World Hypertension League perspective on public health initiatives to reduce global sodium consumption: are we not seeing the elephant in the room?

Sodium reduction is a well-established strategy for the prevention of cardiovascular disease (CVD), yet effective implementation requires context-specific approaches. Low-sodium salt substitutes (LSSS), in which sodium chloride is partially replaced with potassium chloride, have been investigated as an adjunct intervention. Evidence from randomized controlled trials in Peru and China demonstrates substantial increases in potassium intake and corresponding improvements in blood pressure and CVD outcomes. However, reductions in sodium intake were modest or absent, suggesting that the observed benefits are mediated primarily by potassium rather than sodium reduction. Additional concerns include compensatory sodium consumption from alternative sources, limited evaluation beyond high-risk cohorts, and uncertain safety in populations excluded from trials, such as individuals with kidney disease, children, and pregnant women. Current World Health Organization guidance remains ‘conditional’, reflecting these uncertainties. While LSSS may contribute to CVD prevention strategies, the central objective of global policy continues to be the sustained reduction of population sodium intake.