Africa Water, Sanitation & Hygiene September - October 2016 Vol. 11 No.4 | Page 42

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Salt—too much or too little?
Evidence-based policy for salt reduction is needed

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Africa Water, Sanitation & Hygiene • September - October 2016

Evidence-based medicine
has become the bedrock of
treatment guidelines, but
why does evidence-based
medicine not translate into
evidence-based policy?
Governments and health
organizations around the
world are advocating salt
intake be reduced, but little
robust evidence exists to
support a reduction in salt
for the general population.
Indeed, the few randomized
controlled trials (RCTs) available have not strongly
supported the benefit of salt reduction in normotensive
populations. There is no real disagreement that high salt
intake is associated with high blood pressure, and most
studies indicate that high blood pressure is associated
with more cardiovascular events. The level at which salt
intake is regarded as high is not, however, agreed. Even
more concerning is that evidence for the benefit in the
advocated target levels of salt intake is virtually absent;
there are no RCTs measuring health outcomes when
sodium intake is less than 2•3 g (5 g of salt).
The paper by Andrew Mente and colleagues in today’s
Lancet provides reasonable evidence that current dietary
levels of salt in most populations are associated with
the lowest incidence of cardiovascular events. More
importantly, they show the proposed reductions to below
3 g of sodium intake daily are likely to result in harm in
both hypertensive and normotensive people. Although
not from an RCT, these data are as robust as the data used
to advocate reductions to low levels. At the very least,
these data should demand re-evaluation of the wisdom of
reducing levels of dietary salt without high grade evidence
to support such reductions.Before non-legislated salt
reduction programmes are imposed, the public should
demand that the harms, as well as the benefits, are based
solely on robust scientific evidence. Enacting potentially
harmful changes without strong supportive evidence
should be avoided. The Lancet