# Salt substitution (lower-sodium, potassium-containing salt) Intervention · id `cardio:salt-substitution` · Cardiovascular Atlas · release `2b2017b84496b985` (public) > General information from published sources, not medical advice, and not reviewed by clinicians. Check the cited source before relying on anything here. The atlas's own text and curation may be reused under Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0, https://creativecommons.org/licenses/by-nc/4.0/): credit the atlas, and do not use it commercially. See the atlas About page. Text quoted from a source stays under that source's own terms, given as the source's reuse\_basis. The atlas's reuse terms do not cover it. The downloads list each quotation with its source in third\_party\_quotations. Also called: Lower-sodium salt substitutes; LSSS Browse, organ or system: Blood vessels Browse, condition area: Risk and prevention; High blood pressure; Stroke ## In plain language Swapping ordinary table salt for a salt that has part of its sodium replaced with potassium. The aim is lower blood pressure and, over years, fewer strokes. In SSaSS, a trial in rural China among people with a past stroke or aged 60 or over with high blood pressure, villages that used a substitute had fewer strokes and deaths than villages that kept regular salt. WHO suggests adults in general populations use these products if they use table salt, but not people with kidney problems, children or pregnant women. The NICE hypertension guideline says potassium-containing substitutes should not be used by some groups, including older people and people with diabetes. These positions are shown side by side and are not merged. ## Technical summary Replaces part of the sodium chloride in table salt with potassium chloride. SSaSS used 75% sodium chloride and 25% potassium chloride by mass. WHO reviewed 26 randomized trials; in the 23 whose substitutes replaced sodium with potassium, sodium chloride ranged from 41 to 75% and potassium chloride from 19 to 50%. WHO notes that the blood-pressure-lowering effect is partly due to the potassium content, and that too much blood potassium (hyperkalaemia) may be harmful, especially with impaired kidney function. Claims: SSaSS stroke, death and hyperkalemia results in one rural Chinese population; WHO 2025 conditional recommendation (direction for); NICE NG136 1.4.5 caution (direction against) in a subgroup context. ## Claims, with the population each applies to ## Context: Adults with suspected or diagnosed hypertension who are older, have diabetes or kidney disease, or take some blood-pressure medicines (NICE NG136 recommendation 1.4.5) Recipient: Adult; Population: Adults with suspected or diagnosed hypertension in the groups NICE names for potassium chloride salt substitutes: older people (NICE gives no age), people with diabetes, people with kidney disease, and people on some blood-pressure medicines (for example ACE inhibitors and angiotensin II receptor blockers). The recommendation says people and sits in the lifestyle section addressed to people with suspected or diagnosed hypertension. NICE also names pregnant women; that group is outside this context and belongs to the maternal atlas.; Care setting: Not stated on the fetched page; Geography: England, from clause 6 of the NICE terms and conditions, which presents the information as support for people in England who make decisions about funding care. Clause 8 adds that NICE does not write its content as a basis for decisions outside the United Kingdom. The NG136 page itself states no jurisdiction.; Life stage: Adult; older people are named but NICE gives no age bound; Follow-up: Not applicable (recommendation context) ### NICE guideline NG136 advises encouraging people to keep their sodium intake low, either by cutting back on salt or by using a salt substitute in its place. It adds that older people, people with diabetes, people with kidney disease, and people on some blood-pressure medicines (for example ACE inhibitors and angiotensin II receptor blockers) should not use salt substitutes that contain potassium chloride, and says these groups should be encouraged to cut down on salt instead. The recommendation is tagged as dating from 2004 and amended in 2019, so it predates the SSaSS report and the WHO salt-substitute guideline, which are recorded separately. NICE also names pregnant women in this list; that group is outside this claim context and belongs to the maternal atlas. - Category: Recommendation - Evidence stage: Guidance - Certainty: Certainty not assessed - Applies to: Recipient: Adult; Population: Adults with suspected or diagnosed hypertension in the groups NICE names for potassium chloride salt substitutes: older people (NICE gives no age), people with diabetes, people with kidney disease, and people on some blood-pressure medicines (for example ACE inhibitors and angiotensin II receptor