Population reduction in salt intake for the prevention of cardiovascular disease: the “Four Imperatives”

From Top Italian Scientists Journal
March 1, 2024
Population reduction in salt intake for the prevention of cardiovascular disease: the “Four Imperatives”
Francesco P Cappuccio
salt, sodium, population, reduction, blood pressure, CVD, policy, WHO.
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Francesco P Cappuccio

Division of Health Sciences, Warwick Medical School, University of Warwick; Gibbet Hill Road, Coventry CV6 7AL (United Kingdom). f.p.cappuccio@warwick.ac.uk


Salt consumption is now much greater than needed for survival. High salt intake increases blood pressure in both animals and humans. Conversely, a reduction in salt intake causes a dose-dependent reduction in blood pressure in men and women of all ages and ethnic groups, and in patients already on medication. The risk of strokes and heart attacks rises with increasing blood pressure, and a reduction of blood pressure with drugs reduces the risk. However, most events occur in individuals with ‘normal’ blood pressure levels. Non-pharmacological prevention is therefore the only option to reduce such events in the population at large. Reduction in population salt intake reduces the number of vascular events. It is one of the most important public health measures to reduce the global cardiovascular burden. Salt reduction policies are feasible and effective (preventive imperative), cost-saving (economic imperative), powerful, rapid, equitable (political imperative) and life-saving (moral imperative). The World Health Organization recommends reducing salt consumption by 30% globally by 2025, aiming to reduce salt consumption to less than 5g per day, eventually.


Conflict of Interest

The Author declares that there is no conflict of interest.


