This fact sheet and global call to action is aimed at nutrition, hypertension, cardiovascular
and other health care clinicians and scientists, and health advocates, as well as
the organizations to which they belong. The ‘call’ is to align these audiences with
the facts on:
the burden of disease and key evidence supporting reductions in dietary sodium,
the consistent recommendations for reducing dietary sodium from unbiased and comprehensive
health and scientific reviews,
the current levels of sodium intake,
the cost savings expected from reducing high dietary sodium,
the sources of controversial opinions,
the current recommended approaches to reduce dietary sodium, and
how to stay up to date with evidence on how to reduce dietary sodium and the evolving
research on the adverse health effects of a high sodium intake.
Health, nutrition, hypertension and cardiovascular organizations, and their members,
need to become more engaged and advocate for reductions in dietary sodium, and for
a greater priority to be given to high quality research on dietary sodium. The World
Hypertension League, Resolve to Save Lives and International Society of Hypertension
are committed to support reductions in dietary sodium as a high priority.
Diets high in sodium (salt, sodium chloride- see Table 1 for equivalents) are associated
with a high burden of disease from increased blood pressure, cardiovascular disease
(CVD), premature death and disability
Increased blood pressure (BP) is the leading preventable risk factor for heart disease
(heart attack and heart failure), stroke, and kidney failure; and a major contributor
to premature death, dementia, disability and health care costs [1–4].
Sodium is largely ingested as sodium chloride (salt).
Equivalent amounts of salt and sodium in differing units (g, mg and mmol)
Salt (sodium chloride)
The table provides approximate equivalent amounts of sodium and salt.
Approximately 30% of hypertension prevalence can be attributed to high dietary sodium,
which could result in hypertension in 400 to 500 million people, worldwide [5–7].
The evolving definition of hypertension includes all people with a usual systolic
BP of ≥140 mmHg or diastolic ≥90 mmHg and those at high risk for CVD with a usual
systolic BP of ≥130 mmHg . Reductions in dietary sodium can have a larger or smaller
impact on hypertension prevalence, depending on the population distribution of sodium
intake, BP distribution, extent of decrease in dietary sodium and prevalence of other
causes of increased BP . The INTERSALT study and animal studies indicate high dietary
sodium consumption may have a substantively larger life course impact on BP than is
identified in the currently available relatively short-term sodium reduction trials
and suggest that a component of the increased BP may be irreversible [9, 10]. Hence,
the adverse effects may be greater than currently predicted and greater emphasis may
be needed before permanent harm occurs in younger people.
The Global Burden of Disease Study estimated that in 2019 there were over 1.8 million
deaths, and over 44 million disability-adjusted life years lost (including 40.5 million
DALYs from CVD, including stroke), as a result of excess dietary sodium consumption
In populations that consume less than 1000 mg sodium (2.5 gm salt) per day, hypertension
is rare [12–14].
A substantial proportion of BP-related disease occurs in people who have an average
BP below the levels used to identify hypertension [5, 15]. Hence sodium reduction
is relevant both for people with hypertension and those with a BP above the optimal
level but not yet hypertensive.
Meta-analyses of randomized controlled trials demonstrate that reducing dietary sodium
intake decreases BP in both those with and without hypertension, in children and in
adults, and in all ethnic groups [16–20]. The association between BP and dietary sodium
intake is approximately linear above 800 mg (2 gm salt) per day.
Individuals can be more or less prone to the adverse effects of sodium (‘salt sensitivity’)
on a genetic, physiological or pathophysiological basis (e.g., primary hyperaldosteronism).
There is a steeper sodium BP dose response slope in those who have hypertension, are
older, or are of black African ancestry .
A meta-analysis of randomized controlled trials showed a linear decrease in CVD with
reductions in sodium between 4100 mg (10.25 gm salt) and 2300 mg (5.75 gm salt) per
day . Overall, this evidence has been characterized as moderate rather than strong
because of an insufficient number of events. However, the one cohort study that the
National Academies of Sciences, Engineering, and Medicine viewed as having low bias,
found a linear association between sodium intake and mortality with less mortality
at sodium intake below 2300 mg (5.75 gm salt) per day than above 3600 mg (9 gm, salt)
per day [19, 21]. A more recent meta-analysis of cohort studies, that classified usual
sodium intake with multiple 24 h. urine collections, found a direct linear association
between sodium intake (1846 to 5230 mg (4.6 to 13.8 g salt) per day) and cardiovascular
events . Each 1000 mg (2.5 gm salt) per day increase in sodium excretion was associated
with an 18% increase in cardiovascular events .
