JSH2025 retains the target of less than 6 g of salt per day, a value first established by JSH2004. In contrast, many international guidelines set lower targets (Table 1) to achieve greater reductions in blood pressure (BP). JSH2025 established 11’Questions (Q)’ addressing practical clinical questions faced by physicians. Regarding salt reduction, considering that overseas guidelines propose lower target values: Q.3 Is it necessary to further reduce the target salt intake for hypertensive patients in Japan from < 6 g/day? The answer is as follows: “Salt reduction is dose dependent, and a further reduction in salt intake below 6 g/day can be expected to result in further reduction of BP. However, it is not easy to reduce salt intake further while maintaining energy requirements and other nutrients in the daily diet; therefore, unless guidance is available from a dietitian or other specialist, there is no need to reduce salt intake further than <6 g/day” [1]. In other words, the JSH can be stated as having set achievable goals without adversely affecting health.
Regarding salt substitutes (in which some Na (sodium) is replaced with potassium (K)), all guidelines published after the report of a large randomized clinical trial [7] that used them describe and recommend their use. The use of salt substitutes receives a Class I recommendation in both the 2024 CSC and the 2023 ESH guidelines. Given the numerous large‑scale randomized controlled trials (RCTs) conducted in China, the CSC strongly endorses this approach. However, the ESH considers conventional salt‑reduction methods alone insufficient and recommends alternative salts as an additional strategy.
Although many guidelines mention the Na/K ratio, only JSH2025 and ESC2024 specify target values. In JSH2025, the ratio is highlighted in Question 5, which reads: Q.5 Is the spot urine Na/K ratio measurement effective for Na reduction and BP management? What is its target value? The answers to this question are as follows. An optimal target value for urinary Na/K ratio in healthy Japanese is less than 2; this corresponds to the target amount of Na and K in the dietary reference intakes for Japanese. However, a target value of less than 4, which corresponded to less than the average value, was set as the feasible target. The spot urine Na/K ratio can be easily and inexpensively measured at health checkups and healthcare institutions throughout Japan. We anticipate that the urinary Na/K ratio can be further utilized for BP control as an indicator of Na reduction and increased K + intake [1]. In contrast, ESC2024 notes only that the recommended Na and K intakes yield a urinary Na/K ratio of 1.5–2.0, which is associated with a lower risk of cardiovascular disease.
Dietary patterns and nutrients other than Na
The JSH has not previously specified a target value for K intake. Because K consumption among Japanese individuals is low, we aim to encourage increased intake and have therefore established target values based on the Japanese Dietary Reference Intakes [8]. International guidelines also recommend higher K intake; although only some provide explicit targets, all of those targets exceed the values in JSH2025 (Table 1). The lower target in JSH2025 likely reflects the generally low K intake in the Japanese population [9]. Regarding dietary patterns, the DASH diet is the primary recommendation overseas.
Maintain an appropriate body weight
Weight-loss goals were set according to each country’s obesity rate and Body Mass Index (BMI) levels. In the United States, where obesity is prevalent and severe, the AHA/ACC2025 recommends a weight loss of ≥5% of body weight or a reduction in BMI of ≥3 kg/m². It is also characteristic that in guidelines other than JSH2025, this item is titled “Weight reduction”.