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Salt Reduction to Prevent Hypertension and Cardiovascular Disease
Open accessAbstract
There is strong evidence for a causal relationship between salt intake and blood pressure. Randomized trials demonstrate that salt reduction lowers blood pressure in both individuals who are hypertensive and those who are normotensive, additively to antihypertensive treatments. Methodologically robust studies with accurate salt intake assessment have shown that a lower salt intake is associated with a reduced risk of cardiovascular disease, all-cause mortality, and other conditions, such as kidney disease, stomach cancer, and osteoporosis. Multiple complex and interconnected physiological mechanisms are implicated, including fluid homeostasis, hormonal and inflammatory mechanisms, as well as more novel pathways such as the immune response and the gut microbiome. High salt intake is a top dietary risk factor. Salt reduction programs are cost-effective and should be implemented or accelerated in all countries. This review provides an update on the evidence relating salt to health, with a particular focus on blood pressure and cardiovascular disease, as well as the potential mechanisms.
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“People with CVD and T2DM are encouraged to reduce sodium intake, as this may reduce systolic BP by, on average, 5.8 mmHg in hypertensive patients and 1.9 mmHg in normotensive patients.94,95”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [95]
In the citing paper
“In a meta-analysis, in hypertensive and normotensive people, reducing salt intake by 2.5 g/day resulted in a 20% relative reduction of ASCVD events.95”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [95]
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2 retracted
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Self-citationDiet in Scleroderma: Is There a Need for Intervention?
Burlui, A., Cardoneanu, A., Macovei, L. A., Rezuș, C., Boiculese, L. V., Graur, M., & Rezuş, E. (2021) · Diagnostics · doi:10.3390/diagnostics11112118 · Cited by 21
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Key Updates to the 2024 ESC Hypertension Guidelines and Future Perspectives
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Eyles, H. C., Grey, J., Jiang, Y., Umali, E., McLean, R. M., Morenga, L. T., Neal, B. C., Rodgers, A., Doughty, R. N., & Mhurchú, C. N. (2023) · JMIR mhealth and uhealth · doi:10.2196/43675 · Cited by 18
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“24,25 The relationship between salt consumption and CVD is inconclusive and warrants further investigation.”
BackgroundCost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities
Lai, X., Yuan, Y., Wang, H., Zhang, R., Qiao, Q., Feng, X., Jin, A., Li, H., Li, J., Si, L., et al. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.55564 · Cited by 18
Fatores associados ao consumo de sal na população adulta brasileira: Pesquisa Nacional de Saúde
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Recomendaciones preventivas cardiovasculares. Actualización PAPPS 2022
Orozco‐Beltrán, D., Cuixart, C. B., Banegas, J. R., Gil-Guillén, V. F., Cuenca, A. M. C., Rioboó, E. M., Baldó, A. J., Vicuña, J., & Pérez, J. N. (2022) · Atención Primaria · doi:10.1016/j.aprim.2022.102444 · Cited by 64
Wang, Y., Jia, H., Gao, W., Zou, T., Yao, S., Du, M., Zhang, X., Chu, C., Liao, Y., Chen, C., et al. (2021) · Journal of Hypertension · doi:10.1097/hjh.0000000000002846 · Cited by 17
“Among environmental determinants of BP variations, high-dietary salt intake appears most significant [4].”
BackgroundDiagnosis and Management of Resistant Hypertension
Azizi, M., Vongpatanasin, W., Fisher, N. D. L., Mahfoud, F., Amar, L., & Kirtane, A. J. (2026) · JAMA · doi:10.1001/jama.2026.1221 · Cited by 19
High Salt Induces a Delayed Activation of Human Neutrophils
Mazzitelli, I. G., Bleichmar, L., Melucci, C., Gerber, P. P., Toscanini, M. A., Cuestas, M. L., Díaz, F. A. E., & Geffner, J. R. (2022) · Frontiers in Immunology · doi:10.3389/fimmu.2022.831844 · Cited by 17
“High-salt intake induces a chronic low-grade inflammation promoting not only hypertension (12), kidney damage (13), and cardiovascular disease (14) but also a more severe outcome in a number of inflammatory diseases (15–18).”
