age 60 years and
above with poorly controlled blood pressure.7 The trial was conducted
in 600 villages in rural areas of five provinces in China. Two counties
within each province were chosen that represented the socioeconomic
development level of rural counties in that province.

Approximately 35 individuals were recruited from each village -- for a
total of 20,995 participants. Participants were cluster-randomised by
village in a 1: 1 ratio to provision of salt substitute or continued
use of regular salt.

Participants in intervention villages were given free salt substitute
(about 75% sodium chloride and 25% potassium chloride) as a replacement
for regular salt and advised to use it for all cooking, seasoning and
food preservation.

They were also encouraged to use the salt replacement more sparingly than
they previously used salt to maximise their sodium reduction. Sufficient
salt substitute was provided to cover the needs of the entire household
(about 20 g per person per day). Participants in control villages
continued their usual habits.

The average age of participants was 65.4 years and 49.5% were female. Some 72.6% had a history of stroke and 88.4% had a history of hypertension.



========================================================================== During an average follow up of 4.74 years, more than 3,000 people
had a stroke, more than 4,000 died and more than 5,000 had a major cardiovascular event. The risk of stroke was reduced with salt substitute compared to regular salt (29.14 versus 33.65 per 1,000 patient-years;
rate ratio [RR] 0.86; 95% confidence interval [CI] 0.77-0.96; p=0.006).

Regarding secondary outcomes, major cardiovascular events (non-fatal
stroke, non-fatal acute coronary syndrome, vascular death) were reduced
with salt substitute (49.09 versus 56.29 per 1,000 patient-years; RR
0.87; 95% CI 0.80- 0.94; p<0.001) as was total mortality (39.27 versus
44.61 per 1,000 patient- years; RR 0.88; 95% CI 0.82-0.95; p<0.001).

Regarding safety, there was no increased risk of serious adverse events attributed to clinical hyperkalaemia with salt substitute compared to
regular salt (3.35 versus 3.30 per 1,000 patient years; RR 1.04; 95%
CI 0.80-1.37; p=0.76). Neither were any other risks identified.

Principal investigator Professor Bruce Neal of the George Institute
for Global Health, Sydney, Australia said: "This study provides clear
evidence about an intervention that could be taken up very quickly
at very low cost. A recent modelling study done for China projected
that 365,000 strokes and 461,000 premature deaths could be avoided
each year in China if salt substitute was proved to be effective.8 We
have now showed that it is effective, and these are the benefits for
China alone. Salt substitution could be used by billions more with even
greater benefits." He added: "The trial result is particularly exciting because salt substitution is one of the few practical ways of achieving
changes in the salt people eat.

Other salt reduction interventions have struggled to achieve large and sustained impact.''


========================================================================== ''Importantly, salt substitute is very easy to manufacture and it is not expensive. A kilo of regular salt, which lasts for months, costs about
US$1.08 in China. The price for a kilo of salt substitute is $1.62/kg,''
he said. "It is primarily lower-income and more disadvantaged populations
that add large amounts of salt during food preparation and cooking.9 This
means that salt substitute has the potential to reduce health inequities related to cardiovascular disease." Notes 1SSaSS: Salt Substitute and
Stroke Study into the effect of salt substitutes on cardiovascular events
and death 2Tian M, et al. The effect of salt substitute on cardiovascular events and death (SSaSS). N Engl J Med. 10.1056/NEJMoa2105675 3Cogswell
ME, Mugavero K, Bowman BA, Frieden TR. Dietary sodium and cardiovascular disease risk -- measurement matters. N Engl J Med.2016;375:580- 586.

4Aburto NJ, Hanson S, Gutierrez H, et al. Effect of increased potassium
intake on cardiovascular risk factors and disease: systematic review
and meta- analyses. BMJ.2013;346:f1378.

5Greer RC, Marklund M, Anderson CAM, et al. Potassium-enriched
salt substitutes as a means to lower blood
pressure. Hypertension.2020;75:266-274.

6Neal B, Tian M, Li N, et al. Rationale, design, and baseline
characteristics of the Salt Substitute and Stroke Study (SSaSS)-A
large-scale cluster randomized controlled trial. Am Heart
J.2017;188:109-117.

7Poorly controlled blood pressure was defined as: systolic blood pressure

=140 mmHg if on blood pressure lowering medication or systolic blood

pressure >=160 mmHg if not on blood pressure lowering medication.

8Marklund M, Singh G, Greer R, et al. Estimated population wide benefits
and risks in China of lowering sodium through potassium enriched salt substitution: modelling study. BMJ. 2020;369:m824.

9Bhat S, Marklund M, Henry ME, et al. A systematic review of the sources
of dietary salt around the world. Adv Nutr. 2020;11:677-686.

========================================================================== Story Source: Materials provided by European_Society_of_Cardiology. Note: Content may be edited for style and length.


========================================================================== Journal Reference:
1. Bruce Neal, Yangfeng Wu, Xiangxian Feng, Ruijuan Zhang, Yuhong
Zhang,
Jingpu Shi, Jianxin Zhang, Maoyi Tian, Liping Huang, Zhifang Li,
Yan Yu, Yi Zhao, Bo Zhou, Jixin Sun, Yishu Liu, Xuejun Yin, Zhixin
Hao, Jie Yu, Ka-Chun Li, Xinyi Zhang, Peifen Duan, Faxuan Wang, Bing
Ma, Weiwei Shi, Gian Luca Di Tanna, Sandrine Stepien, Sana Shan,
Sallie-Anne Pearson, Nicole Li, Lijing L. Yan, Darwin Labarthe,
Paul Elliott. Effect of Salt Substitution on Cardiovascular
Events and Death. New England Journal of Medicine, 2021; DOI:
10.1056/NEJMoa2105675 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2021/08/210830113323.htm

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