Review 821
Benefit assessment of salt reduction in patients with
hypertension: systematic overview
Eva Matyasa, Klaus Jeitlera,b, Karl Horvatha, Thomas Semlitscha,
Lars G. Hemkensc, Nicole Pignittera and Andrea Siebenhoferd
Objective We assessed the benefits and harm of reduced
salt intake in patients with essential hypertension focusing
on patient-relevant outcomes and blood pressure.
Methods A systematic search of five electronic databases
was performed to identify high-quality secondary literature
based on randomized controlled trials (RCTs). An
update primary literature search (RCTs) was performed for
the time period up to 2010 that was not covered by
secondary literature. Major outcomes were death,
cardiovascular morbidity/mortality, hospital stays, terminal
renal failure, quality of life, and adverse events. Change in
blood pressure was defined as surrogate parameter.
Results Four different systematic reviews and two RCTs
met the inclusion criteria. Only one review reported limited
data on patient-relevant outcomes. Over an intervention
period of up to 12 months, mean SBP was reduced by
3.68.0 mmHg in all reviews. For the same intervention
period, a statistically significant advantage with regard to
mean DBP reduction ranging from 1.9 to 2.8 mmHg was
found in three reviews. The fourth publication reported a
nonsignificant reduction (DBP reduction of 4.7 mmHg).
None of the RCTs identified in the primary literature search
update reported data on patient-relevant outcomes.
However, both RCTs found blood pressure improvements
with salt reduction.
Introduction
Hypertension is a chronic condition associated with an
increased risk of cardiovascular mortality and morbidity.
High blood pressure is estimated to lead to over 7 million
deaths each year, about 13% of the total deaths worldwide
[1]. Lowering blood pressure levels in hypertensive
patients has been shown to be a very effective means
of reducing those patients cardiovascular risk, with a
significant reduction in cardiovascular morbidity and
mortality [2,3].
The main treatments available for essential hypertension
are blood pressure-lowering drugs and various nondrug
treatment options. Consistently, epidemiological inves-
tigations have found an association between high blood
pressure and different lifestyle factors, high sodium
intake among them [47]. This assumption was also
underlined by some recently published systematic
reviews, including randomized controlled trials (RCTs)
showing that salt reduction also lowered blood pressure
[810]. In addition, higher salt intake was found to be
0263-6352 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Conclusion A benefit from a salt-reduced diet in patients
with high blood pressure is not proven with regard to
patient-relevant outcomes based on systematic reviews
and RCTs published up to 2010. The results indicate a blood
pressure-lowering effect through reduced salt intake in
hypertensive patients. J Hypertens 29:821828 Q 2011
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Journal of Hypertension 2011, 29:821828
Keywords: diet, dietary, hypertension, sodium, sodium-restricted
Abbreviations: HTA, health technology assessment; IQWiG, Institute for
Quality and Efficiency in Healthcare; RCTr, andomized controlled trial
a
Department of Internal Medicine, EBM Review Center Medical University of
Graz, bInstitute for Medical Informatics, Statistics and Documentation, Medical
University of Graz, Graz, Austria, cInstitute for Quality and Efficiency in Healthcare
(IQWiG), Cologne and dInstitute of General Practice, Goethe University
Frankfurt, Frankfurt, Germany
Correspondence to Andrea Siebenhofer, MD, Institute of General Practice,
Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
Tel: +49 69 6301 7296; fax: +49 69 6301 6428;
e-mail: siebenhofer@allgemeinmedizin.uni-frankfurt.de
Received 23 June 2010 Revised 14 December 2010
Accepted 28 December 2010
See editorial comment on page 829
associated with increased cardiovascular events [11].
National and international professional associations
recommend the consistent, long-term implementation
of nondrug measures in the treatment of essential hyper-
tension. Reduced salt intake is recommended in major
guidelines as one of the first-line interventions in the
treatment of hypertensive patients [1216].
This investigation is based on a report of the Institute for
Quality and Efficiency in Healthcare in Germany
(IQWiG), which aimed to assess the benefits and harm
of reduced salt intake. This report incorporated existing
systematic reviews. According to the IQWiG methods
[17], such an approach is deemed as resource-saving and
reliable, provided that specific preconditions have been
fulfilled (see below). Such overviews, sometimes called
umbrella reviews or meta-reviews, which combine and
compare different systematic reviews assessing interven-
tions, have recently been adopted by the Cochrane
Collaboration as well [18]. The present publication on
reduced salt intake is part of a package of systematic
DOI:10.1097/HJH.0b013e3283442840
822 Journal of Hypertension 2011, Vol 29 No 5
benefit assessments on different lifestyle interventions.
Results based on previous reports on the effect of weight
reduction have already been published [1921] and
further reports, for example, on physical activity and
alcohol reduction are in preparation. The present inves-