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Wu, W., Jiang, Q., Gao, P., Yu, D., Yang, F., Xu, Y., & Xia, W. (2022) · International Journal of Food Science & Technology · doi:10.1111/ijfs.16207 · Cited by 16
The current state of evidence for sodium and fluid restriction in heart failure
Colin-Ramírez, E., Arcand, J., Saldarriaga, C., & Ezekowitz, J. A. (2024) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2024.01.004 · Cited by 16
Adding salt to foods and risk of psoriasis: A prospective cohort study.
Zhou, G.-W., Gan, L., Zhao, B., Fang, F., Liu, H., Chen, X., & Huang, J.-Q. (2024) · Journal of Autoimmunity · doi:10.1016/j.jaut.2024.103259 · Cited by 12
Kong, F., Liu, Q., Zhou, Q., Xiao, P., Bai, Y., Wu, T., & Xia, L. (2025) · Annals of Medicine · doi:10.1080/07853890.2025.2582065 · Cited by 27
“In addition, sodium concentration may alter the composition and diversity of the gut microbiota, which in turn can influence the development of cardiovascular-related diseases through gut–immune–vascular interactions [55,57,58].”
Karagiannidis, A. G., Theodorakopoulou, M. P., Ferro, C. J., Ortíz, A., Soler, M. J., Halimi, J., Januszewicz, A., Persu, A., Kreutz, R. H., & Sarafidis, P. A. (2022) · Clinical Kidney Journal · doi:10.1093/ckj/sfac235 · Cited by 15
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The direct and indirect costs of cardiovascular diseases in Brazil
de Araújo, J. M., Rodrigues, R. E. D. A., Neta, A. D. C. P. D. A., Ferreira, F. E. L. D. L., de Lima, R. L. F. C., Vianna, R. P. D. T., Moreira, L. V. L., Neto, J. M. D. S., & Moreira, P. V. L. (2022) · PLoS ONE · doi:10.1371/journal.pone.0278891 · Cited by 15
“These UPF have high levels of the above mentioned nutrients, with scientific evidence of their relation to obesity [15, 16], diabetes mellitus [17, 18], hypertension [19] and cardiovascular diseases [20–22].”
BackgroundSodium Homeostasis and Hypertension
Aung, K., Ream-Winnick, S., Lane, M., Akinlusi, I., Shi, T., & Htay, T. (2023) · Current Cardiology Reports · doi:10.1007/s11886-023-01931-5 · Cited by 17
Antihypertensive Effect, ACE Inhibitory Activity, and Stability of Umami Peptides from Yeast Extract
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“Reducing salt intake reduces blood pressure levels in elderly patients 27 and greater reductions in blood pressure can be achieved when reducing salt intake is combined with other lifestyle interventions, 28 therefore knowledge and health education about salt is a continuing focus for community…”
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“…patients, a low salt diet is recommended, which means a daily salt intake of <6 g. Randomized trials have shown that reducing salt intake can not only improve hypertension in patients, but also lowered blood pressure in patients with normal blood pressure (He and MacGregor, 2010; He et al., 2020).”
BackgroundCurrent Advances in the Salt Reduction Properties of Kokumi γ-Glutamyl Peptides: A Review
Li, J., Yi, H.-B., Wang, P., Wang, S., Liu, H., & Zhang, N. (2024) · Food Reviews International · doi:10.1080/87559129.2024.2412866 · Cited by 15
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Epidemiology of cardiovascular risk factors: Behavioural risk factors
Olié, V., Grave, C., Helft, G., Nguyen‐Thanh, V., Andler, R., Quatremère, G., Pasquereau, A., Lahaie, E., Lailler, G., Verdot, C., et al. (2024) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2024.10.328 · Cited by 19
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Toft, U., Riis, N. L., Lassen, A. D., Trolle, E., Andreasen, A. H., Frederiksen, A. K. S., Joergensen, N. R., Munk, J. K., & Bjoernsbo, K. S. (2020) · Nutrients · doi:10.3390/nu12051467 · Cited by 15
Aminde, L. N., Phung, H. N., Phung, D. T., Cobiac, L. J., & Veerman, L. J. (2021) · Frontiers in Public Health · doi:10.3389/fpubh.2021.682975 · Cited by 15
“Mozaffarian et al. showed that sodium intake above 2 grammes/day was responsible for over 1.6 million CVD deaths worldwide in 2010, majority from stroke and ischaemic heart disease (10).”
