New strategy for hypertension control: should potassium enhancement be included in high blood pressure control measures?

Reducing salt intake has been a key dietary recommendation for the prevention and treatment of high blood pressure for decades. However, the authors of a new peer-reviewed article in The American Journal of Clinical Nutrition believe this approach only captures half the physiological picture. They suggest paying equal attention to a second electrolyte, potassium, a deficiency of which can increase sodium retention by the kidneys and contribute to high blood pressure. [1]

The publication's main thesis, however, is not that previous recommendations for salt restriction are erroneous. The authors explicitly call sodium reduction a fundamental strategy for hypertension prevention. They propose expanding this to the formula "less sodium + more potassium," as new physiological and clinical data increasingly demonstrate that the body regulates these two minerals as an interconnected system. [2]

The paper differs from the typical medical research report: it is a Perspective—an analytical review article, not a new randomized trial. Naomi Fukagawa, Paul Welling, and their colleagues reviewed the evidence on sodium and potassium recommendations, blood pressure regulation mechanisms, clinical trials, salt substitutes, the food industry, and potential policy changes. [3]

The authors pay special attention to the so-called renal potassium switch—a system that causes the kidneys to actively retain sodium when potassium is depleted. From an evolutionary perspective, this mechanism helped the body conserve deficient potassium, but in a modern diet, where sodium is often high and potassium is low, this same system can contribute to high blood pressure. [4]

The main point of the article	What the authors propose
Sodium restriction	Remains the foundation of hypertension prevention
Potassium	Should be considered as an equal part of the strategy
The basic approach	Less sodium + more dietary potassium
Possible tool	Partial replacement of NaCl with KCl
Key mechanism	Renal "potassium switch"
Key foods high in potassium	Vegetables, fruits, legumes, dairy products
Are potassium salt substitutes suitable for everyone?	No, there is a risk of hyperkalemia in some patients.
DOI of the article	10.1016/j.ajcnut.2026.101396

[5]

Why Cutting Salt Alone May Not Be Enough

The relationship between excess sodium and blood pressure is well-studied. Increasing sodium intake promotes fluid retention and alters vascular and renal function, while reducing sodium intake has been shown to reduce both systolic and diastolic pressure in controlled studies. Therefore, current recommendations maintain sodium restriction as one of the most effective dietary measures for hypertension. [6]

The problem is that changing salt consumption at the population level has proven very difficult. A significant portion of sodium comes not from the salt shaker in front of a person, but from prepared and processed foods, bread, meat products, cheeses, sauces, and other frequently consumed foods. As a result, even a person who barely adds salt to their food can still consume large amounts of sodium. [7]

The authors of a new article draw attention to another aspect of the modern diet. Despite relatively high sodium intake, many people's diets contain insufficient fruits, vegetables, legumes, and other natural sources of potassium. This creates a combination that differs significantly from the conditions under which human physiology developed: high sodium and low potassium. [8]

From a blood pressure regulation perspective, these changes cannot be considered entirely independently. Sodium and potassium interact primarily in the kidneys, and the amount of potassium consumed can alter how actively the body retains or excretes sodium. Therefore, the same salt intake could theoretically create different physiological stress depending on the amount of potassium in the diet. [9]

Traditional model	Proposed extended model
The main problem is excess sodium	The problem is excess sodium and lack of potassium
The main goal is to reduce salt	Reduce sodium and increase potassium at the same time
Sodium is considered separately	The Na/K interaction is taken into account
The main tool is salt restriction	Diet + food reformulation + salt substitutes
Main target organ	Kidneys and blood vessels
New physiological link	Renal potassium switch

[10]

How the Renal Potassium Switch Works

The kidneys constantly perform two tasks, which sometimes conflict: retaining sufficient potassium while simultaneously regulating sodium levels and fluid volume in the body. One of the central links in this system is located in the distal convoluted tubule of the nephron, where the thiazide-sensitive sodium-chloride cotransporter NCC operates. [11]