tigation aimed to review systematically the benefits and
harm of different interventions involving salt reduction
in patients with essential hypertension according to
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement [22].
Methods
Eligibility of publications
The investigation included systematic reviews of RCTs
of at least 4 weeks duration involving nonpregnant
patients aged 18 years or older with essential hyperten-
sion. The intervention to be tested in these trials was a
reduction in salt intake compared to no such reduction in
salt intake or a lower intended salt intake in the inter-
vention group than in the control group. Any additional
(antihypertensive) treatment had to be given equally in
both groups. Excluded were systematic reviews and
health technology assessment (HTA) reports in which
the reduction in salt intake as a primary intervention was
compared to another antihypertensive treatment as a
primary intervention (e.g., reduced salt intake versus diet
or versus blood pressure-lowering drugs).
Outcomes of interest
The evaluation focused on patient-relevant therapy out-
comes (mortality, cardiovascular morbidity and mortality,
hospital stays, terminal renal failure, capacity for work,
health-related quality of life, patient satisfaction, and
adverse events) and blood pressure as a surrogate end-
point in hypertensive people. Patient-relevant therapy
goals and surrogates were prospectively defined in a
protocol and detailed criteria for assessment of the
patient-relevant endpoints were determined in accord-
ance with the IQWiG methods Version 3.0 [17].
Selection of publications and methods of assessment
As indicated in the Cochrane Handbook [18] and IQWiG
methods Version 3.0 [17], the preparation of a review on
the basis of secondary literature is feasible, if major key
elements are considered as detailed in Table 1 in the
Appendix, http://links.lww.com/HJH/A71.
The bibliographic databases EMBASE and MEDLINE,
and three databases of the Cochrane Library [HTA
Database, The Cochrane Database of Systematic
Reviews (CDSR), Database of Abstracts of Reviews of
Effects (DARE)] were searched for related reviews
published after the year 1997 up to February 2010. All
systematic reviews published in English, German,
French, or Spanish were included. In addition, a primary
literature search update restricted to English and German
publications in EMBASE, MEDLINE/PubMed and
the Cochrane Central Register of Controlled Trials
(CENTRAL) was performed only for the time period
that was not covered by secondary literature. As the last
primary literature search in the systematic reviews was
performed in 2005, we searched for RCTs published
between 2005 and February 2010.
The search strategy is published in detail in the IQWiG
report [23]. Titles and abstracts were screened indepen-
dently by multiple teams of two reviewers (K.H., K.J.,
T.W.G., E.M. and/or A.S.); potentially relevant second-
ary publications were assessed as full texts by the same
reviewers. Differences between reviewers were resolved
by discussion or a third reviewer was involved. The
methodological quality assessment of the relevant
reviews was done according to Oxman and Guyatts index
[24,25]. Systematic reviews were included if they scored
at least five out of seven possible points.
Identical inclusion criteria as for the systematic reviews
were used to identify relevant RCTs. The quality assess-
ment of the included RCTs was based on randomization,
blinding, allocation concealment, intention-to-treat
analysis, and further aspects of bias risk, and was con-
ducted independently by K.H. and E.M., who graded the
relevant RCTs as having no (A), moderate (B), or serious
(C) methodological deficiencies.
Results
Results from the secondary literature
We identified 1729 potentially relevant publications in
the secondary literature and seven systematic reviews
[810,2629] met the inclusion criteria. All of those were
assessed with at least five out of seven possible points by
the Oxman and Guyatts score. These publications were
allocated to four groups of authors and included 62 RCTs
overall (Fig. 1 in the Appendix, http://links.lww.com/
HJH/A71). Table 1 [810,28] in the text gives an over-
view of the included systematic reviews. The search
strategies, selection criteria used for inclusion of primary
studies, number and duration of included RCTs, and the
patient characteristics are shown (Table 1 in the text). In
addition, Table 2 of the Appendix, http://links.lww.com/
HJH/A71 provides an outline of the database of relevant
outcomes within the systematic reviews.
Two systematic reviews (Hooper et al. [28] and Dickinson
et al. [8]) aimed for patient-relevant outcomes, but only
Hooper et al. [28] reported relevant patient-related out-
comes such as mortality, cardiovascular events, quality of
life, and adverse events. None of the reviews reported
data on hospital stays, terminal renal failure, capacity for
work, or patient satisfaction (Table 2 in the Appendix,
http://links.lww.com/HJH/A71). Results of the review
published by Hooper et al. [28] are described in the
following: data on all-cause mortality were provided for
three out of eight primary studies. One study reported
four deaths in the intervention and five deaths in the
 Benefit assessment of salt reduction in hypertension Matyas et al. 823

