1
|
Kong B, Yang S, Long J, Tang Y, Liu Y, Ge Z, Rong S, Wu Y, Ding G, Yang Y, Yao P, Gao C. National Initiatives on Salt Substitutes: Scoping Review. JMIR Public Health Surveill 2023; 9:e45266. [PMID: 37435719 PMCID: PMC10692885 DOI: 10.2196/45266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/29/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Salt substitutes are edible salts that contain less sodium chloride owing to its partial substitution with other minerals, which serve as an important and effective intervention and public health strategy targeting hypertension and its secondary diseases, despite a small degree of controversy. OBJECTIVE This study aimed to identify the current salt substitute initiatives in various nations and intergovernmental organizations (IGOs) worldwide and summarize their types and characteristics. METHODS A scoping review was performed based on Arksey and O'Malley's framework and the latest guidance from the Joanna Briggs Institute. Searches were conducted on Google; government websites on food, health, and other related topics; PubMed; Web of Science; and Google Scholar from January 2022 to May 2022. Initiatives related to salt substitutes that were included in the study focused on the involvement of governments or IGOs through the publication of standards, actions, collaborations, funding, and so on. Data were extracted into Microsoft Excel (version 2019; Microsoft Corp) based on predefined items and analyzed using narrative synthesis and frequency count methods. RESULTS A total of 35 initiatives from 11 countries (of which 9 are high-income countries) and 3 IGOs were identified. We classified all salt substitute initiatives into 5 types, namely benefit-risk assessments and cautions; plans and actions; regulations and standards; labels; and food reformulation, cooperation with the food industry, and media. More than half (18/35, 51%) of the salt substitute initiatives were launched within the past 5 years. Except for regulations and standards, salt substitute initiatives are, in general, part of the salt reduction framework. No nation or IGO has yet reported on the monitoring and implications of the use of salt substitutes. CONCLUSIONS Despite the limited number of salt substitute initiatives worldwide at present, a review on the different types and characteristics of such initiatives could be helpful in providing a reference for policy makers and stakeholders. Given the great potential of salt substitutes in improving hypertension and stroke, we call on more nations to pay attention to these substitutes and propose salt substitute initiatives in line with their national conditions.
Collapse
Affiliation(s)
- Bingxuan Kong
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanyue Yang
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiewei Long
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuhan Tang
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Liu
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zeng Ge
- Cardiovascular Health Program, Vital Strategies (USA) Jinan Representative Office, Jinan, China
| | - Shuang Rong
- Department of Nutrition, School of Public Health, Wuhan University, Wuhan, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University, Beijing, China
| | - Gangqiang Ding
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
- Key Laboratory of Trace Element Nutrition of National Health Commission, Beijing, China
| | - Yuexin Yang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
- Chinese Nutrition Society, Beijing, China
| | - Ping Yao
- Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Ministry of Education Key Laboratory of Environment, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Gao
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
- Key Laboratory of Trace Element Nutrition of National Health Commission, Beijing, China
| |
Collapse
|
2
|
Yuan Y, Jin A, Neal B, Feng X, Qiao Q, Wang H, Zhang R, Li J, Duan P, Cao L, Zhang H, Hu S, Li H, Gao P, Xie G, Yuan J, Cheng L, Wang S, Zhang H, Niu W, Fang H, Zhao M, Gao R, Chen J, Elliott P, Labarthe D, Wu Y. Salt substitution and salt-supply restriction for lowering blood pressure in elderly care facilities: a cluster-randomized trial. Nat Med 2023; 29:973-981. [PMID: 37055566 DOI: 10.1038/s41591-023-02286-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 03/02/2023] [Indexed: 04/15/2023]
Abstract
There is a paucity of high-quality evidence on the effectiveness and safety of salt reduction strategies, particularly for older people, who have the most to benefit but are at higher risk of adverse effects. Here, we conducted a clinical trial in which 48 residential elderly care facilities in China (1,612 participants including 1,230 men and 382 women, 55 years or older) were cluster-randomized using a 2 × 2 factorial design to provision of salt substitute (62.5% NaCl and 25% KCl) versus usual salt and to a progressively restricted versus usual supply of salt or salt substitute for 2 years. Salt substitute compared with usual salt lowered systolic blood pressure (-7.1 mmHg, 95% confidence interval (CI) -10.5 to -3.8), meeting the primary outcome of the trial, whereas restricted supply compared with usual supply of salt or salt substitute had no effect on systolic blood pressure. Salt substitute also lowered diastolic blood pressure (-1.9 mmHg, 95% CI -3.6 to -0.2) and resulted in fewer cardiovascular events (hazard ratio (HR) 0.60, 95% CI 0.38-0.96), but had no effect on total mortality (HR 0.84, 95% CI 0.63-1.13). From a safety standpoint, salt substitute increased mean serum potassium and led to more frequent biochemical hyperkalemia, but was not associated with adverse clinical outcomes. In contrast, salt restriction had no effect on any study outcome. The results of this trial indicate that use of salt substitute, but not efforts to restrict salt supply, may achieve blood pressure lowering and deliver health benefits to residents of elderly care facilities in China. Clinicaltrials.gov registration: NCT03290716.
