Few people with high blood pressure were using salt substitutes, even though they are a simple and effective way to lower sodium intake and manage blood pressure, according to preliminary research presented at the American Heart Association’s Hypertension Scientific Sessions 2025. The meeting is the premier scientific exchange focused on recent advances in basic and clinical research on high blood pressure and its relationship to cardiac and kidney disease, stroke, obesity and genetics.
High blood pressure occurs when the force of blood flowing through the blood vessels is consistently too high. High blood pressure can lead to other serious events such as heart attack and stroke. Using data from 2017 to 2020, 122.4 million (46.7%) adults in the U.S. had high blood pressure and it contributed to more than 130,000 deaths. Too much sodium and too little potassium in the diet are risk factors for high blood pressure.
“Overall, less than 6% of all U.S. adults use salt substitutes, even though they are inexpensive and can be an effective strategy to help people control blood pressure, especially people with difficult-to-treat high blood pressure,” said lead study author Yinying Wei, M.C.N., R.D.N., L.D., and Ph.D. candidate in the departments of applied clinical research and hypertension section, cardiology division, at UT Southwestern Medical Center in Dallas. “Health care professionals can raise awareness about the safe use of salt substitutes by having conversations with their patients who have persistent or hard-to-manage high blood pressure.”
Salt substitutes are products that replace some or all of the sodium with potassium. Potassium salt tastes similar to regular salt, except when heated it can have a bitter aftertaste. Many foods contain some sodium in their natural state, however, the largest amount of sodium comes from processed and packaged foods and meals prepared at restaurants. The American Heart Association recommends consuming no more than 2,300 mg of sodium a day, with an ideal limit of less than 1,500 mg per day for most adults, especially for those with high blood pressure. For most people, cutting back by 1,000 mg a day can improve blood pressure and heart health.
This study is the first to examine long-term trends in salt substitute use among a nationally representative sample of U.S. adults. Using data from the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2020, researchers analyzed the use of products that replace salt with potassium-enriched or other alternative salts.
The investigation focused on people with high blood pressure, and an additional analysis was conducted among adults eligible to use salt substitutes, including people with normal kidney function and those not taking medications or supplements that affect blood potassium levels. Some salt substitutes contain potassium, and they can raise blood potassium to dangerous levels in people with kidney disease or those taking certain medications or potassium supplements. Excessive potassium can lead to irregular heart rhythms. People with high blood pressure who are thinking about switching from regular salt to a salt substitute should first consult with a health care professional.
The analysis found:
- Overall, salt substitute use among all U.S. adults remained low, peaking at 5.4% in 2013-2014 before falling to 2.5% by 2017-March 2020. Data collection for 2020 stopped before March because of the pandemic.
- Among adults eligible to use salt substitutes, only 2.3% to 5.1% did so.
- Usage was highest in people with high blood pressure whose BP was controlled with medications (3.6%-10.5%), followed by those with high blood pressure whose BP was not controlled despite medications (3.7%-7.4%).
- Salt substitute use remained consistently less than 5.6% among people with untreated high blood pressure and for people with normal blood pressure.
- Adults who ate at restaurants three or more times a week appeared less likely to use salt substitutes compared to those who ate out less often, but this difference was no longer statistically significant after accounting for age, race/ethnicity, education level and insurance status.
“Salt substitute use remained uncommon over the last two decades including among people with high blood pressure,” Wei said. “Even among individuals with treated and poorly managed or untreated high blood pressure, most continued to use regular salt.”
“This study highlights an important and easy missed opportunity to improve blood pressure in the U.S. — the use of salt substitutes,” said Amit Khera, M.D., M.Sc., FAHA, an American Heart Association volunteer expert. “The fact that use of salt substitutes remains so low and has not improved in two decades is eye-opening and reminds patients and health care professionals to discuss the use of these substitutes, particularly in visits focused on high blood pressure.” Khera, who was not involved in this study, is a professor of medicine, clinical chief of cardiology and director of preventive cardiology at UT Southwestern Medical Center in Dallas.
The study has several limitations. First, information about salt substitute use was self-reported, so there may have been underreporting or misclassification. In addition, all types of salt substitutes were included in the analysis, therefore, the analysis could not specifically separate potassium-enriched salt from other types of salt substitutes. Finally, the survey data did not capture how much salt substitute the participants used.
“Future research should explore why salt substitute-use remains low by investigating potential barriers, such as taste acceptance, cost and limited awareness among both patients and clinicians,” said Wei. “These insights may help guide more targeted interventions.”
Study details, background and design:
- The analysis included 37,080 adults, ages 18 and older (37.9% were aged 18-39, 36.9% were aged 40-59 years, and 25.2% were aged 60 and older). 50.6% of participants were women, 10.7% of participants self-reported their race as non-Hispanic Black, and 89.3% self-reported they were from other racial and ethnic groups.
- Participants were categorized into four subgroups based on presence or absence of high blood pressure (≥130/80 mm Hg) and whether they were using blood pressure lowering medication: 1) high blood pressure that was treated and controlled; 2) high blood pressure that was treated and not controlled; 3) untreated high blood pressure; and 4) those with normal blood pressure.
- Salt types were classified as ordinary salt (iodized salt, sea salt, kosher salt), salt substitute (potassium-enriched or other salt substitute) and no salt use.
- An additional analysis was conducted on a subgroup of individuals eligible to use salt substitutes — those with healthy kidney function (estimated glomerular filtration rate ≥ 60) and not taking medications or supplements that affect blood potassium levels.
- The frequency of eating at restaurants to assess its influence on salt substitute use was also evaluated.
- All analyses incorporated NHANES sampling weights and complex survey design.
Research Highlights:
- Despite their effectiveness in lowering sodium intake and managing blood pressure, salt substitutes were rarely used by people with high blood pressure, according to a review of almost 20 years of U.S. health survey data.
- Researchers recommend increasing awareness of salt substitutes as a strategy to help effectively treat blood pressure, especially for individuals with difficult-to-treat or treatment-resistant high blood pressure.
- The study is supported by a grant from the National Institutes of Health.
- Note: The study featured in this news release is a research abstract. Abstracts presented at American Heart Association‘s scientific meetings are not peer-reviewed, and the findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.