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“A reduction in dietary sodium not only decreases the blood pressure and the incidence of hypertension, also is associated with a reduction in morbidity and mortality from cardiovascular diseases [32,33].”
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“The activation of the renin-angiotensinaldosterone system (RAAS), oxidative stress, and inflammation are all related to high salt-induced renal damage [7].”
BackgroundTotal Body Sodium Balance in Chronic Kidney Disease
Martin, K., Tan, S., & Toussaint, N. D. (2021) · International Journal of Nephrology · doi:10.1155/2021/7562357 · Cited by 15
“As the ability to excrete sodium decreases with progressive kidney decline [8], the negative impact of sodium on health outcomes is accentuated, with higher sodium intake linked to CKD progression [9], worsening hypertension, cardiovascular mortality and morbidity [10], increasing risk of left ventricular hypertrophy…”
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“Achieving and sustaining salt reduction by limiting the habit of adding salt at the table, even by a modest amount, will bring enormous benefits worldwide [35].”
BackgroundLess sodium and more potassium to reduce cardiovascular risk
Muiesan, M. L., Buso, G., & Rosei, C. A. (2023) · European Heart Journal Supplements · doi:10.1093/eurheartjsupp/suad084 · Cited by 14
“At the same time, experimental evidence and observational studies have been collected to demonstrate that the reduction in salt consumption is associated with a reduction in BP and a lower incidence of CV events and death from all causes.(4,5) In most countries in the world, the consumption of salt far exceeds the amo…”
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“Numerous studies have shown that high sodium intake was associated with increased blood pressure [3,5,18,19], whereas reduced sodium intake may lower blood pressure [3,6,8,18,20–22].”
BackgroundHigh Adherence to Mediterranean Diet Is Not Associated with an Improved Sodium and Potassium Intake
Viroli, G., Gonçalves, C., Pinho, O., Silva-Santos, T., Padrão, P., & Moreira, P. A. M. (2021) · Nutrients · doi:10.3390/nu13114151 · Cited by 16
“Cardiovascular disease (CVD) is the leading cause of disease in the world [1,2] causing an estimated 31% of worldwide deaths [3] and hypertension is one of the known major risk factors for CVD, in addition to lifestyle, physical inactivity, genetic and dietary factors [4].”
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Carnauba wax utilization in salt encapsulation: application in bread
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Modelling the impact of sodium intake on cardiovascular disease mortality in Mexico
Vargas-Meza, J., Nilson, E. A. F., Nieto, C., Khandpur, N., Denova‐Gutiérrez, E., Valero‐Morales, I., Barquera, S., & Campos‐Nonato, I. (2023) · BMC Public Health · doi:10.1186/s12889-023-15827-0 · Cited by 13
Wang, Z., Lu, C., Wang, Y., Fenfen, E., Mentis, A. A., Li, X., & Yang, K. (2023) · Hellenic Journal of Cardiology · doi:10.1016/j.hjc.2023.07.010 · Cited by 15
Charlton, K. E., Pretorius, B., Shakhane, R., Naidoo, P., Cimring, H., Hussain, K., Nojilana, B., & Webster, J. L. (2023) · Journal of Food Composition and Analysis · doi:10.1016/j.jfca.2023.105908 · Cited by 13
Multisectoral action to address noncommunicable diseases: lessons from three country case studies
Akselrod, S., Collins, T. E., Berlina, D., Campos, K. D. P., Fones, G., Neves, D. D. S., Bashir, F., & Allen, L. N. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1303786 · Cited by 12
“…a 7% reduction in salt intake from the period 2005–2019 from 8.1 to 7.5 g/day (27), and 2.7-mm Hg fall in average population systolic blood pressure, and a significant reduction in mortality from stroke and ischemic heart disease that is largely attributable to the fall in salt intake (28, 29).”