When potassium intake is low and its plasma concentration decreases, a signaling cascade involving the WNK and SPAK family of kinases is activated. As a result, the NCC begins to more actively return sodium and chloride from the primary urine back into the blood. This response helps reduce subsequent potassium losses, but at the same time, the body retains more sodium. [12]

From a biological perspective, this is a reasonable survival mechanism. If potassium is low, the kidneys do everything possible to conserve it, even if the price is additional sodium reabsorption. But in a modern diet, where sodium is either sufficient or excessive, chronic activation of this system can become undesirable: increased sodium retention contributes to high blood pressure. [13]

With increased potassium intake, the opposite occurs. NCC activity decreases, and more sodium passes further down the nephron and is excreted in the urine. This sodium-excreting effect is called natriuresis. Potassium also affects vascular tone, so the reduction in pressure is likely the result of several interacting mechanisms, not just additional salt excretion. [14]

The authors cite this system as one of the main arguments against the exclusively "sodium-centric" model of hypertension prevention. If low dietary potassium levels themselves cause the kidneys to become more "sparing" with respect to sodium, then increasing potassium may enhance the effect of moderate salt restriction. [15]

Situation	Kidney response	Possible consequence
Potassium is low	WNK-SPAK-NCC is activated	More NaCl is reabsorbed
NaCl reabsorption is increased	Sodium is retained	The pressure may increase
More potassium	NCC activity decreases	Sodium reabsorption is reduced
More sodium is excreted	Natriuresis increases	The pressure may decrease
Evolutionary meaning	Save potassium	Useful for K deficiency
Modern problem	Lots of Na + little K	The mechanism may contribute to hypertension

[16]

What clinical research says about combining sodium and potassium

The authors' argument isn't based solely on kidney physiology. Randomized trials have repeatedly shown that reducing sodium lowers blood pressure, and increasing potassium intake can also have a hypotensive effect, especially in people with already elevated blood pressure. Back in 2019, the US National Academies of Sciences characterized the evidence for blood pressure reduction with potassium supplementation as moderately strong, although they deemed it insufficient to establish a separate chronic risk indicator for potassium. [17]

A particularly compelling example of a combined approach was the large Salt Substitute and Stroke Study. It included 20,995 people from 600 rural villages in China—mostly elderly people with hypertension or a history of stroke. Instead of regular salt, participants in the intervention group used a mixture of 75% sodium chloride and 25% potassium chloride. [18]

Over a mean follow-up period of 4.74 years, the stroke rate was 29.14 versus 33.65 events per 1000 person-years, or approximately 14% lower in the salt substitute group. The rate of major cardiovascular events was approximately 13% lower, and all-cause mortality was 12% lower. [19]

At the same time, urine analysis showed that the intervention actually had a bidirectional effect: average sodium excretion decreased by approximately 350 milligrams per day, while potassium excretion increased by approximately 803 milligrams. Therefore, the experiment almost perfectly illustrates the central idea of the new paper – the clinical effect is achieved not only by removing some sodium, but also by simultaneously supplementing potassium. [20]

The study was conducted in a high-risk group in rural China, where a significant portion of salt was added directly during cooking. Its findings cannot be automatically generalized to young, healthy individuals or countries where most sodium comes from industrially produced foods. But the very evidence that the combined intervention can reduce actual cardiovascular events is one of the strongest arguments made by the Perspective authors. [21]

Salt Substitute and Stroke Study	Regular salt	Salt NaCl/KCl	Relative effect
Participants	colspan	20,995	-
Salt composition	100% NaCl	75% NaCl + 25% KCl	-
Strokes per 1000 person-years	33.65	29.14	RR 0.86
Major cardiovascular events	56.29	49.09	RR 0.87
Death from any cause	44.61	39.28	RR 0.88
Severe hyperkalemia	3.30	3.35	RR 1.04; no significant difference
Observation	colspan	4.74 years	-

[22]