Other diseases that have been associated with a high sodium intake include gastric
cancer (probable procarcinogen) [23, 24], recurrent calcium-oxalate kidney stones
, osteoporosis , obesity [27, 28], Meniere’s disease [29, 30], headache ,
and renal and cardiac damage . The quality of evidence for many of these disease
associations is mixed and they are largely based on observational studies in which
it is difficult to confirm causality. A variety of pathophysiologic mechanisms (e.g.,
increased inflammation and generation of reactive substances [32–35]) support the
potential for high sodium intake causing a broad range of disease.
Scientific reviews of the evidence by governmental and nongovernmental health organizations
Several independent, comprehensive, and unbiased scientific reviews of the evidence
conducted by governmental organizations provide recommendations for reduction in dietary
sodium (Table 2) [19, 36–39].
Selected government / governmental organization / multilateral agency recommendations
population recommendations for dietary sodium in adultsa.
Government / governmental organization / multilateral agency recommendations
Dietary sodium recommendations for adults, mg per day (salt g per day)
World Health Organization 
United States and Canada (National Academies of Sciences, Engineering, and Medicine)
<2300 (<5.75) for chronic disease risk reduction; adequate intake 1500 (3.75)
China (Healthy China Action Plan https://www.nhc.gov.cn/guihuaxxs/s3585u/201907/e9275fb95d5b4295be8308415d4cd1b2.shtml,
accessed July 23, 2021)
European Union 
~ 2000 (5)
Australia and New Zealand 
<2000 (<5); adequate intake 460–920 (1.15–2.3)
United Kingdom (https://pathways.nice.org.uk/pathways/diet/national-policy-on-diet#content=view-node:nodes-reducing-salt-saturated-and-trans-fats,
accessed June 18 2021; https://www.nhs.uk/conditions/vitamins-and-minerals/others/,
accessed June 18 2021)
<2400 (<6) with the National Institute for Health and Care Excellence indicating an
ultimate goal of 1200 (3)
South Africa 
aSeveral guidelines recommend lower limits for children based on their lower caloric
intake or by providing specific lower targets for age categories of children .
Most non governmental health and scientific organizations provide recommendations
to reduce dietary sodium (e.g., International Society of Hypertension , Chinese
Hypertension League , British and Irish Hypertension Society , Turkish Hypertension
Consensus Report , European Societies of Hypertension and of Cardiology ,
American College of Cardiology and American Heart Association , Japanese Society
of Hypertension , Brazilian Hypertension Guideline  and a broad rage of Canadian
Health and Scientific organizations (https://hypertension.ca/wp-content/uploads/2019/01/Sodium-Fact-Sheet-FINAL-Jan-23-2019.pdf).
The American Heart Association and the American College of Cardiology - American Heart
Association Hypertension Recommendations advise that adults with hypertension should
optimally consume less than 1500 mg sodium (3.75 gm salt) per day but that any reduction
is beneficial .
Globally, people consume too much sodium
The average global intake of sodium in adults is estimated to be about 4000 mg per
day (salt 10 g per day), with higher intakes in Asia than other regions [48–50]. However,
there is uncertainty regarding the exact levels of population sodium intake in many
countries because few representative population studies have been based on 24 h. urine
collections, the best way of estimating sodium intake [49, 50].
Only a small portion of dietary sodium intake results from consumption of unprocessed
natural foods: <700 mg per day (salt < 1.75 g per day) in a typical mixed paleolithic
non-vegetarian diet and <200 mg per day (salt < 0.5 g per day) in a paleolithic vegetarian
In many high-income countries, most of the sodium consumed (70–80%) results from addition
of sodium during food manufacturing and during food preparation in fast-food and sit-down
restaurants. In many middle- and low-income countries, excessive sodium intake results
from ‘discretionary’ addition of sodium, high-sodium sauces and condiments during
home cooking and use of saltshakers at the table. However, globalization of the food
industry (nutrition transition) is increasing the exposure of populations in middle-
and low-income countries to sodium in processed foods  [52–55].