blockers). The recommendation says people and sits in the lifestyle section addressed to people with suspected or diagnosed hypertension. NICE also names pregnant women; that group is outside this context and belongs to the maternal atlas.; Care setting: Not stated on the fetched page; Geography: England, from clause 6 of the NICE terms and conditions, which presents the information as support for people in England who make decisions about funding care. Clause 8 adds that NICE does not write its content as a basis for decisions outside the United Kingdom. The NG136 page itself states no jurisdiction.; Life stage: Adult; older people are named but NICE gives no age bound; Follow-up: Not applicable (recommendation context) - Limitations: The fetched page gives no reasoning for the caution, and the NICE rationale was not read. It says people, and sits in the lifestyle section whose first recommendation is addressed to people who may have hypertension or have been diagnosed with it. Older people has no age bound. What the 2019 amendment changed was not checked. The wording is imperative with no NICE strength label, and its meaning was not verified. The NG136 page states no jurisdiction. NICE's terms present the information as support for people in England who make decisions about funding care, and say the content is not written as a basis for decisions outside the United Kingdom. The page shows a last update of 26 February 2026. NICE's reuse terms limit outside use of its wording, so this atlas states the caution in its own words. This caution and the WHO suggestion are shown side by side; neither is shown to be right. - Last checked: Not recorded - Sources: 1. Supports: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter (Guideline, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.) Locator: Recommendation 1.4.5, sentence 2. Retrieved 2026-10-09T15:59:21Z. Source state: Current. Snapshot hash: 68ce72f3487ffa4715f92ddfa8aaf6e093f5aecd3598cd59a0ab58f74ce86f28. How it applies: The caution on potassium chloride salt substitutes and the groups it names. 2. Supports: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter (Guideline, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.) Locator: Recommendation 1.4.5, sentence 1. Retrieved 2026-10-09T15:59:21Z. Source state: Current. Snapshot hash: 68ce72f3487ffa4715f92ddfa8aaf6e093f5aecd3598cd59a0ab58f74ce86f28. How it applies: The advice to keep sodium low by reducing or substituting salt. 3. Supports: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter (Guideline, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.) Locator: Recommendation 1.4.5, sentence 3 and tag. Retrieved 2026-10-09T15:59:21Z. Source state: Current. Snapshot hash: 68ce72f3487ffa4715f92ddfa8aaf6e093f5aecd3598cd59a0ab58f74ce86f28. How it applies: Advice to reduce salt in these groups, with the 2004 and 2019 tag. 4. Background: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter (Guideline, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.) Locator: Recommendation 1.4.1 and section 1.4 heading. Retrieved 2026-10-09T15:59:21Z. Source state: Current. Snapshot hash: 68ce72f3487ffa4715f92ddfa8aaf6e093f5aecd3598cd59a0ab58f74ce86f28. How it applies: The section the recommendation sits in addresses people with suspected or diagnosed hypertension. 5. Background: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter (Guideline, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.) Locator: Page header, Published and Last updated. Retrieved 2026-10-09T15:59:21Z. Source state: Current. Snapshot hash: 68ce72f3487ffa4715f92ddfa8aaf6e093f5aecd3598cd59a0ab58f74ce86f28. How it applies: Guideline first published 28 August 2019, last updated 26 February 2026. 6. Background: NICE terms and conditions, including the Notice of Rights (Webpage, edition The page as fetched on 2026-10-11. It shows no version date; its footer carries the year 2026.) Locator: Clause 6, sentence 1. Retrieved 2026-10-11T19:11:33Z. Source state: Current. Snapshot hash: 663d4a4be632810ae88513ec6386193a7b373159e5e2ecd4ec61419e2e4c408a. How it applies: Source of the England audience read for this claim. 7. Background: NICE terms and conditions, including the Notice of Rights (Webpage, edition The page as fetched on 2026-10-11. It shows no version date; its footer carries the year 2026.) Locator: Clause 8. Retrieved 2026-10-11T19:11:33Z. Source state: Current. Snapshot hash: 663d4a4be632810ae88513ec6386193a7b373159e5e2ecd4ec61419e2e4c408a. How it applies: Source of the United Kingdom reliance limit read for this claim. ## Context: People with a past stroke, or aged 60 or over with high blood pressure, in rural Chinese villages (SSaSS) Recipient: Recipient not specified; Population: People who had had a stroke, or who were 60 years of age or older and had high blood pressure, living in rural villages in China. The registry defines high