The ECLA/PHRI Intervention in the Community Trial

The effect of reduced sodium salt preparations has been evaluated in clinical studies (observational and randomized clinical trials) and in meta-analyses, and although a reduction in blood pressure was observed, they have particular characteristics that make them difficult to extrapolate their results to Western populations. In one of these trials, conducted in rural Indian hypertensive patients, the use of a salt substitute of 75% sodium chloride and 25% potassium chloride showed a significant reduction of systolic blood pressure with a mean difference of -4.58 mmHg in 3 months from baseline to the end of the trial. Recently, a large cluster-randomized trial conducted in 600 villages in rural areas of five provinces of China (SSaSS trial) among patients with a history of stroke or 60 years of age or elder with elevated blood pressure showed that stroke rates, major cardiovascular events and death from any cause were significantly lower with a salt substitute than with regular salt. The salt substitute used in this trial had 1/3 less sodium than regular salt and substantially more potassium. Therefore, the salt substitute led to an 8% less sodium intake but a 50% higher intake in potassium. This suggests that the greatest impact of salt substitution in this RCT may have been due to an increase in potassium intake rather than the modest decrease in sodium intake that was associated with an average reduction of 2.65 mmHg for SBP (-4.32 to -0.97) and +0.30 mmHg (-0.72 to +1.32) for DBP. In addition, the mean sodium intake in the studied population in this trial was approximately 4.2 gr/d, which is higher than the global average worldwide sodium consumption of 3.9 gr/d. In contrast, potassium intake was lower than the average global potassium intake. Therefore, several considerations that limit the applicability to other populations remain unresolved. The sodium intake of the Chinese rural population is higher than in many other countries, while the potassium intake is relatively low. In addition, in many countries commercially available foods may have added sodium chloride for preservation and thus increase the amount of sodium to the diet. Therefore, the use of salt substitutes would not fully account for salt intake in most cases. Finally, Chinese social and environmental features may be somewhat different to most western countries. EPIC's investigators stated the hypothesis that salt substitutes could lower systolic blood pressure in a dose-response mode. Therefore, they propose to conduct a randomized cluster trial to evaluate the effect of consuming two doses enriched potassium salt substitutes preparations compared to regular salt intake on systolic blood pressure in individuals from Rosario department.