European Salt Action Network restates its support for WHO goal of reducing salt intake to 5 g per day or less

The WHO European Salt Action Network (ESAN) has issued an authoritative statement in support of population approaches for salt reduction to prevent cardiovascular diseases. This comes in the wake of recent studies that have generated controversy by suggesting that a reduction in salt consumption towards 5 g per day may be dangerous and lead to cardiovascular events. This suggestion contradicts the recommendations set by the WHO, and the consensus among Member States, for a 30% reduction in salt consumption by 2025 aiming at a final goal of no more than 5 g per day.

The statement by ESAN supporting salt reduction, published in the journal Nutrition, Metabolism and Cardiovascular Diseases, calls on countries to work towards the WHO guideline on salt intake. It responds directly to recent scientific publications that have questioned the guideline and generated controversy in popular media such as blogs, newspapers and magazines. WHO/Europe welcomes the statement from ESAN.

Cardiovascular diseases account for half of the premature mortality in the WHO European Region, and high blood pressure is the main risk factor. The WHO guideline reviewed all available evidence and concluded that high salt intake causes a rise in blood pressure, and that a reduction in its consumption leads to lower blood pressure.

Flawed methodology in studies questioning the validity of salt reduction

After a thorough examination of the methodologies used in the recent studies that questioned the WHO guideline, the ESAN statement concludes that they have numerous and substantial flaws. The methodological errors found in the papers include biased estimations of habitual salt consumption, which result in a biased and unreliable assessment of relationships between consumption and cardiovascular outcomes.

The inclusion in the latest studies of sick individuals already suffering from cardiovascular diseases and on polypharmacy introduce further bias (reverse causality), thereby producing misleading results and interpretations.

Past and more recent studies using optimal methodologies (including some randomized clinical trials) confirm the graded and linear relationship between salt consumption and cardiovascular outcomes, with no increased risk at levels around 5 g per day or less. The body of evidence supports the WHO guideline and global salt reduction policies.

The populations of all countries of the Region have a high salt intake, contributing to high blood pressure and cardiovascular diseases. Reducing salt consumption to moderate levels of 5 g per day or less is a feasible, cost-effective and equitable public health measure that will bring great benefits.