blood pressure as uncontrolled: systolic 140 mmHg or more on treatment, or 160 mmHg or more without treatment. In the trial 72.6% had a history of stroke and 88.4% a history of hypertension, and the mean age was 65.4 years. No source read gives a minimum age, and the past-stroke group has no stated age floor, so the recipient is recorded as unknown rather than adult. Pregnancy is not mentioned in the sources read.; Care setting: Rural villages in China, 600 of them. The registry names five Northern Chinese provinces and Tibet. A household phone was an entry requirement.; Geography: Rural China: five Northern Chinese provinces and Tibet (registry description); Life stage: Mixed ages with a mean of 65.4 years. Age 60 or over is required for people without a past stroke; no age floor is stated for people with one.; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Mean follow-up 4.74 years (abstract). The registry gives a time frame of 5 years. ### In SSaSS, serious adverse events attributed to hyperkalemia (too much potassium in the blood) were not significantly more frequent with the salt substitute: 3.35 events per 1000 person-years against 3.30 with regular salt (rate ratio 1.04, 95% CI 0.80 to 1.37). Not significantly higher is not the same as no difference or no risk. - Category: Safety - Evidence stage: Interventional - Certainty: Certainty not assessed - Applies to: Recipient: Recipient not specified; Population: People who had had a stroke, or who were 60 years of age or older and had high blood pressure, living in rural villages in China. The registry defines high blood pressure as uncontrolled: systolic 140 mmHg or more on treatment, or 160 mmHg or more without treatment. In the trial 72.6% had a history of stroke and 88.4% a history of hypertension, and the mean age was 65.4 years. No source read gives a minimum age, and the past-stroke group has no stated age floor, so the recipient is recorded as unknown rather than adult. Pregnancy is not mentioned in the sources read.; Care setting: Rural villages in China, 600 of them. The registry names five Northern Chinese provinces and Tibet. A household phone was an entry requirement.; Geography: Rural China: five Northern Chinese provinces and Tibet (registry description); Life stage: Mixed ages with a mean of 65.4 years. Age 60 or over is required for people without a past stroke; no age floor is stated for people with one.; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Mean follow-up 4.74 years (abstract). The registry gives a time frame of 5 years. - Limitations: The abstract names clinical hyperkalemia as the safety outcome and reports serious adverse events attributed to it. The registry excluded households using potassium-sparing diuretics or potassium supplements and people with serious renal impairment, so the result does not speak to those groups. WHO notes that all trials in its review excluded people who might be harmed by extra potassium. One open-label, cluster-randomized trial in rural China. The result applies to people who had had a stroke or were 60 or over with high blood pressure and met the other entry rules, such as no potassium-sparing diuretic, potassium supplement or serious kidney impairment in the household. It does not show the same effect in other groups or places. The tested package is ongoing dietary advice plus the substitute, compared with dietary advice at baseline only (registry). The abstract calls the trial open-label, while the registry records masking as DOUBLE (investigator and outcomes assessor); the two are not reconciled. The registry counts 20996 participants and the abstract 20,995; the reason is unknown. Only the abstract and the registry were read: the NEJM full text returned HTTP 403 and no open copy exists, so event counts, person-years, per-arm intervals and any correction are not recorded. - Last checked: Not recorded - Sources: 1. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, RESULTS, sentence 5. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Abstract of the main report, for the same population and follow-up as this context. 2. Background: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, METHODS, sentence 4. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Names clinical hyperkalemia as the safety outcome. 3. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.eligibilityModule.eligibilityCriteria, exclusion. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: Registry exclusions on potassium-sparing diuretics, potassium supplements and serious renal impairment. 4. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, The evidence, page viii. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: WHO says all trials in its review excluded people who could be harmed by extra potassium. 5. Background: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, METHODS, sentences 1 to 3. