Salt substitution and salt-supply restriction for lowering blood pressure in elderly care facilities: a cluster-randomized trial

Yifang Yuan, Aoming Jin, Bruce Neal, Xiangxian Feng, Qianku Qiao, Hongxia Wang, Ruijuan Zhang, Jiayu Li, Peifen Duan, La’e Cao, Hui Zhang, Senke Hu, Huijuan Li, Pei Gao, Gaoqiang Xie, Jianhui Yuan, Lili Cheng, Sujuan Wang, Haijun Zhang, Wenyi NiuHai Fang, Minghui Zhao, Runlin Gao, Junshi Chen, Paul Elliott, Darwin Labarthe, Yangfeng Wu*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)973-981
Number of pages9
JournalNature Medicine
Issue number4
StatePublished - Apr 2023

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)


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