BackgroundInfluentialLi, X.-A., Sui, Y., Lu, J., Ren, J., Kong, B., Li, Y., Chen, Q., & Yang, W. (2024) · LWT · doi:10.1016/j.lwt.2024.116115 · Cited by 13
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“Although salt is one of the most essential dietary components, excessive salt intake has been extensively studied and proven to cause a wide range of diseases through its effects on the gut microbiome (8).”
Yang, T., Wang, B., Lv, T., Wang, P., Zhou, Q., Jiang, D., & Jiang, H. (2024) · Food Hydrocolloids · doi:10.1016/j.foodhyd.2024.110827 · Cited by 13
Mizuta, E., Kitada, K., Nagata, S., Ogura, S., Sakima, A., Suzuki, J., Arima, H., & Miura, K. (2025) · Hypertension Research · doi:10.1038/s41440-025-02181-4 · Cited by 13
“Additionally, sodium reduction has promoted vascular smooth muscle relaxation, thereby improving vasodilation, as well as suppressing system activation, both of which further contribute to decreasing BP [51].”
Egan, B. M., Lackland, D. T., Sutherland, S. E., Rakotz, M., Williams, J., Commodore-Mensah, Y. Y., Jones, D. W., Kjeldsen, S. E., Campbell, N. R. C., Parati, G., et al. (2025) · Journal of Human Hypertension · doi:10.1038/s41371-025-00990-1 · Cited by 14
Self-citationRiis, N. L., Lassen, A. D., Bjoernsbo, K. S., Toft, U., & Trolle, E. (2022) · Nutrients · doi:10.3390/nu14183852 · Cited by 12
Holmberg, A. H., Martinsson, L., Lidin, M., Rück, C., Mataix‐Cols, D., & de la Cruz, L. F. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05566-w · Cited by 14
“Excessive consumption of meat and salt is linked to various health risks [47, 48], and their intake is advised to be restricted [42].”
BackgroundKnowledge, attitudes, and practices related to dietary salt among older adults in Abha, Saudi Arabia
Alhazmi, A. H., Hawash, M. M., Ali, H., Narapureddy, B. R., & Aziz, F. (2024) · Journal of Health Population and Nutrition · doi:10.1186/s41043-024-00545-z · Cited by 16
Theodorakis, N., Nikolaou, M., & Krentz, A. J. (2025) · Biomolecules · doi:10.3390/biom15030373 · Cited by 12
“…technological advancements such as telemedicine, wearable devices, and mobile health applications can further facilitate patient engagement and adherence to lifestyle modifications [23,67–69]. applications can further facilitate patient engagement and adherence to lifestyle modifications [67–70].”
InfluentialLeonberg, K. E., Maski, M. R., Scott, T. M., & Naumova, E. N. (2025) · Nutrients · doi:10.3390/nu17091560 · Cited by 15
“Another potential explanation may be the effect of a high-sodium diet and increasing oxidative stress and causing alterations in the kidney and vascular systems [35,36].”
Less Salt, Same Taste: Food Marketing Strategies via Healthier Products
Campo, R., Rosato, P., & Giagnacovo, D. (2020) · Sustainability · doi:10.3390/su12093916 · Cited by 12
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“Furthermore, salt reduction has an additive effect, direct and independent of the effect on blood pressure in cardiovascular diseases, for example, in reducing the risk of stroke [3,12].”
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Mechanisms of sodium‐mediated injury in cardiovascular disease: old play, new scripts
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“The consumption of these products in excess promotes an excessive intake of sugar and salt, which are recognized as risk factors for the development of numerous metabolic diseases, including obesity, diabetes, cancer and cardiovascular diseases [22,23].”
