Abstract
Objectives: To estimate the overall health impact in India of nationwide salt substitution (i.e., replacement of regular salt used at home for cooking or at the table with potassium-enriched reduced-sodium salt substitute). Methods: We used a comparative risk assessment framework to estimate 1) the number of cardiovascular disease (CVD) deaths averted due to blood pressure reductions in all adults, 2) the potential number of hyperkalemia deaths from increased potassium intake in individuals with advanced chronic kidney disease (CKD, estimated glomerular filtration rate <60 mL/min per 1.73 m 2 ), and 3) the net averted deaths (calculated as the difference of 1 and 2) from nationwide salt substitution in India. We evaluated a conservative scenario, deriving key model inputs and assumptions from a large, long-term pragmatic trial recently concluded in rural China; and an optimistic scenario informed by findings from our recent salt substitution trial in India. The models incorporated existing data and corresponding uncertainties from randomised trials, national surveys, the Global Burden of Disease Study, and the CKD Prognosis Consortium. Sensitivity analyses were conducted to assess the robustness of the findings to alterations in model inputs and assumptions. Results: In the conservative scenario, salt substitution was estimated to result in a net ~191 000 (95% uncertainty interval: 69 683; 329 147) fewer CVD deaths annually in the overall population, and ~30 000 (1 052; 58 409) fewer deaths among 28 million individuals with advanced CKD (Figure). In the optimistic scenario, the corresponding numbers were ~343 000 (120 035; 537 134) and ~57 000 (14 253; 96 606). Net benefits were consistent in deterministic sensitivity analyses (Figure). Conclusions: Nationwide salt substitution in India was consistently estimated to result in substantial net benefits, preventing around 8-14% of annual CVD deaths in India. Even considering risks of hyperkalaemia, net benefits were also projected for individuals with CKD
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