Table 1 Characteristics of the systematic reviews/number and duration of the included relevant randomized controlled trials
Number/duration
(median) of Patient
Systematic review Relevant selection criteria Search included RCTs characteristics

Dickinson et al. [8]; Sponsoring:
National Institute for Clinical
Excellence (NICE)
He and MacGregor [9]
(Update 2006); Sponsoring:
no sponsor
Hooper et al. [28]; Sponsoring:
NW Research Development
Training Fellowship
Jurgens and Graudal [10];
Sponsoring: no sponsor
Inclusion criteria: RCTs; MEDLINE (1998 to May 2003); 8 RCTs, 8 to Number of patients:
duration
8 weeks; adults; EMBASE (1998 to May 2003); 52 weeks 520; mean %
SBP
140 and/or DBP CENTRAL (1998 to May 2003); (52 weeks) female: 24; mean

85 mmHg; exclusion criteria: references of hypertension age: 52 years; mean
pregnancy; secondary guidelines, systematic reviews BP: 151/95 mmHg
hypertension; change in and meta-analyses (before 1998)
antihypertensive medication
during follow-up
Inclusion criteria: RCTs; duration: MEDLINE (1966 to April 2005); 20 RCTs, 4 to Number of patients:

4 weeks; age
18 years; EMBASE (1980 to April 2005); 52 weeks 802; Median %
net reduction in 24-h urinary CINHAL (1982 to June 2001); (5 weeks) female: 47 (range:
sodium must be equal to or Cochrane Library (up to April 1576); median
greater than 40 mmol; exclusion 2005); references of original age: 50 years;
criteria: pregnancy articles and reviews median BP:
149/94 mmHg
Inclusion criteria: RCTs; duration MEDLINE (up to July 2000); 8 RCTs, 6 months Number of patients:

26 weeks; age
16 years; EMBASE (up to July 2000); to 7 years 1188; median %
exclusion criteria: pregnancy, Cochrane Library (up to July (12 months) female: 50 (range:
hospitalized patients 2000); CAB abstracts, 058); Mean age:
CVRCT registry, SIGLE (up n.a.; median BP:
to May 1998); bibliographies 145/86 mmHg
of identified publications
and reviews
Inclusion criteria: RCTs, additional MEDLINE (1966 to December 54 RCTs, 4 to Number of patients:
interventions had to be 2001); EMBASE, CCTR 365 days n.a.a; % female: n.a;
comparable in the intervention (no data of search (28 days) mean age: 49 years;
groups; at least 8 h urinary time available) mean BP: n.a.
sodium excretion; age >15 years;
exclusion criteria: pregnancy

BP, blood pressure; n.a., no data available; RCT, randomized controlled trial. a In the meta-analyses, n 3391 (DBP) and n 3367 (SBP) were included. These numbers
also include cross-over comparisons and several primary studies <4 weeks of duration.