  1. Federal Food Safety and Veterinary Office FSVO. Report on the composition of prevalent salt varieties. (2016)https://www.blv.admin.ch/dam/blv/de/dokumente/lebensmittel-und-ernaehrung/ernaehrung/report-on-the-composition-of-prelevant-salt-varieties.pdf.download.pdf/report-on-the-composition-of-prelevant-salt-varieties.pdf
  2. Cappuccio FP, Capewell S. Facts, issues and controversies in salt reduction for the prevention of cardiovascular disease. Funct Food Rev 7: 41-61(2015). https://doi.org/10.2310/6180.2015.00005
  3. Mattes R, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr 10: 383-93 (1991). https://doi.org/10.1080/07315724.1991.10718167
  4. World Health Organization. Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), pp.1-56 (2012). https://www.who.int/publications/i/item/9789241504836
  5. MacGregor GA, Markandu ND, Sagnella GA, Singer DRJ, Cappuccio FP. Double-blind study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet ii: 1244-7 (1989). https://www.sciencedirect.com/science/article/abs/pii/S0140673689918527
  6. Elijovich F, Weinberger MH, Anderson CAM, et al. Salt Sensitivity of Blood Pressure: A Scientific Statement from the American Heart Association. Hypertension 68: e7– e46 (2016). https://www.ahajournals.org/doi/10.1161/HYP.0000000000000047
  7. Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl J. Effect of lower sodium intake on health outcomes: systematic review and meta-analysis. Br Med J 346: f1326 (2013). https://www.bmj.com/content/346/bmj.f1326
  8. Strazzullo P, D'Elia L, Kandala N-B, Cappuccio FP. Salt intake, stroke and cardiovascular disease: a meta-analysis of prospective studies. Br Med J 339: b4567 (2009). https://www.bmj.com/content/339/bmj.b4567
  9. Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake and reduced cardiovascular risk. Circulation 129: 981-9 (2014). https://doi.org/10.1161/CIRCULATIONAHA.113.006032
  10. Cook NR, Appel LJ, Whelton PK. Sodium intake and all-cause mortality over 20 years in the Trials of Hypertension Prevention. J Am Coll Cardiol 68: 1609-17 (2016). https://www.jacc.org/doi/10.1016/j.jacc.2016.07.745?_ga=2.44320164.1420539151.1704821801-1917898752.1704821801
  11. He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet 378: 380-2 (2011). https://doi.org/10.1016/S0140-6736(11)61174-4
  12. He FJ, Campbell NRC, Ma Y, et al. Errors in estimating usual sodium intake by the Kawasaki formula alter its relationship with mortality: implications for public health. Int J Epidemiol 47: 1784-95 (2018). https://doi.org/10.1093/ije/dyy114
  13. Cappuccio FP, Beer M, Strazzullo P, on behalf of the European Salt Action Network. Population dietary salt reduction and the risk of cardiovascular disease. A scientific statement from the European Salt Action Network. Nutr Metab Cardiovasc Dis 29: 107-11 (2019). https://doi.org/10.1016/j.numecd.2018.11.010
  14. Cappuccio FP, Sever PS. The importance of a valid assessment of salt intake in individuals and populations. A scientific statement of the British and Irish Hypertension Society. J Hum Hypert 33: 345-8 (2019). DOI: 10.1038/s41371-019-0203-1
  15. Mente A, O’Donnell MJ, Dagenais G, et al. Validation and comparison of three formulae to estimate sodium and potassium excretion from a single morning fasting urine compared to 24-h measures in 11 countries. J Hypertens 32: 1005-15 (2014). doi: 10.1097/HJH.0000000000000122.
  16. Huang L, Woodward M, Stepien S, et al. Spot urine samples compared with 24-h urine samples for estimating changes in urinary sodium and potassium excretion in the China Salt Substitute and Stroke Study. Int J Epidemiol 47: 1811-20 (2018). https://doi.org/10.1093/ije/dyy206
  17. Webb M, Fahimi S, Singh GM, et al. Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations Br Med J 356: i6699 (2017). https://www.bmj.com/content/356/bmj.i6699
  18. Bibbins-Domingo K, Chertow GM, Coxson OG, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. N Engl J Med 362: 590-9 (2010) DOI: 10.1056/NEJMoa0907355
  19. Martikainen JA, Soini EJ, Laaksonen DE, et al. Health economic consequences of reducing salt intake and replacing saturated fat with polyunsaturated fat in the adult Finnish population: estimates based on the FINRISK and FINDIET studies. Eur J Clin Nutr 65: 1148-55 (2011). DOI: 10.1038/ejcn.2011.78
  20. Murray CJ, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 361: 717-25 (2003). DOI: 10.1016/S0140-6736(03)12655-4
  21. Cappuccio FP, Capewell S, Lincoln P, McPherson K. Policy options to reduce population salt intake. Br Med J 343: 402-5 (2011). https://www.bmj.com/content/343/bmj.d4995
  22. Hyseni L, Elliot-Green A, Lloyd-Williams F, et al. Systematic review of dietary salt reduction policies: evidence for an effectiveness hierarchy? PLoS ONE 12: e0177535 (2017) https://doi.org/10.1371/journal.pone.0177535
  23. Ji C, Kandala N-B, Cappuccio FP. Spatial variation of salt intake in Britain and association with socio-economic status. BMJ Open 3: e002246 (2013). https://bmjopen.bmj.com/content/3/1/e002246
  24. Cappuccio FP, Ji C, Donfrancesco C, et al. Geographic and socio-economic variation of sodium and potassium intake in Italy. Results from the MINISAL-GIRCSI programme. BMJ Open 5: e007467 (2015). https://bmjopen.bmj.com/content/5/9/e007467
  25. Ji C, Cappuccio FP. Socio-economic inequality in salt intake in Britain 10 years after a national salt reduction programme. BMJ Open 4: e005683 (2014) https://bmjopen.bmj.com/content/4/8/e005683
  26. Gillespie DOS, Allen K, Guzman-Castillo M, et al. The health equity and effectiveness of policy options to reduce dietary salt intake in England: policy forecast. PLoS ONE 10: e0127927 (2015). https://doi.org/10.1371/journal.pone.0127927
  27. Mozzafarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. New Engl J Med 371: 624-34 (2014). DOI: 10.1056/NEJMoa1304127
  28. Cappuccio FP, Capewell S, He FJ, MacGregor GA. Salt: the dying echoes of the food industry. Am J Hypert 27: 279-81 (2014). DOI: 10.1093/ajh/hpt216
  29. Cappuccio FP. Section 44.6. Sodium and potassium intake, blood pressure and cardiovascular prevention. In: The ESC Textbook of Cardiovascular Medicine, Third edition. AJ Camm, TF Luscher, G Maurer, PW Serruys eds. Oxford University Press (2018). https://www.amazon.co.uk/Textbook-Cardiovascular-Medicine-European-Cardiology/dp/0198784902
  30. Campbell NRC, He FJ, Cappuccio FP, MacGregor GA. Dietary sodium 'controversy': issues and potential solutions. Curr Nutr Rep 10: 188-99 (2021). https://link.springer.com/article/10.1007/s13668-021-00357-1
  31. Cappuccio FP, Campbell NRC, He FJ, et al. Sodium and health: old myths, and a controversy based on denial. Curr Nutr Rep 11:172–84 (2022). https://link.springer.com/article/10.1007/s13668-021-00383-z
  32. He FJ, Markandu ND, Sagnella GA, MacGregor GA. Effect of salt intake on renal excretion of water in humans. Hypertension 38: 317-20 (2001). https://doi.org/10.1161/01.HYP.38.3.317
  33. He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 51: 629-34 (2008). https://doi.org/10.1161/HYPERTENSIONAHA.107.100990