Table 3 provides standardized nomenclature for describing levels of sodium intake
recommended by the World Hypertension League, and partner organizations, based on
the level of sodium intake recommended by the World Health Organization .
Standardized nomenclature of levels of sodium intake.
Dietary Intake, per day
Reduction in dietary sodium saves lives, health care resources and costs
Noncommunicable diseases threaten the global economy and economic development. In
response, the World Health Assembly supports nine targets for prevention and control
of noncommunicable diseases, including a key recommendation to reduce dietary sodium
by 30% by 2025 .
Reducing dietary sodium is one of the most impactful and cost-effective mechanisms
to improve population health and is one of the World Health Organization’s ‘best buys’
for prevention of chronic disease [57, 58] (https://resolvetosavelives.org/cardiovascular-health/lives-saved-calculator,
accessed July 25, 2021).
A modest 15% reduction in dietary sodium is estimated to prevent 8.5 million deaths
over 10 years in 23 developing countries where 80% of chronic disease deaths in developing
nations occur . An analysis published in 2019 showed that a 30% reduction of sodium,
could save 40 million lives globally within 25 years .
In low- and -middle income countries, programs to reduce dietary sodium were estimated
to provide a return on investment of 13–18:1 [61–63].
Controversies related to dietary sodium reduction are based largely on low quality
There are no definitive randomized controlled trials to define the optimum level of
sodium intake to reduce mortality and morbidity, which creates controversy for some
. Very large, expensive trials of long duration in different populations would
be required, and it is difficult for individuals, even in a clinical trial setting,
to maintain a substantially reduced sodium diet in the current high sodium food environments
. Nevertheless, there is evidence that sodium reduction prevents CVD events in
randomized comparisons of those assigned to a dietary sodium reduction behavioral
intervention compared with usual care during long-term follow up (trial and post-trial
experience) even though optimal levels of sodium intake remain undefined [19, 21,
Several prospective cohort studies in high profile journals have identified paradoxical
J- and U-shaped relationships between sodium intake and CVD events, leading to a controversial
conclusion that dietary sodium intake should only be reduced in adults with a very
high daily sodium intake (>5000 mg (12.5 gm salt) per day) [64, 67, 68]. These studies
have been criticized as having significant methodological limitations that could alter
sodium intake disease associations (e.g., inaccurate measurement of baseline sodium
intake, residual confounding, reverse causality, inadequate adjustment of confounding
factors, inadequate sample sizes, and follow-up duration) . Many of the controversial
studies that have identified a paradoxical relationship between sodium intake and
CVD have employed spot (single untimed spontaneously voided) urine samples to estimate
usual sodium intake. The Kawasaki, and other formulae, used to estimate 24 h sodium
intake based on spot urine measurements have been shown to result in biased estimates
of sodium intake compared with estimates based on 24 h. urinary collections [50, 70,
71], to result in a spurious J-shaped association between sodium intake and mortality,
and to provide an inaccurate representation of the association between dietary sodium
and BP [72–74].
A 2019 report from the U.S. National Academies of Sciences, Engineering, and Medicine
confirmed an Agency for Healthcare Research and Quality report that many of the controversial
studies had a high risk of bias and stated “the paradoxical J- and U-shaped relationships
of sodium intake and CVD and mortality are likely observed because of methodological
limitations of the individual observational studies” .
Similarly, international scientific organizations and scientific reviews concluded
that low quality research methods and designs were a source of controversy regarding
the benefits of reducing the intake of dietary sodium [42, 75–78].
A major issue is that estimation of dietary sodium intake is challenging because intake
varies substantially from day to day, depending on food choice and portion size, as
well as random variation [79, 80]. The best feasible estimate of dietary sodium intake
for individuals in clinical research is based on multiple, carefully collected, 24 h
urines on nonconsecutive days, but few studies have used this methodology [77, 81].