control group (Morgan et al. [30]), whereas the other two
studies counted no death (Alli et al. [31] and TONE
[32,33]). Cardiovascular events were described in two
(Alli et al. [31] and TONE [32,33]) out of eight studies
and the presented meta-analysis showed no significant
difference between the salt-reduced and control groups
(Hooper et al. [28]). In the review of Hooper et al. [28],
health-related quality of life was described in only one
trial (Thaler et al. [34]). Data were not scaled by a
conventional measurement and it was not possible to
compare the study groups. Adverse events were reported
in two studies within the 2004 review by Hooper et al. In
the study by Thaler et al. [34], muscle cramps were more
frequent in the intervention group. As the difference
between the groups with regard to frequency of muscle
cramps was similar at study entry (29.5% in the inter-
vention group versus 15.3% in the control group), there
was no evidence of an increase in muscle cramps. A
statistically significant smaller number of participants
in the salt-reducing group reported headache in the
TONE trial [32,33], but further details necessary to
interpret this finding were not reported.
For investigations on blood pressure as a surrogate, most
of the analyses showed a blood pressure-lowering effect
in hypertensive patients through reduced salt intake
when compared to a control treatment (Fig. 1 in the text;
Table 3 in the Appendix, http://links.lww.com/HJH/A71).
Over an intervention period of up to 12 months, the
analyses showed a statistically significant difference
with regard to mean SBP reduction ranging from 3.6 to
8.0 mmHg in favor of the intervention groups. For the
same intervention period, a statistically significant differ-
ence with regard to mean DBP reduction ranging from
1.9 to 2.8 mmHg was found in three reviews. In the
fourth publication (Hooper et al. [28]), a more pronounced
reduction was also observed for the intervention (differ-
ence of 4.7 mmHg compared to control treatment),
but this was based on only four trials and without
statistical significance. All data primarily apply to analyses
of patients without concomitant antihypertensive drug
treatment.
In the study by Dickinson et al. [8], results on blood
pressure were based on a meta-analysis of six studies
including 450 untreated patients and showed no hetero-
geneity. There was a statistically significant weighted
mean difference in studies lasting from 8 to 52 weeks in
favor of the salt-reduced group. Including only studies
with a duration of at least 6 months, there was no longer
any statistically significant weighted mean difference.
Similar effects in untreated hypertensive patients favor-
ing the intervention group were obtained in the meta-
analysis lasting between 4 and 52 weeks of follow-up of
824 Journal of Hypertension 2011, Vol 29 No 5

Fig. 1

SBP DBP
Systematic RCTs Weighted mean difference (95% CI) RCTs Weighted mean difference (95% CI)
review [n] [mmHg] [n] [mmHg]

Dickinson 20068 6 3.6 (4.6; 2.5) 6 2.5 (3.2; 1.7)

He 20049 19 5.3 (6.7; 3.9) 20 2.8 (3.6; 2.0)

Hooper 2004 28
4 8.0 (15.8; 0.2) 4 4.7 (9.3; 0.04)

Jrgens 2004 10
53 4.2 (5.1; 3.3) 54 1.9 (2.5; 1.3)

15 0 15 15 0 15
Favours salt reduction Favours control Favours salt reduction Favours control

Weighted mean differences for SBP and DBP: comparison of the results for the follow-up up to 12 months.

He et al. [9], including 20 comparisons with about 800
patients. There was marked heterogeneity in the blood
pressure results and possible reasons given by the authors
were differences between studies in age, ethnic group,
baseline blood pressure levels, the amount and the
duration of salt intake reduction, and the study quality.
They did not perform further sensitivity analyses due to
the small number of trials and the very limited infor-
mation reported in the studies.
A meta-analysis by Hooper et al. [28] containing four
studies lasting between 6 and 12 months of follow-up
covering 179 hypertensive patients without antihyper-
tensive drug treatment showed a statistically significant
advantage in favor of the intervention group for the SBP
only. There was moderate heterogeneity (P 0.15;
I2 43%). For DBP, there were two studies with the
same follow-up period with 87 untreated hypertensive
patients that only showed a trend in favor of the inter-
vention group. Hooper et al. identified only one small trial
(Morgan et al. [30,35]) with 62 patients lasting more than a
year in which only the DBP was significantly reduced due
to salt reduction. In addition, Hooper et al. [28] included
three studies with treated hypertensive patients as well,
but the authors did not explain why a meta-analysis was
not performed. One of these trials (TONE [32,33]) did
not report any blood pressure results. In a study by
Morgan and Anderson [36], in which antihypertensive
drug treatment was withdrawn after 3 months in both
groups, after 9 months of follow-up, blood pressure
increased less under salt reduction. In the study by Arroll
and Beaglehole [37], there was a greater mean decrease
after 6 months of intervention for SBP in the salt-reduced
group than in the control group [9.1 (standard deviation
21.7); 6.2 (standard deviation 21.0) mmHg]. For DBP,
the mean decrease was smaller in the salt-reduced group

Table 2 Characteristics of the randomized controlled trials from primary literature search update
Relevant selection Study design/
RCT criteria duration of study Intervention Patient characteristics Outcomes