BackgroundSalt reduction strategies and enhanced saltiness perception mechanisms for prepared dishes: A review
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Current physical processing technologies for salt reduction in prepared dishes
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“Although numerous complex and interrelated physiological pathways have been implicated in the salt–blood pressure relationship, many of these underlying mechanisms remain incompletely understood [216,217].”
Salt: the forgotten foe in UK public health policy
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“However, they have higher intakes of carbohydrates and unhealthy foods, which are associated with the risk of several diseases [19, 47, 48].”
BackgroundDiversity of hypertension in obesity
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Magnetic resonance imaging determination of tissue sodium in patients with chronic kidney disease
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“K E YWORD S cardiovascular disease, chronic kidney disease, hypertension, inflammation, sodium SUMMARY AT A GLANCE A review on the understanding of sodium physiology, and the development and the role of sodium-23 MRI in measuring total body sodium and its implications on hyper- tension, vascular disease, and immune dy…”
BackgroundInfluentialSodium Content of Foods Sold in the Spanish Market. Results from the BADALI Project
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“Randomized trials demonstrate that salt reduction lowers blood pressure in normotensive, as well as in hypertensive individuals additively to antihypertensive treatments [14].”
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Fermented Vegetables and Legumes vs. Lifestyle Diseases: Microbiota and More
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Effects of High- Versus Low-Sodium Oxybate on Blood Pressure in Patients With Narcolepsy
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Serum sodium and risk of hypertension: a cohort study
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“Various types of studies, including epidemiological, migration, intervention, genetic and animal studies, have consistently shown that dietary sodium intake is a major cause of hypertension [4].”
BackgroundSelf-citationDietary management of dyslipidemia
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“91,92 100 Rather, several meta-analyses of prospective observational studies report a J/U-shaped mortality curve, suggesting a troubling increase in all-cause mortality with low-sodium diets both in hypertensive as well as normotensive individuals.”
BackgroundUsing Genetics to Inform Interventions Related to Sodium and Potassium in Hypertension
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“32 Scientific evidence confirms that reducing salt intake leads to a decrease in blood pressure in both individuals with hypertension and those with normal blood pressure, typically observed within weeks of implementing sodium restriction.”
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“The health benefits of sodium reduction have been examined in many aspects [34,35].”
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eHypertension: A prospective longitudinal multi‐omics essential hypertension cohort
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“However, we modelled the effect mediated through BP, for which the evidence is strongest [7].”
BackgroundStructuring meat analogs by citrus fiber with reduced salt intake
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Are Household Potato Frying Habits Suitable for Preventing Acrylamide Exposure?
Mesías, M., Delgado‐Andrade, C., & Morales, F. J. (2020) · Foods · doi:10.3390/foods9060799 · Cited by 10
“Thus, as long as the amount of added salt is not high and adheres to health recommendations for salt consumption [32], the population should be encouraged to add salt before frying.”
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“Similarly, higher salt intake is associated with increased hypertension and CVD mortality [37].”
Background
Metadata
- Authors
- He, F. J., Tan, M., Ma, Y., & MacGregor, G. A.
- Affiliations
- Queen Mary University of London (GB)
- Harvard University (US)
- Corresponding author
- He, Feng J.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2020-02
- Volume
- 75
- Issue
- 6
- Pages
- 632-647
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W3005813910
- Cited by
- 589
- References
- 182
- Citations by year
- 2026: 71 · 2025: 125 · 2024: 123 · 2023: 86 · 2022: 97 · 2021: 64 · 2020: 22
- FWCI
- 8.29
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Queen Mary Research Online (Queen Mary University of London) (submittedVersion, cc-by-nc-nd)
- Funders
- National Institute for Health and Care Research (16/136/77)
- Medical Research Council (MR/P012590/1, MR/J015903/1)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Keywords
- salt reduction, dietary sodium, hypertension, blood pressure, cardiovascular disease, all-cause mortality, kidney disease, gastric cancer, osteoporosis, fluid homeostasis, inflammation, gut microbiota, immune response, dietary risk factors, cost-effectiveness
- MeSH terms
- Blood Pressure, Humans, Hypertension, Legislation, Food, Sodium Chloride, Dietary
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