Instead, most studies use methods that are very inaccurate with both systematic and
random error in assessing usual sodium intake [19, 69, 77, 81–84].
Other studies with controversial findings have used dietary recall or food frequency
questionnaire methods for estimation of 24 h dietary sodium intake. These are not
recommended for this purpose because they are known to underestimate dietary sodium
intake and to be unreliable for assessing an individual’s sodium intake [83, 84].
One study found that a single 24 h. estimate of usual sodium intake had a spurious
J curve association with cardiorenal outcomes that became linear when multiple 24 h
urine assessments defined usual sodium intake .
Resources for keeping up to date on the evolving evidence on dietary sodium and how
to reduce dietary sodium
The World Hypertension League, along with other national and international partners
and the Journal of Human Hypertension, have developed multiple mechanisms to ensure
that the evidence on dietary sodium intake is maintained up to date.
The ‘science of salt’, a regularly updated critical appraisal of research evidence
related to dietary sodium measurement and consumption, clinical consequences, and
effectiveness of programs to reduce dietary sodium intake has been published in the
Journal of Clinical Hypertension from 2013 until 2020 and more recently in the Journal
of Human Hypertension [49, 86–92] (https://www.georgeinstitute.org/projects/science-of-salt-weekly,
accessed June 19, 2021).
Resolve To Save Lives maintains a website that includes best practices in dietary
sodium reduction and an updated annotated bibliography which summarizes important
evidence on sodium intake, reduction strategies, and measurement (https://resolvetosavelives.org/cardiovascular-health/sodium,
and https://linkscommunity.org/toolkit/salt-reduction; accessed July 18, 2021).
The Nourishing Framework provides regular updates to governmental policies to promote
healthier nutrition including reducing dietary sodium (https://www.iccp-portal.org/system/files/resources/PPA_Nourishing_A5%2520leaflet_web%2520FINAL.pdf,
accessed June 18, 2021).
The Centre for Disease Control and Prevention (USA) has a CDC salt bites newsletter
that provides updates on sodium reduction research and activities (https://www.cdc.gov/salt/index.htm).
The WHO Collaborating Centre on Population Salt Reduction at the George Institute
for Global Health also regularly reviews national salt reduction activities around
the world  and features a regular newsletter updating sodium reduction activities
and science (https://www.whoccsaltreduction.org/).
The Centre for Science in the Public Interest hosts a sodium listserv communications
group (subscribe by contacting email@example.com).
World Action on Salt, Sugar and Health (WASSH) provides regular updates on publications
and worldwide salt reduction activities (http://www.worldactiononsalt.com/news/salt-in-the-news/2021/).
The World Health Organization and the Pan American Health Organization provide updated
national policy actions on dietary sodium reduction (https://extranet.who.int/nutrition/gina/es/scorecard/sodium
respectively, accessed August 16, 2021).
Multicomponent comprehensive policies can be effective in reducing dietary sodium
intake and have been associated with reductions in BP and CVD [94, 95]
The World Health Organization technical package for dietary sodium reduction ‘SHAKE’
is based on
Surveillance: to measure and monitor the amount of sodium consumed, the main dietary
sources of sodium and the amount of sodium in specific foods.
Harnessing (through policies that include regulations) the food industry to reduce
the amount of sodium added in food processing including the setting of targets and
timelines for sodium content of foods [96, 97].
Adopting front of package food labels and implementing strategies to reduce misleading
marketing of high sodium foods.
Knowledge enhancement to empower individuals to eat less sodium.
Environmental changes through healthy food procurement policies.
The World Health Organization has developed global benchmarks for the sodium content
of packaged foods (https://www.who.int/publications/i/item/9789240025097, accessed
Aug 16, 2021), as has the Food and Drug Administration (FDA United States, https://www.fda.gov/media/98264/download,
accessed Oct 19, 2021) and the Pan American Health Organization has updated its regional
benchmarks for sodium content of packaged foods [98, 99].