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Design, population, villages and what each arm used. ### In the same trial and time window, deaths from any cause were less frequent with the salt substitute: 39.28 events per 1000 person-years against 44.61 with regular salt (rate ratio 0.88, 95% CI 0.82 to 0.95). Death from any cause was a secondary outcome. - Category: Effect - Evidence stage: Interventional - Certainty: Certainty not assessed - Applies to: Recipient: Recipient not specified; Population: People who had had a stroke, or who were 60 years of age or older and had high blood pressure, living in rural villages in China. The registry defines high blood pressure as uncontrolled: systolic 140 mmHg or more on treatment, or 160 mmHg or more without treatment. In the trial 72.6% had a history of stroke and 88.4% a history of hypertension, and the mean age was 65.4 years. No source read gives a minimum age, and the past-stroke group has no stated age floor, so the recipient is recorded as unknown rather than adult. Pregnancy is not mentioned in the sources read.; Care setting: Rural villages in China, 600 of them. The registry names five Northern Chinese provinces and Tibet. A household phone was an entry requirement.; Geography: Rural China: five Northern Chinese provinces and Tibet (registry description); Life stage: Mixed ages with a mean of 65.4 years. Age 60 or over is required for people without a past stroke; no age floor is stated for people with one.; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Mean follow-up 4.74 years (abstract). The registry gives a time frame of 5 years. - Limitations: Secondary outcome. The limits of the stroke claim apply: One open-label, cluster-randomized trial in rural China. The result applies to people who had had a stroke or were 60 or over with high blood pressure and met the other entry rules, such as no potassium-sparing diuretic, potassium supplement or serious kidney impairment in the household. It does not show the same effect in other groups or places. The tested package is ongoing dietary advice plus the substitute, compared with dietary advice at baseline only (registry). The abstract calls the trial open-label, while the registry records masking as DOUBLE (investigator and outcomes assessor); the two are not reconciled. The registry counts 20996 participants and the abstract 20,995; the reason is unknown. Only the abstract and the registry were read: the NEJM full text returned HTTP 403 and no open copy exists, so event counts, person-years, per-arm intervals and any correction are not recorded. - Last checked: Not recorded - Sources: 1. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, RESULTS, sentence 4 (death). Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Abstract of the main report, for the same population and follow-up as this context. 2. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, RESULTS, sentence 3. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Mean follow-up stated in the abstract. 3. Background: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, METHODS, sentences 1 to 3. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Design, population, villages and what each arm used. 4. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.armsInterventionsModule.armGroups and interventions\[0\].description. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: Registry description of the two arms: ongoing advice plus the substitute, versus advice at baseline only. 5. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.designModule.designInfo.maskingInfo. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: The registry records masking as DOUBLE (investigator and outcomes assessor); the abstract says open-label. Not reconciled. 6. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.designModule.enrollmentInfo.count. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: Registry enrollment 20996, against 20,995 in the abstract. Not reconciled. ### In SSaSS, in rural Chinese villages, people who had had a stroke or were 60 or older with high blood pressure had fewer strokes when their village used a lower-sodium, potassium-enriched salt substitute, with ongoing dietary advice, than when it kept using regular salt. Over a mean follow-up of 4.74 years the stroke rate was 29.14 events per 1000 person-years with the substitute and 33.65 with regular salt (rate ratio 0.86, 95% CI 0.77 to 0.96). - Category: Effect - Evidence stage: Interventional - Certainty: Certainty not assessed - Applies to: Recipient: Recipient not specified; Population: People who had had a stroke, or who were 60 years of age or older and had high blood pressure, living in rural villages in China. The registry defines high blood pressure as uncontrolled: systolic 140 mmHg or more on treatment, or 160 mmHg or more without treatment. In the trial 72.6% had a history of stroke and 88.4% a