By- Wanpen Vongpatanasin, M.D., Program Director, Hypertension Fellowship Program, Internal Medicine – Hypertension and John Giacona, PA-C, Ph.D., CHC, Internal Medicine – Cardiology at UT Southwestern Medical Center
Americans have had a long love affair with sodium. From fast food to processed grocery items to saltshakers on the table, it’s far too easy to consume too much salt in the U.S.
For people with high blood pressure, reducing sodium intake can help lower blood pressure and reduce the risk of stroke and heart attack. Research shows that replacing table salt with a potassium-containing substitute is a simple way to bring sodium levels down.
But a new analysis of U.S. national survey data suggests that despite those potential benefits, Americans aren’t embracing salt substitutes as an option. In fact, use of these products has declined over time.
In a research letter published in the American Heart Association journal Hypertension, a team of UT Southwestern researchers found that only about 2.5% to 5.4% of U.S. adults reported using a salt substitute. Our analysis of National Health and Nutrition Examination Survey data from 2003 to 2020 showed that even among people being treated for hypertension, fewer than 1 in 10 reported using salt substitutes.
These numbers raise a valid question: If salt substitutes can help, why aren’t more people using them?
Let’s discuss the risks associated with consuming too much sodium, possible barriers to salt substitutes and tips for using them, and who can benefit from choosing potassium-based seasonings.
How can excessive sodium harm our health?
High sodium intake is strongly linked to elevated blood pressure, a leading risk factor for heart attack, stroke, heart failure, and kidney disease. But the potential harm may go beyond blood pressure. Emerging research suggests excessive sodium consumption may also be associated with:
- Increased risk of cognitive decline
- Greater likelihood of memory impairment
- Higher risk of dementia and Alzheimer’s disease
Some of these links cannot be explained by blood pressure alone, suggesting sodium may have additional effects on blood vessels and brain health. Recent updates to the Dietary Guidelines for Americans and national hypertension guidelines have not significantly altered sodium intake targets:
- 1,500 mg a day or less for people with hypertension
- 2,300 mg a day or less for adults who don’t have hypertension
Given that nearly half of U.S. adults have hypertension, the public health impact of reducing sodium intake could be substantial. However, our research showed that the declining use of salt substitutes could be happening for a variety of reasons, including:
- Limited awareness of lower-sodium options
- Concerns about taste
- Confusion about product safety
- Lack of clinician counseling
- Increased reliance on processed foods and restaurant meals
“In our hypertension clinic, we advise patients to focus less on the saltshaker and more on reading food labels. Our favorite practical rule of thumb is to look for about 140 mg of sodium per serving or less. The math behind it is simple: If you stay around that level, it gets easier to maintain a lower daily target,” said Wanpen Vongpatanasin, M.D., Professor of Internal Medicine and Program Director of the Hypertension Fellowship Program at UT Southwestern.
Why do Americans eat so much sodium?
While the saltshaker gets most of the blame, most of the sodium in the American diet comes from processed and packaged foods. A single meal can easily approach 1,000 mg of sodium – nearly two-thirds of the daily sodium budget for people with hypertension.
Bread is a prime example. One slice can range from 0 mg to more than 300 mg of sodium. Two slices for a sandwich may contribute 400 to 600 mg before adding cheese, deli meat, or condiments. Some bread with extra cheese or added “whole grain” may contain more sodium than a bag of potato chips. On the other hand, certain brands such as Ezekiel 4:9 bread may contain no sodium at all. Reading food labels to search for sodium per serving is very important.
Canned goods, frozen meals, restaurant dishes, and fast food are also major contributors. Even foods marketed as “whole grain,” “multigrain,” or “natural” often contain high sodium levels.
Nutrition labels can make the sodium content look modest – until you realize a serving might be five crackers, half a cup of soup, or one slice of bread. Many people eat two, three, or four servings without noticing.
“It’s empowering for patients to learn how to read nutrition labels. They can stick to their daily allowance of sodium and enjoy that success while protecting their health,” said John Giacona, PA-C, Ph.D., CHC, Assistant Professor of Applied Clinical Resaerch at UT Southwestern.
What are salt substitutes made of?
The phrase “salt substitute” can mean a few different things, and that’s where some of the confusion begins:
- Potassium-enriched seasonings: Lite-salt products such as Microsalt or LoSalt replace part of the sodium chloride with potassium chloride. A common grocery store version, such as Morton Lite Salt, is roughly a 50/50 blend. Potassium chloride triggers some of the same salt-sensing pathways on the tongue, so it can taste salty – though not identical to table salt.
- Sodium-free substitutes: Products such as Nu-Salt and Salt Substitute contain no sodium, and many are 100% potassium chloride. Several Dash (formerly Mrs. Dash) seasoning blends are also sodium-free.
- Salt-free seasoning blends: Swapping salt for seasonings such as garlic, onion, smoked paprika, cumin, chili powder, pepper, lemon, and vinegar can enhance the flavor of food as it cooks. Many “no-salt-added” blends are flavoring mixes of herbs, spices, citrus, and acids rather than a chemical substitute for sodium chloride.
Keep this in mind: Himalayan pink salt, sea salt, or “Celtic” salt aren’t healthier alternatives to sodium chloride. These trendy products can contribute just as much (or more) sodium to your diet as ordinary salt.
Who can benefit from salt substitutes?
For most healthy adults with normal kidney function, potassium-containing salt substitutes are generally considered safe in typical amounts. These products offer two advantages: less sodium and more potassium.
Potassium helps the kidneys excrete sodium and can support healthier blood vessel function. Salt substitutes can be particularly helpful for:
- People with elevated or high blood pressure
- Those with a family history of stroke
- Anyone trying to reduce cardiovascular risk
- Individuals who cook at home and can control ingredients
Who should avoid potassium-based seasonings?
For some people, consuming extra potassium can cause heart rhythm problems. Talk with your doctor before using potassium-based salt substitutes if you have chronic kidney disease, reduced kidney function, or heart failure. If a doctor has recommended that you watch your potassium intake or if you have a history of high potassium levels, avoid using potassium-based salt substitutes.
Certain medications can increase potassium levels. Ask a doctor if it is safe for you to use potassium-based salt substitutes if you take medications including:
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin II receptor blockers (ARBs)
- Potassium-sparing diuretics
- Potassium supplements (prescribed or over the counter)
Tips for making the switch
Potassium chloride activates some of the same sensory receptors as sodium chloride, creating a salty taste. But at higher amounts, it can taste briny or bitter. That’s why many retail products use a blend: enough potassium chloride to decrease the sodium level, but not so much that the flavor becomes unpleasant.
Where you use it also matters. Cooking with a substitute – stirring it into soups, stews, sauces, and marinades – can blend the flavor more evenly. Sprinkling it on food at the table can bring out the bitterness.
If your doctor says you can safely use salt substitutes, start small to learn what works for your taste preferences. Try a 50/50 “lite salt” in cooked dishes such as soups or sauces, then gradually move to using salt-free seasoning blends for everyday cooking.
Using salt substitutes regularly can help retrain your palate. Many patients report that once they reduce their sodium intake, highly salted foods no longer taste as good as they once did. Track your blood pressure at home and share trends with your doctor to see your progress in real time.
Reducing sodium doesn’t mean eliminating flavor. As evidence grows, so does the opportunity to rethink how we season our food and protect our hearts in the process. By being mindful of food labels and exploring salt substitutes where safe, we can make a significant impact on our long-term heart and brain health.