The Pan American Health Organization  and the World Health Organization Regional
Office for Europe (https://www.euro.who.int/__data/assets/pdf_file/0006/457611/Accelerating-salt-reduction-in-Europe.pdf),
accessed August 2, 2021) also have useful technical resources for reducing dietary
Resolve to Save Lives has a comprehensive framework for dietary sodium reduction programs
that includes resources, implementation tools and examples of successful interventions
(https://linkscommunity.org/toolkit/sodium-framework, accessed Nov 25, 2021).
As of 2020, 96 countries had national strategies to reduce dietary sodium intake .
A recent systematic review of sodium reduction found that 4 population-based interventions
had reduced average sodium intake levels by 800 or more mg (>2 gm salt)/day (Argentina,
China, South Korea, Turkey) and 9 countries had reduced between 400 and 800 mg (1–2 gm
salt)/day . Gradual (over a few months) but substantial reductions in sodium of
processed foods can be made without altering the perceived taste of food .
Population-based sodium reduction interventions in Japan, Finland and the United Kingdom
have also been associated with reduction in BP and CVD [103–107].
Clinical trials longer than 5 weeks indicate reducing dietary sodium to 2300 mg (5.75 g
salt) /day in older adults is feasible and could reduce mortality from stroke by 39%
and ischemic heart disease by 30% . A good practical example of the successful
implementation of a salt intake reduction program on a national level is Japan, where
such an intervention was associated with a dramatic reduction in stroke mortality
Governments in more countries should take action to develop and implement multi-sectoral
national strategies based on the WHO SHAKE technical package to reduce sodium consumption
using implementation research methodology [95, 109, 110].
Broad policies to reduce dietary sodium and consumption of ultra processed foods to
improve nutrition (e.g., mandatory sodium targets, front of pack warning labels, marketing
restrictions especially to children, healthy public food procurement, and fiscal measures
(i.e., taxes)) are believed to be important to reduce population sodium intake [95,
Industry-based voluntary approaches to reduce the addition of sodium during food processing
have a long history of being ineffective unless they are coupled with strong government
oversight and close monitoring . Government-led regulated approaches may be more
Public education (particularly through mass media campaigns) and behavior change interventions
(e.g., using a COMBI framework) are likely important as part of a broader strategy,
especially where discretionary sodium is the major dietary source [113–116]. The use
of social marketing strategies and ‘whole of society’ approaches may be beneficial
to change social norms and behaviours related to the use of discretionary sodium [113,
In a recent randomized controlled trial, replacing regular salt with a reduced-sodium
salt (where 25% of the sodium was replaced with potassium) in adults with stroke or
at high risk for stroke reduced the risk of stroke (14%), cardiovascular events (13%)
and premature death (12%) without any evidence of an increased risk of hyperkalemia
. Reduced sodium salt can be considered as part of a population sodium reduction
strategy and is likely to be most effective in countries where discretionary salt
constitutes a significant source of dietary sodium (annotated bibliography https://linkscommunity.org/toolkit/sodium-reduction-an-annotated-bibliography#_Toc14352403,
accessed July 25, 2021) [119–124]. Reduced sodium salts and condiments may also help
to reduce sodium intake from packaged foods, restaurant foods and discretionary use
. Regulatory changes, such as making labeling of potassium additives in processed
food products more consumer friendly, may help (e.g., labeling potassium additives
as potassium or potassium salt versus potassium chloride).
Integrating efforts to reduce dietary sodium with those to optimize dietary potassium
and iodine through salt fortification are important to enhance health [119, 120, 126,
Close monitoring of sodium intake, sources of sodium in the diet, sodium levels in
foods, as well as knowledge, attitudes and behaviours of the public are essential
components of sodium reduction programs [100, 109].
National hypertension, CVD, nutrition, and health organizations
Hypertension, CVD, nutrition, and health organizations have important roles in research,
interpretation of research, education, and advocacy. We call on these organizations
Provide organizational support for this Call to Action by contacting the World Hypertension
League at firstname.lastname@example.org. An updated list of supporting organizations will be
maintained until 2025.
Promote research, presentations and publications on high quality research related
to dietary sodium emphasizing the importance of high-quality research methodology,
data that are in the public domain and where interpretation is free of commercial
Educate members on the health risks of high dietary sodium and how to reduce sodium
Broadly disseminate relevant information on dietary sodium integrated with other healthy
nutrition and physical activity advice to the public and patients.