history of hypertension, and the mean age was 65.4 years. No source read gives a minimum age, and the past-stroke group has no stated age floor, so the recipient is recorded as unknown rather than adult. Pregnancy is not mentioned in the sources read.; Care setting: Rural villages in China, 600 of them. The registry names five Northern Chinese provinces and Tibet. A household phone was an entry requirement.; Geography: Rural China: five Northern Chinese provinces and Tibet (registry description); Life stage: Mixed ages with a mean of 65.4 years. Age 60 or over is required for people without a past stroke; no age floor is stated for people with one.; Gestational age: Not reported; Postnatal age: Not reported; Follow-up: Mean follow-up 4.74 years (abstract). The registry gives a time frame of 5 years. - Limitations: One open-label, cluster-randomized trial in rural China. The result applies to people who had had a stroke or were 60 or over with high blood pressure and met the other entry rules, such as no potassium-sparing diuretic, potassium supplement or serious kidney impairment in the household. It does not show the same effect in other groups or places. The tested package is ongoing dietary advice plus the substitute, compared with dietary advice at baseline only (registry). The abstract calls the trial open-label, while the registry records masking as DOUBLE (investigator and outcomes assessor); the two are not reconciled. The registry counts 20996 participants and the abstract 20,995; the reason is unknown. Only the abstract and the registry were read: the NEJM full text returned HTTP 403 and no open copy exists, so event counts, person-years, per-arm intervals and any correction are not recorded. - Last checked: Not recorded - Sources: 1. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, RESULTS, sentence 4. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Abstract of the main report, for the same population and follow-up as this context. 2. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, RESULTS, sentence 3. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Mean follow-up stated in the abstract. 3. Supports: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, CONCLUSIONS, sentence 1. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: The authors conclude for the same population. 4. Background: Effect of Salt Substitution on Cardiovascular Events and Death (Publication, edition Abstract only, from PubMed, fetched 2026-10-11. The published date is the print issue date; PubMed also gives an electronic publication date of 2021-08-29. The version of record at nejm.org returned HTTP 403. Europe PMC reports the article as not open access and not in PMC.) Locator: Abstract, METHODS, sentences 1 to 3. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 81ecee71f40d1529e615632d4873d8288566233e5de0fa8bfbf25db8c5ace858. How it applies: Design, population, villages and what each arm used. 5. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.armsInterventionsModule.armGroups and interventions\[0\].description. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: Registry description of the two arms: ongoing advice plus the substitute, versus advice at baseline only. 6. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.designModule.designInfo.maskingInfo. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: The registry records masking as DOUBLE (investigator and outcomes assessor); the abstract says open-label. Not reconciled. 7. Background: China Salt Substitute and Stroke Study (Registry, edition Record last posted 2021-04-08, status verified 2021-04, fetched 2026-10-11. The JSON has no results section.) Locator: protocolSection.designModule.enrollmentInfo.count. Retrieved 2026-10-11T19:11:27Z. Source state: Current. Snapshot hash: 7fb59c0de28942b6334a4072776326676f525b7454e1d33a3c60ee6c7c4cf6d3. How it applies: Registry enrollment 20996, against 20,995 in the abstract. Not reconciled. ## Context: Adults in general populations, not pregnant, without kidney impairment (WHO 2025 salt-substitute guideline) Recipient: Adult; Population: Adults in general populations. The recommendation excludes pregnant women, children, and people with kidney impairment or other circumstances or conditions that might compromise potassium excretion.; Care setting: Not stated as a care setting. The recommendation concerns table salt that a person adds to food while cooking or eating.; Geography: Global guideline; no country is specified; Life stage: Adult; the guideline states no age bounds and excludes children; Follow-up: Not applicable (recommendation context). The trials behind it followed adults from 56 days to 5 years. ### If adults in a general population choose to use table salt, WHO suggests replacing regular table salt with a lower-sodium salt substitute that contains potassium. This is a conditional recommendation, made