He and MacGregor Inclusion criteria: age:
[38]; Sponsoring:
UK Food
Standards Agency
Meland and Aamland Inclusion criteria: age:
[39]; Sponsoring:
Norske Hoechst
AS, University
of Bergen
student grant,
Solstrandsfondet
3075 years; SBP
140170 or DBP
90105 mmHg; exclusion
criteria: pregnancy, previous
treatment for raised BP;
secondary hypertension,
previous stroke, ischemic
heart disease, heart failure,
diabetes mellitus,
malignancy or liver disease;
women on oral contraceptives
2075 years, patients on
antihypertensive drugs;
SBP 160210 and/or DBP
90115 mmHg; exclusion
criteria: drug-induced
hypertension; use of
antihypertensives due to
other cardiovascular
illnesses
RCT; double-blind; 2 weeks run-in phase No separate analyses for
cross-over/ on a reduced-salt diet;
6 weeks IG: 9 slow sodium
tablets (10 mmol per
tablet) daily; CG:
9 placebo tablets daily
RCT; double-blind; Salt-reduced diet in both Number of patients
parallel/8 weeks groups; IG: 5 capsules
of 10 mmol sodium/day;
CG: 5 placebo capsules
/day (identical capsules
to IG)
Patient-relevant endpoints:
IG and CG available; n.a.; surrogate endpoints:
number of patients: duration and extent of
169; % female: n.a.; blood pressure changes;
mean age: 50 years; BP at study end [mean
mean BP: difference (mmHg]: SBP:
147/91 mmHg 4.8 (95%CI: 6.4 to
3.2); P < 0.001; DBP:
2.2 (95%CI: 3.1 to
1.4); P < 0.001]
Patient-relevant endpoints:
IG/CG: 57/55; n.a.; surrogate endpoints:
% female: n.a; duration and extent of
mean age: IG/CG: blood pressure changes;
57/55 years; mean BP at study end [mean
BP: IG/CG; SBP: difference (mmHg): SBP:
157/155 mmHg; 5 (95%CI: 11 to 0);
DBP 93/92 mmHg P < 0.07; DBP: 5
(95% CI: 7 to 1);
P < 0.02

