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The Journal of Clinical Hypertension logoLink to The Journal of Clinical Hypertension
. 2016 Aug 12;18(11):1082–1085. doi: 10.1111/jch.12894

2016 Dietary Salt Fact Sheet and Call to Action: The World Hypertension League, International Society of Hypertension, and the International Council of Cardiovascular Prevention and Rehabilitation

Norm R C Campbell 1, Daniel T Lackland 2, Mark L Niebylski 2,✉, Marcelo Orias 2, Kimbree A Redburn 2, Peter M Nilsson 2, Xin‐Hua Zhang 2, Louise Burrell 3, Masatsugu Horiuchi 3, Neil R Poulter 3, Dorairaj Prabhakaran 3, Agustin J Ramirez 3, Ernesto L Schiffrin 3, Alta E Schutte 3, Rhian M Touyz 3, Ji‐Guang Wang 3, Michael A Weber 3; International Council of Cardiovascular Prevention and Rehabilitation4
PMCID: PMC8032122  PMID: 27515460

Diets high in salt (sodium) are associated with a high burden of hypertension, premature death, and disability

  • The Global Burden of Disease Study estimated that there were 3.7 million deaths, 68 million years of life lost, and 74 million years of disability as a result of excess dietary salt in 2013. (Institute for Health Metrics and Evaluation, http://vizhub.healthdata.org/gbd-compare/. Accessed December 22, 2015.)

  • One half of blood pressure (BP)–related disease occurs in people with raised BP within the normal range. However, high dietary salt increases BP in this normal range and in patients with hypertension.

  • High dietary salt causes an estimated 30% of hypertension or over 300 million people to have hypertension.1, 2

  • Increased BP is a leading preventable risk factor for heart disease (heart attack and heart failure), stroke, and kidney failure and a major contributor to premature death, dementia, disability, and healthcare costs.2

  • Other diseases that have been associated with high salt intake include gastric cancer (probable procarcinogen), total cancer, recurrent kidney stones (causal association), osteoporosis, obesity, fatty liver, headache, multiple sclerosis, rheumatoid arthritis, cataracts, infertility, and direct renal, and vascular and cardiac damage.3, 4, 5, 6, 7, 8, 9, 10, 11

Globally, people consume too much salt

  • The recommended daily intake level of salt for healthy adults is <5 g/d (sodium <2000 mg/d), with lower levels in children based on their lower caloric needs.12

  • The average intake of salt per adult globally is about 10 g/d (sodium 4000 mg/d), with higher intakes in Asia.13

  • Salt intake in fully developed economies largely comes from prepackaged, processed, and restaurant foods; in undeveloped economies, the largest source is “discretionary” and added in cooking and at the table. Only a small portion is naturally found in food (salt <2.0 g/d or sodium <800 mg/d in a meat/vegetarian diet, and salt <1.25 g/d or sodium <500 mg/d in a vegetarian diet). In developing economies, globalization of the food industry (nutritional transition) is increasing the exposure of populations to salt in processed foods.14, 15

There is a strong consensus that reduction in dietary salt saves lives, healthcare resources, and dollars

  • Reducing dietary salt is one of the most impactful and cost‐effective mechanisms to improve population health, and is considered one of the World Health Organization's (WHO's) “best buys” to prevent chronic disease.14, 15

  • Noncommunicable diseases threaten the global economy and economic development and led the World Health Assembly to support nine targets for prevention and control, including a key recommendation to reduce dietary salt by 30%.16

  • Repeated comprehensive critical appraisals of the literature under the auspices of national governments and high‐profile scientific organizations uniformly conclude that dietary salt needs to be reduced and that high dietary salt causes disease. 12, 17, 18, 19, 20, 21, 22, 23

  • Controversy surrounding dietary salt reduction is largely related to competing commercial financial interests and the use of weak research methods (especially the use of single spot urine samples to estimate usual salt intake).40, 41, 42, 43 The use of a spot urine test to assess an individual's usual salt intake is not recommended.44

Keeping up to date on the evolving evidence on dietary salt and how to reduce dietary salt

  • The World Hypertension League (WHL) with other national and international partners and the Journal of Clinical Hypertension have developed multiple mechanisms to maintain up‐to‐date evidence on dietary salt.