alongside WHO's strong recommendation to keep sodium intake below 2 g a day. It is not intended for pregnant women, children, or people with kidney impairment or other conditions that might make it harder to clear potassium. - Category: Recommendation - Evidence stage: Guidance - Certainty: Low certainty (method: Stated by WHO in the guideline rationale, which describes the evidence behind this recommendation as "moderate-to-low certainty (an assessment of low certainty overall ...)". The atlas records the overall assessment, low. This is WHO's assessment, not an atlas reviewer judgement.) - Applies to: Recipient: Adult; Population: Adults in general populations. The recommendation excludes pregnant women, children, and people with kidney impairment or other circumstances or conditions that might compromise potassium excretion.; Care setting: Not stated as a care setting. The recommendation concerns table salt that a person adds to food while cooking or eating.; Geography: Global guideline; no country is specified; Life stage: Adult; the guideline states no age bounds and excludes children; Follow-up: Not applicable (recommendation context). The trials behind it followed adults from 56 days to 5 years. - Limitations: WHO describes the evidence behind the recommendation as "moderate-to-low certainty (an assessment of low certainty overall ...)". The per-outcome levels are in WHO's Annex 6 GRADE table, which this record does not extract. It covers table salt that a person adds to food, not condiments such as soy sauce or sodium already in manufactured foods and restaurant meals. All trials in WHO's review excluded people who could be harmed by extra potassium and some also excluded people with diabetes, so evidence for those groups is uncertain. WHO says reducing sodium from all sources is the preferred strategy, and that a household member at risk of hyperkalaemia should not have food prepared with a substitute. It is recorded beside the NICE caution and does not resolve it. - Last checked: Not recorded - Sources: 1. Supports: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, WHO recommendation box, page ix (recommendation sentence). Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: The recommendation as worded, with its condition. 2. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, WHO recommendation box, page ix (scope sentences). Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: Adults, not pregnant women or children, excluding kidney impairment. 3. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, Scope of the recommendation, page ix. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: Discretionary use of table salt only; condiments are outside the scope. 4. Supports: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, Rationale, first bullet, page xi. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: WHO states low certainty overall under GRADE. 5. Supports: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, Rationale, bullet 5, page xii. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: WHO says the recommendation is conditional because the certainty was low. 6. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, The evidence, page viii. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: Trials excluded people who could be harmed by extra potassium. 7. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, Remarks, bullet 1, page xii. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: Reducing sodium from all sources is preferred. 8. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Executive summary, Remarks, last bullet, page xiii. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: e7111969908bbf588c20b457b6f5f26ce16e6d9e023e7e179d8a9c1b54a318a0. How it applies: Household members at risk of hyperkalaemia. 9. Background: Use of lower-sodium salt substitutes: WHO guideline (Guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.) Locator: Page header, date line. Retrieved 2026-10-11T19:11:28Z. Source state: Current. Snapshot hash: 45cb6814f63da77e114e3dbc744dc1b8e2295a14f12cd9bc8c289216407d2c47. How it applies: Publication date shown on the WHO page. ## Guidance, authorization and access ### Recommendation `cardio:rec-nice-ng136-1-4-5` - Intervention: Salt substitution (lower-sodium, potassium-containing salt) (`cardio:salt-substitution`) - Direction: Recommended against - Issued by: National Institute for Health and Care Excellence (`cardio:nice`) - Guideline: Hypertension in adults: diagnosis and management (NICE guideline NG136), Recommendations chapter, edition The Recommendations chapter as shown on 2026-10-09 and fetched again on 2026-10-11 with identical bytes. The page header gives 26 February 2026 as the last update. This atlas cites six recommendations from it, each with the version tag the page shows: 1.1.3 is tagged \[2004\]; 1.2.3, 1.2.4 and 1.2.8 are tagged \[2019\]; 1.4.5 is tagged \[2004, amended 2019\]; 1.4.20 is tagged \[2019, amended 2022\]. Which edition of each recommendation these tags point to was not checked.; snapshot `cardio:nice-ng136-recs-2026-10-09` - Jurisdiction: England, from clause 6 of the NICE terms and conditions, which presents the information as support for people in England who make decisions about funding care. Clause 8 adds that NICE does not write its content as a basis for decisions outside the United Kingdom. The NG136 page itself states no jurisdiction. - Strength: Not labeled on the fetched page. The caution uses the wording should not be used. (Not stated on the fetched NG136 page. The caution is imperative wording with no NICE strength label, and how NICE treats this wording was not verified.) - Effective: 2019-08-28 (The date NG136 was first published. Recommendation 1.4.5 is tagged \[2004, amended 2019\], so it predates the guideline publication date. The page shows a last update of 26 February 2026.) - Applies to: Recipient: Adult; Population: Adults with suspected or diagnosed hypertension in the groups NICE names for potassium chloride salt substitutes: older people (NICE gives no age), people with diabetes, people with kidney disease, and people on some blood-pressure medicines (for example ACE inhibitors and angiotensin II receptor blockers). The recommendation says people and sits in the lifestyle section addressed to people with suspected or diagnosed hypertension. NICE also names pregnant women; that group is outside this context and belongs to the maternal atlas.; Care setting: Not stated on the fetched page; Geography: England, from clause 6 of the NICE terms and conditions, which presents the information as support for people in England who make decisions about funding care. Clause 8 adds that NICE does not write its content as a basis for decisions outside the United Kingdom. The NG136 page itself states no jurisdiction.; Life stage: Adult; older people are named but NICE gives no age bound; Follow-up: Not applicable (recommendation context) - Basis: claim `cardio:claim-nice-ng136-1-4-5-salt-caution` ### Recommendation `cardio:rec-who-2025-lsss` - Intervention: Salt substitution (lower-sodium, potassium-containing salt) (`cardio:salt-substitution`) - Direction: Recommended - Issued by: World Health Organization (`cardio:who`) - Guideline: Use of lower-sodium salt substitutes: WHO guideline, edition Guideline dated 27 January 2025 on the WHO page; English PDF from WHO IRIS, both fetched 2026-10-11. The PDF title page shows only the year 2025.; snapshot `cardio:who-lsss-pdf-2026-10-11` - Jurisdiction: Not tied to one country: a WHO global guideline. The document states no legal jurisdiction. - Strength: Conditional recommendation (WHO guideline process with GRADE: strong or conditional. A conditional recommendation is one where the group is less certain that the desirable consequences outweigh the undesirable ones (footnote 6 of the executive summary). WHO describes the evidence as "moderate-to-low certainty (an assessment of low certainty overall ...)"; the atlas records low.) - Effective: 2025-01-27 (Publication date shown on the WHO page. The PDF title page shows only the year 2025.) - Applies to: Recipient: Adult; Population: Adults in general populations. The recommendation excludes pregnant women, children, and people with kidney impairment or other circumstances or conditions that might compromise potassium excretion.; Care setting: Not stated as a care setting. The recommendation concerns table salt that a person adds to food while cooking or eating.; Geography: Global guideline; no country is specified; Life stage: Adult; the guideline states no age bounds and excludes children; Follow-up: Not applicable (recommendation context). The trials behind it followed adults from 56 days to 5 years. - Basis: claim `cardio:claim-who-2025-lsss` ## Connected pages - SSaSS, rural China (past stroke, or 60 or over with high blood pressure): fewer strokes with the substitute: Stroke (`core:stroke`) [a claim, not a settled fact; see claim `cardio:claim-ssass-stroke-effect` and its context] - WHO 2025: conditional, for adults in general populations who use table salt, as part of cutting sodium (not a test for individual high intake): High sodium intake (`cardio:high-sodium-intake`) [a claim, not a settled fact; see claim `cardio:claim-who-2025-lsss` and its context] - NICE 1.4.5: not for the groups it lists (always read with that subgroup context): Hypertension (high blood pressure) (`core:hypertension`) [a claim, not a settled fact; see claim `cardio:claim-nice-ng136-1-4-5-salt-caution` and its context] - Investigated in: China Salt Substitute and Stroke Study (SSaSS) (`cardio:ssass`) ## Provenance Content hash: 043dd285f13c1471eb0dc488f95a30876e032c98151230857d3d43c9ee35e04d Last substantive edit: 2026-10-12 Evidence last checked: 2026-10-12