CG, control group; CI, confidence interval; IG, intervention group; n.a., no data available; RCT, randomized controlled trial.
 Benefit assessment of salt reduction in hypertension Matyas et al. 825
than in the control group [1.7 (standard deviation 34.9);
4.8 (standard deviation 36.1) mmHg].
In the fourth systematic review including 54 studies
(Jurgens and Graudal [10]), no separate analyses for
treated and untreated hypertensive people were per-
formed. For both SBP including 3391 participants in
the analysis and for the DBP including 3367 participants,
there was a significant weighted mean difference in favor
of the intervention group. There was no significant
heterogeneity found for either of the blood pressure
analyses.
Results from randomized controlled trials published
between 2005 and 2010
The primary literature search update revealed 573
additional references. Two RCTs [38,39] were included
in this systematic overview. The trial flow is given in
Fig. 2 in the Appendix, http://links.lww.com/HJH/A71.
Table 2 [38,39] in the text provides information on
relevant characteristics of the included RCTs. The qual-
ity assessment of these two studies is presented in
Table 4 in the Appendix, http://links.lww.com/HJH/
A71; one was judged to have moderate and the other
one serious risk of bias.
Both trials lasted only a few weeks and no data on patient-
relevant outcomes were reported. However, blood pres-
sure changes were shown in both studies and indicated a
benefit in the salt-reduced patient groups. The results in
the study by He et al. [38] showed a statistically signi-
ficant difference in SBP and DBP between the inter-
vention and the control groups [SBP: 4.8 mmHg
(95% confidence interval 6.4 to 3.2); P < 0.001;
DBP: 2.2 mmHg (95% confidence interval 3.1 to
1.4); P < 0.001]. In the study by Meland and Aamland
[39], there was a statistically significant difference
between the groups in favor of the intervention group
only in the DBP [5 mmHg (95% confidence interval 7
to 1); P < 0.02]. For the SBP, the difference was not
statistically significant [5 mmHg; (95% confidence
interval 11 to 0); P < 0.07; see Table 2 in the text].
Discussion
Based on high quality secondary literature and an exten-
sive update search for RCTs, we conducted a systematic
overview examining the question of whether salt
reduction in patients with essential hypertension is
beneficial or harmful. The robustness of the results
appears plausible as this overview covers the high quality
evidence available to date, and a primary literature search
update was performed. Within the systematic reviews
included, no primary study was identified in which the
primary objective was to investigate the reduction in salt
intake as an intervention in order to prevent patient-
relevant complications. In relation to blood pressure, all
analyses showed a blood pressure-lowering effect in
hypertensive patients through reduced salt intake when
compared to a control treatment. The reported extent of
the effect size varied among the reviews.
Our findings are not unexpected against the background
of the epidemiological data suggesting that salt intake
is positively associated with blood pressure levels
[11,4144]. None of the RCTs included in the identified
systematic reviews was powered to detect a potential
benefit indicating that salt-reduced diet decreases unfa-
vorable patient-relevant outcomes. Consequently, evi-
dence for the assumption that salt restriction is associated
with a tremendous reduction in cardiovascular outcomes
as well, is only based on epidemiological observations
[11,41,45]. In the recently published systematic review
and meta-analysis of prospective studies published by
Strazzullo et al. in 2009 [11], including 19 independent
cohort samples with more than 170 000 participants and a
follow-up between 3.5 and 19 years, higher salt intake
was associated with a significantly greater risk of stroke
(pooled relative risk 1.23; 95% confidence interval 1.06
1.43; P 0.007) and a tendentially higher, though non-
significant, risk of cardiovascular disease was observed
(pooled relative risk 1.14, 95% confidence interval 0.99
1.32; P 0.07). In a recently published narrative review,
multiple studies have shown that the adjusted relative
risk reduction in controlled observational studies aiming
for reduced sodium intake ranged from 25% over 15 years
to 41% over 3 years [45]. The effect of a direct application
of a salt reduction in daily life has been demonstrated
in an RCT, which investigated the Dietary Approaches
for Stop Hypertension (DASH) diet, rich in fruits and
vegetables and low-fat diary products in combination
with reduced dietary sodium uptake. In patients having
such a diet, it has been shown that the SBP was
11.5 mmHg lower compared to patients with control diet
with high sodium intake [46]. It has been reported that
this blood pressure reduction has been further improved
when patients on the DASH diet additionally exercise
and follow a weight management program [47].
This evidence is further underlined in a long-term obser-
vational follow-up study of two hypertension prevention
trials (TOHP I and II) with prehypertensive patients.
This study does not meet the inclusion criteria of our
review; however, as long-term results are of major
relevance in this context, we would like to discuss them
in further detail. A total of 3126 patients randomly
assigned to salt restriction in TOPH I and TOPH II
were observed for a further 1015 years after the end of
the original RCTs lasting for 1848 months. Follow-up
information on cardiovascular outcomes was 77% and for
death 100%, and blinded endpoint evaluation by medical
records was performed. In this long-term observation, the
risk of a cardiovascular event was about 2530% lower
among those in the salt-reduced group and there was a
trend to a lower mortality rate, which was, however, not
statistically significant [48]. On the basis of those studies,
reduced salt intake is recommended by many leading
826 Journal of Hypertension 2011, Vol 29 No 5
national and international professional associations
[1216]. There is solid evidence for a health benefit
when blood pressure is reduced to recommended levels,
and in certain patients, lifestyle changes may enable
them to reduce or stop drug therapy as well [32]. In
terms of salt intake, experts in this field advise patients to
first decrease their consumption of processed food, refrain
from adding salt, and eat more fruits and vegetables [49].