Collapse
Affiliation(s)
- Yifang Yuan
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Aoming Jin
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Public Health, Imperial College London, London, UK
| | | | - Qianku Qiao
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Hongxia Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Ruijuan Zhang
- Department of Public Health, Xi'an Jiaotong University, Shaanxi, China
| | - Jiayu Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | | | - La'e Cao
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Hui Zhang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Senke Hu
- Department of Public Health, Xi'an Jiaotong University, Shaanxi, China
| | - Huijuan Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Gaoqiang Xie
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | | | - Lili Cheng
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Sujuan Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Haijun Zhang
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Wenyi Niu
- Department of Social Medicine and Health Education, Peking University School of Public Health, Beijing, China
| | - Hai Fang
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Junshi Chen
- China National Food Safety Risk Assessment Center, Beijing, China
| | - Paul Elliott
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- UK Dementia Research Institute at Imperial College London, London, UK
- British Heart Foundation Centre for Research Excellence, Imperial College London, London, UK
| | - Darwin Labarthe
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yangfeng Wu
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China.
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China.
| |
Collapse
|
3
|
Sharif S, Tang J. Potassium Derangements: A Pathophysiological Review, Diagnostic Approach, and Clinical Management. Physiology (Bethesda) 2022. [DOI: 10.5772/intechopen.103016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Potassium is an essential cation critical in fluid and electrolyte balance, acid–base regulation, and neuromuscular functions. The normal serum potassium is kept within a narrow range of 3.5–5.2 meq/L while the intracellular concentration is approximately 140–150 meq/L. The total body potassium is about 45–55 mmol/kg; thus, a 70 kg male has an estimated ~136 g and 60 kg female has ~117 g of potassium. In total, 98% of the total body potassium is intracellular. Skeletal muscle contains ~80% of body potassium stores. The ratio of intracellular to extracellular potassium concentration (Ki/Ke) maintained by Na+/K+ ATPase determines the resting membrane potential. Disturbances of potassium homeostasis lead to hypo- and hyperkalemia, which if severe, can be life-threatening. Prompt diagnosis and management of these problems are important.
Collapse
|
4
|
Morris TG, Lamba S, Fitzgerald T, Roulston G, Johnstone H, Mirzazadeh M. The potential role of the eGFR in differentiating between true and pseudohyperkalaemia. Ann Clin Biochem 2020; 57:444-455. [PMID: 33016076 DOI: 10.1177/0004563220966858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Differentiating between true and pseudohyperkalaemia is essential for patient management. The common causes of pseudohyperkalaemia include haemolysis, blood cell dyscrasias and EDTA contamination. One approach to differentiate between them is by checking the renal function, as it is believed that true hyperkalaemia is rare with normal function. This is logical, but there is limited published evidence to support it. The aim of this study was to investigate the potential role of the estimated glomerular filtration rate in differentiating true from pseudohyperkalaemia. METHODS GP serum potassium results >6.0 mmol/L from 1 January 2017 to 31 December 2017, with a repeat within seven days, were included. Entries were retrospectively classified as true or pseudohyperkalaemia based on the potassium reference change value and reference interval. If the initial sample had a full blood count, it was classified as normal/abnormal to remove blood cell dyscrasias. Different estimated glomerular filtration rate cut-points were used to determine the potential in differentiating true from pseudohyperkalaemia. RESULTS A total of 272 patients were included with potassium results >6.0 mmol/L, with 145 classified as pseudohyperkalaemia. At an estimated glomerular filtration rate of 90 ml/min/1.73 m2, the negative predictive value was 81% (95% CI: 67-90%); this increased to 86% (95% CI: 66-95%) by removing patients with abnormal full blood counts. When only patients with an initial potassium ≥6.5 mmol/L were included (regardless of full blood count), at an estimated glomerular filtration rate of 90 ml/min/1.73 m2, the negative predictive value was 100%. Lower negative predictive values were seen with decreasing estimated glomerular filtration rate cut-points. CONCLUSION Normal renal function was not associated with true hyperkalaemia, making the estimated glomerular filtration rate a useful tool in predicting true from pseudohyperkalaemia, especially for potassium results ≥6.5 mmol/L.
Collapse
Affiliation(s)
- Thomas G Morris
- Blood Sciences, Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Sushmita Lamba
- Blood Sciences, Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Thomas Fitzgerald
- Nephrology, Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Gary Roulston
- Nephrology, Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Helen Johnstone
- Blood Sciences, Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - Mehdi Mirzazadeh
- Blood Sciences, Epsom and St Helier University Hospitals NHS Trust, London, UK
| |
Collapse
|
5
|
Schnaubelt S, Niederdoeckl J, Schoergenhofer C, Cacioppo F, Schuetz N, Spiel AO, Hecking M, Domanovits H. Hyperkalemia: A persisting risk. A case report and update on current management. Clin Case Rep 2020; 8:1748-1753. [PMID: 32983489 PMCID: PMC7495804 DOI: 10.1002/ccr3.2974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
We report a case of hemodynamic instability due to bradycardia on the basis of severe hyperkalemia. Diabetic ketoacidosis and acute kidney injury together with polypharmacy triggered the acute onset. Potentially life-threatening hyperkalemia is often induced by drug interactions. ECG features may be crucial for diagnosis, and treatment depends on setting and resources.