Potassium is not just an "antidote" to salt

The authors emphasize that dietary potassium should not be viewed as a substance that allows unlimited sodium consumption. High salt intake remains an independent factor in high blood pressure, so the primary goal is not to compensate for excess sodium with bananas or potassium supplements, but to simultaneously improve both sides of the balance. [23]

The most natural way to increase potassium intake is to change the structure of your diet. Potassium-rich foods include vegetables, fruits, legumes, and many dairy products. These foods also provide fiber, vitamins, minerals, and other components, so switching to a diet rich in minimally processed plant foods can't be attributed solely to the electrolyte's effect. [24]

The second option is to use potassium chloride in food production. It has a salty flavor and can replace some of the sodium chloride. According to the article discussed, the practical limitation is organoleptic properties: excessive amounts of KCl produce bitter or metallic flavors, so in many products it's realistic to replace approximately 25-30% of the sodium chloride, rather than all of the salt. [25]

There are also technological limitations. Sodium chloride is used in some products not only for flavor but also affects texture, fermentation, shelf life, and the production process. Therefore, the authors propose not a universal replacement formula, but a combination of gradually reducing sodium, increasing potassium, modifying recipes, and adapting to consumer taste habits. [26]

How much sodium and potassium is recommended to consume?

It's important to differentiate between recommendations from different organizations. The World Health Organization recommends that adults limit sodium intake to less than 2,000 milligrams per day, which is equivalent to approximately 5 grams of table salt. At the same time, the organization notes that consuming at least 3,510 milligrams of potassium per day may be beneficial. [27]

The Dietary Reference Intakes system used in the United States and Canada is structured somewhat differently. The National Academies established an adequate sodium intake for adults of 1,500 milligrams per day and a chronic risk reduction indicator: if an adult consumes more than 2,300 milligrams of sodium, it is recommended to reduce their intake. [28]

For potassium, the US-Canadian reference intakes are 3,400 milligrams per day for adult men and 2,600 milligrams per day for adult women. These are adequate intakes, not proven optimal therapeutic thresholds. The National Academies specifically emphasize that there is insufficient data on the precise dose-response relationship between potassium and clinical outcomes to establish a specific level for chronic risk reduction. [29]

This is precisely the gap that the new article proposes to more actively fill. The authors believe that the lack of a perfectly established universal threshold should not lead to ignoring the obvious problem: many populations consume more sodium than recommended and less potassium than desirable. Therefore, public health can work simultaneously on both fronts, continuing to refine optimal intakes. [30]

Recommendation for adults	Sodium	Potassium
World Health Organization	<2000 mg/day	≥3510 mg/day
National Academies of the USA/Canada - Men	At >2300 mg it is recommended to reduce	AI 3400 mg/day
National Academies of the USA/Canada - Women	At >2300 mg it is recommended to reduce	AI 2600 mg/day
2000 mg of sodium is approximately equivalent to	≈5 g salt	-
The main idea of the article	Reduce excess	Eliminate underconsumption

[31]

Why the sodium-potassium ratio may be more informative than salt alone

The authors discuss the possibility of paying more attention to the sodium-to-potassium ratio. This ratio reflects both aspects of the diet simultaneously: it increases when a person eats more sodium, less potassium, or both. Physiologically, this is attractive because the kidneys regulate the two minerals together. [32]

Observational studies with repeated 24-hour urine collections have also shown that higher sodium, lower potassium, and especially an unfavorable sodium-to-potassium ratio are associated with cardiovascular risk. In one large analysis, each additional 1,000 milligrams of sodium in daily excretion was associated with an approximately 18 percent increase in cardiovascular risk, whereas each additional 1,000 milligrams of potassium was associated with an approximately 18 percent decrease.[33]

However, the authors of the new Perspective do not propose replacing all dietary recommendations with a single Na/K ratio tomorrow. The electrolyte content of foods, individual kidney function, and methods for assessing actual intake create significant uncertainty. Furthermore, recommendations for the population must remain clear enough to be used without laboratory analysis of the diet. [34]

Using the ratio as a tool for the food industry appears much more practical: when developing a recipe, one can simultaneously assess how much sodium is reduced and how much potassium is increased. The authors believe that this approach better reflects the physiological purpose of reformulation than simply reporting the percentage of salt reduced. [35]

Potassium-rich salt substitutes are not suitable for everyone.