Limitations of our overview are that most of the RCTs
included in the systematic reviews provided only a small
number of patients and short follow-up. As a consequence,
none had the power to evaluate patient-relevant outcomes
and no answer can be provided on these aspects. In
addition, the included systematic reviews differ in their
chosen outcomes, inclusion criteria, and search strategies,
which also might cause the differences in the numbers of
studies included in the systematic reviews. Although we
included only high quality systematic reviews, another
limitation is that the reviews might have some flaws that
are passed over to our review as well. Nonetheless, the
results obtained in terms of blood pressure point in the
same direction, which once again further confirms the
assumptions known for a long time that dietary salt restric-
tion appears to be effective with regard to this surrogate.
However, an important limitation is that almost none of the
analyses presented results on patients who were simul-
taneously taking antihypertensive drugs, and an additional
blood pressure-lowering capacity in those patients taking
such medication remains unclear. This needs to be empha-
sized as this raises the question whether the results are
generalizable to patients being treated with antihyper-
tensive drugs. In addition, only one (Hooper et al. [28])
of the four included systematic reviews presented some
limited information on how salt intake was reduced with
the different interventions. This in turn means that no
recommendations can be given on the basis of these results
as to how salt intake should best be reduced. Moreover,
valid long-term data are not available and well founded
information on patient-relevant outcomes does not exist.
The importance of this uncertainty is emphasized by an
example from a study with successful weight reduction.
The Swedish Obese Subject Study (SOS) in which more
than 1700 patients successfully reduced their body weight
by means of bariatric surgery has shown that the initial
postsurgical blood pressure reduction was still present after
2 years, but was almost gone 10 years later [50]. In terms of
adverse events, Klaus et al. [45] gave an overview on
possible risks in terms of a dietary salt reduction,
suggesting that with a modest dietary salt restriction to
56 g/day, short episodes of severe diarrhea or longer
episodes of vomiting are not likely to cause sodium
deficiency. Even in geriatric patients and pregnant
women, Klaus et al. [45] deem the benefit as exceeding
potential harm. Drastic salt restrictions to 1 g/day are not
recommended due to pathophysiological considerations
[45].
Since the 1980s, the salt industry has tried to promote
the view that salt reduction provides only a negligible
benefit [41,51], but now, concerted efforts of relevant
working groups and advisory panels throughout the
world and the WHO are exerting pressure on them to
change their strategy [49,52]. These organizations pub-
lish action plans for the implementation of salt-reducing
strategies and give recommendations for a population-
wide salt intake reduction. For example, the WHO has
set out a worldwide target of less than 5 g/day for adults
[49], or a reduction of salt intake by approximately one
half per day assuming that western people consume
about 10 g sodium daily. Though these measures are
all voluntary and not regulated by law, reduction of
sodium in the diet is increasingly becoming a public
health issue. A coronary heart disease model including
the entire US population has recently indicated that
lowering salt intake in the population would in all like-
lihood reduce cardiovascular disease and deaths, and
lower medical costs [53]. Most of the strategies are based
on the United Kingdom Food Standards Agencys pro-
gram on salt reduction, the Consensus Action on Salt and
Health (CASH) [52]. CASH involves government,
business, and consumer and health groups, based on
the premise that action must address people, environ-
ment, and products. Since CASH was set up in 1996, with
the stepwise and slow reduction of salt content in
primary processed foods bought in supermarkets, public
health campaigns, and a clear labeling, salt intake has
already fallen as documented by a random sample of the
population [40]. Preexisting strategies can now act as a
model for other initiatives in different countries such as
the less salt for all task force [54], which is currently
being planned in Germany. After the critical assessment
of risks and benefits of a general restriction of dietary salt
intake, they want to implement short-term, medium-
term and long-term goals. Short and medium goals are to
concentrate on the improvement of the health status of
the population aiming for sodium labeling of food pro-
ducts and the stepwise reduction of salt in processed
food, in fast food chains and restaurants. For long-term
goals, individual patients should be addressed via sus-
tainable health promotion (e.g. advice for nutritional
behavior changes with the focus of promotion in media,
schools, and other education sites). For hypertensive
patients, structured training courses could be a key,
because such training programs with appropriate infor-
mation on nutrition have been successfully imple-
mented to improve patients understanding of hyper-
tension and associated complications, thus increasing
adherence with nondrug and drug-based treatments
and improving patient-relevant outcomes [5559].
Our overview based on secondary and primary literature
published to date proves a blood pressure-lowering effect
when hypertensive patients reduce their salt intake.
However, no valid information was available to show
 Benefit assessment of salt reduction in hypertension Matyas et al. 827
conclusively that salt reduction is beneficial or harmful in
terms of patient-relevant outcomes.
Acknowledgements
The authors thank Siw Waffenschmidt (IQWiG) for
assistance with the literature search strategies, Thomas
Werner Gratzer and Ursula Puringer for support in data
editing, and Eugenia Lamont for final editing of the
article.
E.M., K.J., K.H., T.S., N.P., and A.S. are involved as
external experts in the preparation of rapid reports on
the benefit assessment of nondrug treatment strategies
in patients with essential hypertension for IQWiG, the
German Institute for Quality and Efficiency in Health-
care. L.G.H. is an employee of IQWiG.
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