Educate policy and decision makers on the health benefits of lowering BP among normotensive
and hypertensive people, regardless of age.
Advocate for policies and regulations that will contribute to population-wide reductions
in dietary sodium, possibly in collaboration with other health advocacy groups. The
World Health Organization has released a Sodium Country Score Card to track governmental
progress to reduce dietary sodium that can be used by health and nutrition organizations
and experts in advocacy. (https://extranet.who.int/nutrition/gina/es/scorecard/sodium
accessed July 18, 2021).
Provide opportunities for members to be involved in advocacy. Reach the public and
policy makers by promoting and advocating through media releases and social media
campaigns on dietary sodium reduction.
Promote coalition building, increase organizational capacity for advocacy, and develop
advocacy tools to promote civil society actions.
Be cautious about the role of low-quality research, research from domains that are
not publicly accessible to be independently validated, and of investigators with commercial
conflicts of interest in generating controversy related to dietary sodium reduction.
Global networks of concerned health care professionals and scientists have formed
to help support reductions in dietary sodium. World Action on Salt, Sugar and Health
(WASSH) sponsors World Salt Awareness Week annually during the second week of March
(www.worldactiononsalt.com/, accessed June 12, 2021). Other organizations with a similar
goal include the European Salt Action Network (euro.who.int/en/health-topics/disease-prevention/nutrition/policy/member-states-action-networks/reducing-salt-intake-in-the-population),
WHO Collaborating Centre on Population Salt Reduction at the George Institute for
Global Health (https://www.georgeinstitute.org/projects/world-health-organization-collaborating-centre-for-population-salt-reduction-who-cc-salt,
accessed July 18, 2021), and Action on Salt (http://www.actiononsalt.org.uk/, accessed
June 12, 2021).
Resolve to Save Lives, a global initiative to save 100 million lives in 30 years,
has reducing dietary sodium as one of its four pillars .
Public health dietary sodium research priorities
Research is urgently required to accelerate the reduction of dietary sodium in populations.
Priorities include research to:
Better define optimal policies and interventions for reducing dietary sodium in populations
including discretionary sodium, sodium from street foods, sodium from packaged foods,
and sodium from restaurants. This research is needed in a wide variety of settings
and cultures to better understand the obstacles and facilitators to dietary sodium
Better define optimal interventions for reducing dietary sodium in individuals including
discretionary sodium, sodium from street foods, sodium from packaged foods, and sodium
Accelerate the uptake of best practices in sodium reduction particularly in low- and
middle-income countries [128, 129].
Develop more rapid, feasible and accurate methods to assess individual and population
average sodium intake, sources of dietary sodium and levels of sodium in specific
Better define potential interactions between dietary sodium and potassium in causing
Implement large scale randomized controlled trials to define optimal levels of sodium
and potassium intake in the general population to prevent disease, if feasible designs
can be developed.
Implement large scale randomized controlled trials to assess long term health and
common non-CVD diseases reported to be associated with high sodium intake if feasible
designs can be developed.
Define the role of salt (consumed in excess) as a vehicle for providing nutrients
that are deficient in the diet (e.g., iodine, fluoride, folate).
Better identify individuals more or less prone to adverse health consequences from
dietary sodium (‘salt sensitivity’).
Explore the intake of sodium and vulnerability to and complications from COVID -19
Uncover the causes and solutions for misinformation on dietary sodium, the role of
low-quality research and the role of commercial conflicts of interest in hindering
dietary sodium reduction programs.
World Hypertension League Actions
The World Hypertension League, Resolve to Save Lives and the International Society
of Hypertension have led the development of this fact sheet and call to action targeted
at hypertension, cardiovascular, nutrition and health experts and scientists and their
organizations to support achievement of the WHO recommended sodium intake levels.
The World Hypertension League has developed the Graham MacGregor Award and Excellence
Awards to recognize organizations and individuals who have contributed to efforts
to reduce dietary sodium at the population level. (http://www.whleague.org/index.php/news-awards-recognition,
accessed June 1, 2021).
Assisting the global and national efforts to reduce dietary sodium is a top priority
of the World Hypertension League.