Collapse
Affiliation(s)
| | - Jan Niederdoeckl
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | | | - Filippo Cacioppo
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Nikola Schuetz
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Alexander O. Spiel
- Department of Emergency MedicineMedical University of ViennaViennaAustria
- Department of Emergency MedicineWilheminenspital ViennaViennaAustria
| | - Manfred Hecking
- Division of Nephrology and DialysisDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Hans Domanovits
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| |
Collapse
|
6
|
Greer RC, Marklund M, Anderson CAM, Cobb LK, Dalcin AT, Henry M, Appel LJ. Potassium-Enriched Salt Substitutes as a Means to Lower Blood Pressure: Benefits and Risks. Hypertension 2019; 75:266-274. [PMID: 31838902 DOI: 10.1161/hypertensionaha.119.13241] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: -5.58 [-7.08 to -4.09] and -2.88 [-3.93 to -1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.
Collapse
Affiliation(s)
- Raquel C Greer
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
| | | | - Cheryl A M Anderson
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Department of Family Medicine and Public Health, University of California San Diego School of Medicine (C.A.M.A.)
| | | | - Arlene T Dalcin
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
| | - Megan Henry
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.)
| | - Lawrence J Appel
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.C.G., C.A.M.A., M.H., L.J.A.).,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (R.C.G., A.T.D., L.J.A.)
| |
Collapse
|
7
|
Cepanec K, Vugrinec S, Cvetković T, Ranilović J. Potassium Chloride-Based Salt Substitutes: A Critical Review with a Focus on the Patent Literature. Compr Rev Food Sci Food Saf 2017; 16:881-894. [PMID: 33371617 DOI: 10.1111/1541-4337.12291] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 11/30/2022]
Abstract
High dietary sodium intake (DSI) represents a major health-related public issue in most countries all over the world. Such a diet can lead to increased risk of hypertension and related cardiovascular diseases. This situation has resulted in important public policies for various salt reduction strategies. One of these is based on the use of salt substitutes or salts with reduced sodium content. Among several options, potassium chloride (KCl) has proved to be a key nutritional ingredient for this purpose. It provides similar properties like common salt (NaCl), but with several unwanted side effects, of which the most important have relatively offensive side tastes: bitter, acrid, and metallic. To successfully formulate KCl-based salt substitutes, numerous taste-improving agents and formulation concepts have been used. The field of salt substitutes is mainly described in the patent literature. Since patents are both scientific and legal documents, careful and critical consideration is required when using them as a source of scientific information. This review brings a deep insight into the area of KCl-based salt substitutes with a focus on the patent literature through the eyes of food science and technology. The most important classes of taste-improving agents that have been employed in numerous formulation concepts of KCl-based salt substitutes are nutritionally acceptable mineral salts; food acids, amino acids, and their nutritionally acceptable salts; simple carbohydrates and sugar substitutes; food polymers; umami ingredients; spices, vegetables, and flavors; miscellaneous taste improvers; as well as a plethora of their specific combinations. A critical review of the respective patent literature is given.
Collapse
Affiliation(s)
- Katica Cepanec
- Amelia d.o.o., Zagorska 28, Bunjani, HR-10314, Križ, Croatia
| | - Sašenka Vugrinec
- Podravka Inc., Research & Development Dept., A., Starčevića 32, HR-48000, Koprivnica, Croatia
| | - Tanja Cvetković
- Podravka Inc., Research & Development Dept., A., Starčevića 32, HR-48000, Koprivnica, Croatia
| | - Jasmina Ranilović
- Podravka Inc., Research & Development Dept., A., Starčevića 32, HR-48000, Koprivnica, Croatia
| |
Collapse
|
8
|
Abstract
Hyperkalemia is a common electrolyte problem in patients with chronic kidney disease. It is typically caused by medications in patients with poor kidney function. Patients with comorbodities such as heart failure and diabetes are predisposed to electrolyte problems. Salt substitutes and dietary supplements are uncommon causes of hyperkalemia, but we propose that they are under-recognized and underdiagnosed causes in patients with chronic kidney disease. Our case report and literature review illustrates that a careful dietary history is essential in patients presenting with electrolyte disorders, especially hyperkalemia.
Collapse
Affiliation(s)
- Vivek Batra
- Johns Hopkins Community Physicians, The Johns Hopkins Hospital
| | - Vipin Villgran
- Johns Hopkins Community Physicians, The Johns Hopkins Hospital
| |
Collapse
|