  • A weekly MEDLINE search with independent abstracting of relevant studies is available at http://www.hypertensiontalk.com/science-of-salt-weekly/. (Canadian Institute for Health Research and Heart and Stroke Foundation [CIHR HSF] Chair in Hypertension Prevention and Control. Accessed December 22, 2015.)

  • An annual update of the evidence on dietary salt and outcomes 2013–2014 was published in the Journal of Clinical Hypertension with a 2014–2015 update pending.45

  • A more regularly updated critical appraisal and update of the evidence on dietary salt, outcomes, and programs to reduce dietary salt has also been published in the Journal of Clinical Hypertension.46, 47

Approaches to reduce dietary salt need to be strengthened globally

  • Governments in most countries need to take action to develop and implement multisectoral national strategies to reduce salt

  • Industry‐based voluntary approaches to reduce salt additives to food that do not have strong government oversight and close monitoring have a long history of being ineffective.21

  • Regulatory approaches are most effective while voluntary approaches with strong government oversight have had some success.21, 33

  • Public education is important especially where discretionary salt is the major dietary source.48

  • Close monitoring of salt intake, sources of salt in the diet, salt levels in foods, as well as knowledge, attitudes and behaviors of the public are essential components of salt reduction programs.49

  • Integrating efforts to reduce dietary salt with those to increase dietary potassium and prevent iodine deficiency through salt fortification are important to optimize population health.50, 51

  • Global networks of concerned healthcare professionals and scientists have formed to help support reductions in dietary salt. The World Action on Salt and Health (WASH) sponsors World Salt Week annually during the second week of March (www.worldactiononsalt.com/‎. Accessed December 22, 2015.) Other organizations include the Australian Division of World Action on Salt and Health (www.awash.org.au), Consensus Action on Salt and Health (http://www.actiononsalt.org.uk/), and ALASS Coalition (Latin America Action on Health or Salt) (http://www.alass.net/).

National hypertension and cardiovascular organizations

  • Highlight the important roles of hypertension and cardiovascular organizations in research, education, and advocacy.

  • Promote research, presentations, and publications on high‐quality research related to dietary salt emphasizing the importance of high‐quality research methodology and interpretation that is free of commercial bias.

  • Educate members on the health risks of high dietary salt and how to reduce salt intake.

  • Broadly disseminate relevant literature on dietary salt to the public.

  • Educate policy and decision makers on the health benefits of lowering BP among normotensive and hypertensive persons, regardless of age.

  • Advocate for policies and regulations that will contribute to population‐wide reductions in dietary salt.

  • Provide opportunities for members to be involved in advocacy. Promote and advocate through media releases on dietary salt reduction to reach the public.

  • Promote coalition building, increase organizational capacity for advocacy, and develop advocacy tools to promote civil society actions.

  • Be cautious about the role of low‐quality research and commercial conflicts of interest in generating controversy related to dietary salt reduction.

The WHL Actions

  • The WHL and the International Society of Hypertension have developed a policy statement to support the WHO‐recommended salt intake levels.37

  • The WHL has developed annual certificates of excellence and of notable achievement to recognize organizations and individuals who have contributed to efforts to reduce dietary salt at the population level.52 (http://www.whleague.org/index.php/news-awards-recognition. Accessed December 22, 2015.)

  • Assisting the global and national efforts to reduce dietary salt is a top priority of the WHL.

Disclosures

Dr Mark Niebylski and Kimbree Redburn are paid WHL consultants but report no other conflicts. Dr Ji‐Guang Wang reports receiving research grants and consulting fees from several BP‐measuring device companies including A&D, AViTA, Honsun, Omron, and Rossmax but reports no other conflicts. Dr Michael Weber is a consultant for and received travel support from Omron but reports no other conflicts. All other authors including those from WHL and the International Society of Hypertension report no conflicts of interest.

Acknowledgments

This work is an updated version of the WHL 2014 Dietary Salt Fact Sheet.53

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