Potassium-Enriched Salt Substitution (PESS) - Why It Makes a Difference

Last year, when I wrote about salt, I discussed the results of two papers, one from India and one from China that showed reduction in blood pressure and lower rates of stroke, cardiovascular events and deaths in those who used a potassium-enriched salt substitute (PESS) as compared to those who used regular salt.

What is PESS? It is salt, where between 15-30% of the sodium is replaced by potassium. The salt tastes the same, but the amount of sodium that goes into the body is less as compared to regular salt.

There are very few salt substitutes currently available in India. A check on Amazon showed two brands; two different formulations from Tata (15% and 30% potassium respectively) and one from Aashirvaad along with a few other unknown brands. When I mentioned this to my parents, they immediately said we use “sindhaloo” salt, which is a type of rock salt, considered to be “better” and “purer” than packaged salt, often advertised in popular media these days as Himalayan salt. Unfortunately, this is still just salt, i.e. just sodium chloride and in reality, no different from packaged branded salt as far as health benefits or adverse effects are concerned.

The group that did the China study also recently did a cost-effective analysis and showed that even at slightly higher prices, PESS was cost-effective, given the reduced expenditure on health problems due to the benefits of the salt substitution [1]. The group that did the India study (though the authors of both groups overlap) recently published a modeling paper [2] to show how many lives would likely be saved annually in India due to PESS. Given that almost 13.5 to 15.0 lakh (1.3 to 1.5 million) deaths occur directly or indirectly due to high blood pressure, the use of PESS would likely prevent between 9% (conservative) to 14% (optimistic) of these deaths. With all the limitations of a modeling study, these are amazing numbers. The only contraindication to the use of PESS is in patients with chronic kidney disease, where the potassium can cause hyperkalemia…hence in those with chronic kidney disease, PESS should be avoided.

What does this mean for you and I in our atmasvasth quest to live long, healthy?

First, we should not consume more than two teapoons of salt per day, preferably less.

Second, we should switch to a potassium-enriched salt substitute, unless we have chronic kidney disease.  At present, the only PESS  available with 30% potassium is Tata Ultralite. I am sure with better public awareness, more and more companies will start offering PESS alternates.

Footnotes

1. Li KC et al. Cost-Effectiveness of a Household Salt Substitution Intervention: Findings From 20 995 Participants of the Salt Substitute and Stroke Study. Circulation. 2022 May 17;145(20):1534-1541

2. Marklund M et al. Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study. Hypertension. 2022 Jul 26:101161HYPERTENSIONAHA12219072.