An Expert Recommendation on Salt Intake and Blood Pressure Management in Chinese Patients with Hypertension

A Statement of the Chinese Medical Association Hypertension Professional Committee

Abstract

1. Background and Rationale

• Epidemiological Context: Hypertension is highly prevalent in China, with average daily salt intake exceeding 9 g—far above the WHO-recommended <5 g/day and the Chinese guideline target of <5 g/day (equivalent to sodium <2 g/day). Approximately one-third of Chinese adults are salt-sensitive, amplifying the hypertensive effects of sodium.
• Pathophysiological Link: Excess sodium intake directly elevates blood pressure by increasing extracellular volume and peripheral vascular resistance. It also exacerbates endothelial dysfunction, arterial stiffness, and renal injury, increasing the risk of stroke, heart failure, and chronic kidney disease.
• Clinical Imperative: Lifestyle intervention centered on salt reduction is a first-line, cost-effective strategy for hypertension prevention and management. Individualized assessment of sodium/potassium intake is essential for targeted therapy and improved blood pressure control.

2. Core Recommendations for Salt Intake and Blood Pressure Management

2.1 Sodium Restriction Targets

• Primary Target: All hypertensive patients should reduce daily sodium intake to <2 g (equivalent to 5 g of salt). For patients with severe hypertension, cardiovascular disease, or renal impairment, stricter control (sodium <1.5 g/day) may be considered under medical supervision.
• Gradual Reduction: Initially reduce sodium intake by 30% from baseline, then titrate down to the target to improve adherence.
• Total Sodium Accountability: Include sodium from cooking salt, condiments (soy sauce, monosodium glutamate, pickles), processed foods (cured meats, canned goods, snacks), and restaurant meals in daily calculations.

2.2 Potassium Supplementation

• Intake Target: Increase dietary potassium to 3.5–4.7 g/day to counteract sodium’s hypertensive effects, promote sodium excretion, and protect vascular function.
• Food Sources: Prioritize fresh vegetables (spinach, celery, potatoes), fruits (bananas, oranges, kiwifruit), legumes, and low-fat dairy. Potassium supplements are not recommended for blood pressure control unless prescribed for deficiency.
• Renal Caution: Avoid high-potassium diets or low-sodium/potassium-rich salt substitutes in patients with impaired renal function (eGFR <60 mL/min/1.73 m²) to prevent hyperkalemia.

2.3 Salt Substitute Strategy

• Recommendation: For patients with normal renal function, replace regular salt with low-sodium, high-potassium salt substitutes (≈75% NaCl + 25% KCl). The SSaSS study demonstrated that this intervention reduces stroke risk by 14%, major cardiovascular events by 13%, and premature death by 12% in high-risk populations.
• Contraindications: Severe renal failure, hyperkalemia, or use of renin-angiotensin-aldosterone system inhibitors (RAASi) without electrolyte monitoring.

2.4 Lifestyle and Dietary Modifications

1. Cooking Practices: Use quantitative salt spoons; reduce or eliminate salt, soy sauce, and MSG. Flavor food with garlic, ginger, chili, vinegar, pepper, or herbs instead.
2. Avoid Hidden Sodium: Limit pickled vegetables, cured meats, instant noodles, processed snacks, and high-sodium sauces. Read nutrition labels and choose low-sodium products (sodium <120 mg/100 g).
3. Dining Out: Request “no added salt” or “light seasoning” and avoid consuming soup bases, which are typically high in sodium.
4. Weight Management: Maintain BMI 18.5–23.9 kg/m²; waist circumference <85 cm (men) and <80 cm (women) to enhance blood pressure controlChina CDC.
5. Other Interventions: Limit alcohol, engage in regular moderate aerobic exercise (150 minutes/week), and manage stress.

2.5 Sodium/Potassium Intake Assessment

• Clinical Methods:
  • 24-hour urinary sodium/potassium excretion (gold standard for estimating intake).
  • Spot urine sodium-to-potassium ratio (surrogate for population screening and follow-up).
  • Dietary recall questionnaires (for initial patient counseling).
   
• Stratification: Classify patients as low (<2 g/day), moderate (2–3 g/day), or high (>3 g/day) sodium intake to guide intervention intensity.

2.6 Pharmacological Management Based on Sodium Status

• For patients with moderate/high sodium intake who cannot adhere to dietary restrictions, or those with uncontrolled blood pressure despite lifestyle intervention:
  • Prioritize diuretics (thiazides or thiazide-like agents) or calcium channel blockers (CCBs) for salt-sensitive hypertension.
  • Combine RAASi with diuretics in patients with high sodium and volume overload, monitoring renal function and electrolytes closely.
  • Individualize drug selection based on sodium/potassium balance, renal function, and comorbidities (e.g., diabetes, coronary artery disease).
   

2.7 Blood Pressure Targets

• General Hypertensive Patients: <140/90 mmHg; <130/80 mmHg if tolerated.
• High-Risk Patients (diabetes, coronary heart disease, heart failure, CKD with proteinuria): <130/80 mmHg.
• Elderly (65–79 years): <140/90 mmHg; <130/80 mmHg if tolerated.
• Elderly (≥80 years): <140/90 mmHg; avoid aggressive lowering to prevent hypotension and falls.

3. Clinical Implementation Pathway

1. Initial Evaluation: Assess 24-hour urinary sodium/potassium, dietary habits, renal function, electrolytes, and blood pressure phenotype (salt-sensitive vs. resistant).
2. Tiered Intervention:
   • Low sodium: Standard lifestyle counseling + routine antihypertensive therapy.
   • Moderate/high sodium: Intensive salt restriction education + potassium-rich diet + salt substitute (if eligible) + diuretic/CCB-based therapy.
    
3. Follow-Up: Reassess urinary sodium/potassium and blood pressure every 4–8 weeks; adjust diet and medications to achieve targets.
4. Long-Term Maintenance: Regular patient education, home blood pressure monitoring, and annual reassessment of sodium intake and target organ damage.

4. Conclusion

References

1. Sun N, et al. An expert recommendation on salt intake and blood pressure management in Chinese patients with hypertension: A statement of the Chinese Medical Association Hypertension Professional Committee. J Clin Hypertens. 2019;21:446–450.
2. Chinese Center for Disease Control and Prevention. Adult Hypertension Dietary Guidelines (2023 Edition).
3. Chinese Guidelines for the Prevention and Treatment of Hypertension (2024 Revision).
4. Salt Substitute and Stroke Study (SSaSS) Collaborative Group. Effect of salt substitution on cardiovascular events and death. N Engl J Med. 2021;385:1067–1077.

Key Metadata

• Issuing Body: Chinese Medical Association Hypertension Professional Committee
• Publication: Journal of Clinical Hypertension, 2019, Volume 21, Pages 446–450
• DOI: 10.1111/jch.13501
• PMC ID: PMC8030444
• Core Target: Sodium <2 g/day (salt <5 g/day), potassium 3.5–4.7 g/day, individualized blood pressure targets <130–140/80–90 mmHg.