The most important precaution applies to people with impaired renal potassium excretion. Normally, excess potassium is effectively eliminated in the urine, but with severely impaired kidney function, it can accumulate in the blood. Excessively high potassium levels—hyperkalemia—are potentially dangerous due to their impact on the heart's electrical activity. [36]

Therefore, the study's findings should not be interpreted as universal advice to replace all table salt with potassium chloride. The National Academies specifically warn of the need for caution with large amounts of supplemental potassium in people with impaired or potentially impaired kidney function. [37]

The World Health Organization also clarifies in its current recommendations that salts with reduced sodium and added potassium can be used primarily in people without an increased risk of hyperkalemia. At the population level, the organization recommends implementing this strategy in areas where the healthcare system is capable of promptly identifying and treating kidney disease. [38]

Thus, there is a significant difference between increasing potassium levels in a healthy person through vegetables, fruits, and legumes and consuming concentrated salts or potassium supplements on their own. The new publication focuses on public nutrition strategies, not on recommending that everyone start taking potassium supplements. [39]

Situation	Potassium from regular foods	Potassium salt/supplements
Healthy adult	Usually the primary preferred source	Possible, but not required
Normal kidney function	The body usually regulates K well.	The risk is lower, but a smart approach is needed
Impaired renal function	Requires individual assessment	It may be dangerous
Risk of hyperkalemia	A doctor's consultation is required	Replacing salt on your own is not recommended.
Perspective's Goal	More dietary potassium at the population level	Not mass uncontrolled use of additives

[40]

Could boosting potassium be the new national strategy against hypertension?

The authors believe that simply informing the public is not enough. A significant portion of sodium comes from the food environment, over which individuals have little control. Therefore, real change requires the participation of food producers, the restaurant industry, labeling systems, healthcare, and government programs. [41]

One option is to gradually reduce sodium in foods to allow consumers' taste buds time to adapt. Another is to partially replace NaCl with KCl. A third is to increase the availability of foods naturally rich in potassium, especially vegetables, fruits, and legumes. The authors emphasize that cultural eating habits and food costs must be taken into account separately for different countries and social groups. [42]

This approach is already gradually moving beyond academic debate. The World Health Organization now explicitly considers low-sodium salt substitutes with potassium as a possible tool for reducing cardiovascular risk in people without the risk of hyperkalemia. This means that the idea of simultaneously modifying two electrolytes is already present in international nutrition policy. [43]

But the authors of Perspective believe that potassium's potential remains underappreciated. Sodium receives far more attention on food labels and in government campaigns, while inadequate potassium intake often goes largely unnoticed by consumers. Their proposal is to correct this imbalance—not by weakening the fight against excess salt, but by adding a second, equally visible target. [44]

What's new in the article - and what's long been known

The idea that potassium lowers blood pressure isn't a new discovery in 2026. Clinical trials and meta-analyses demonstrated this effect much earlier, and the World Health Organization has been recommending increased potassium intake for many years. The novelty of Perspective lies in its attempt to combine old clinical data with new understanding of renal physiology and translate this into a proposal for a change in public policy. [45]

The use of salt with potassium chloride is also nothing new. Such mixtures have been around for a long time, and a large Chinese study in 2021 showed a reduction in strokes and cardiovascular events. But new data on the renal potassium switch helps better understand why this combination may work as more than just a mechanical way to reduce sodium intake. [46]

Thus, the article represents more of a shift in emphasis than a revolutionary refutation of previous science. The authors propose to stop perceiving hypertension as a problem solely of excessive salt consumption and to also consider it as a possible consequence of the imbalance between high sodium and insufficient potassium in the modern diet. [47]

That's why the headline "scientists have proven that salt doesn't raise blood pressure" would be the opposite of the study's content. The authors unequivocally confirm the importance of sodium and consider its reduction fundamental; the novelty lies in the assertion that combating sodium alone is less logical than simultaneously normalizing potassium. [48]

Important limitation: This is not a new clinical trial.

Perspective did not recruit a new group of patients, randomly assign participants to different diets, or measure their blood pressure. Therefore, the publication itself does not provide a new value such as "adding 1,000 milligrams of potassium reduced blood pressure by X millimeters of mercury." The authors analyze and interpret the existing literature. [49]

This is important when assessing the strength of the output. The physiological mechanism of the potassium switch is supported by experimental studies, and the benefits of combined sodium-potassium interventions are supported by clinical trials, but the optimal amount of supplemental potassium for each individual has not yet been established. [50]

This is precisely why the National Academies were unable to establish a specific Chronic Disease Risk Reduction Intake (CRI) for potassium in 2019: the available data were insufficient to reliably characterize dose-response and long-term clinical outcomes. The new article explicitly highlights additional research on potassium dosage and form as one of the necessary areas. [51]

There's also the issue of food technology compatibility. Replacing some NaCl with potassium chloride looks good on paper, but taste, cost, technological properties of the products, and safety for people at risk of hyperkalemia limit the feasibility of a simple global reformulation of all food products. Therefore, the authors advocate a comprehensive strategy rather than a single, universal salt substitute. [52]

Funding and potential conflicts of interest

This work was supported by the Sodium in Food and Health Implications Committee of the Institute for the Advancement of Food and Nutrition Sciences. The Institute acknowledges this support on the publication page. [53]

The composition of the authors is also noteworthy when interpreting the topic of food reformulation. Janice Johnson is with Cargill, Kristin Reimers is with Conagra Brands, Patricia Zecca is with the Institute for the Advancement of Food and Nutrition Sciences; the remaining authors represent the University of Vermont, Johns Hopkins, and Washington State University. [54]

In the published declaration, the authors reported no conflicts of interest, but the original article also indicates that some authors received travel funding to attend the IAFNS event that gave rise to the relevant scientific discussion. Therefore, it is reasonable to consider industrial and organizational involvement as part of the context, especially since the article discusses food product reformulations. [55]

Such funding alone does not refute physiological or clinical data: key evidence on sodium, potassium, and salt substitutes comes from multiple independent studies. But Perspective is an expert interpretation of this data and simultaneously proposes changes to food policy, so transparency of funding sources is especially important. [56]

What the article showed - and what it didn't show

Correct conclusion	Incorrect conclusion
Excess sodium remains a major cause of high blood pressure.	"Salt turned out to have nothing to do with it"
Potassium deficiency can also contribute to hypertension.	"Hypertension only occurs due to a lack of potassium."
Sodium and potassium interact physiologically	One indicator completely determines the pressure
Potassium can increase the excretion of sodium by the kidneys	Potassium completely neutralizes any dose of salt
Potassium-rich salt substitutes may reduce cardiovascular risk	Everyone needs to switch to KCl on their own.
Natural sources of potassium are important in the diet.	Everyone needs potassium tablets.
Renal potassium switch explains part of the mechanism	This is the only mechanism of hypertension.
Perspective proposes a change in healthcare strategy	A new clinical trial has been conducted
Further research on potassium dosage is needed	The optimal dose has already been definitively established.

Results

The main conclusion of the new publication can be formulated quite simply: dietary prevention of hypertension should not stop at the phrase "eat less salt." Reducing sodium remains necessary, but modern physiology shows that adequate potassium intake helps the kidneys manage sodium differently and can enhance blood pressure reduction. [57]

Studies of salt substitutes provide a particularly strong argument. In the Salt Substitute and Stroke Study, partial replacement of NaCl with KCl in more than 20,000 high-risk individuals was associated with a reduction in stroke rates of approximately 14%, major cardiovascular events of approximately 13%, and overall mortality of approximately 12%. [58]

However, the correct practical approach does not consist of uncontrolled consumption of potassium-containing salt. For the majority of the population, a diet lower in sodium-rich foods and higher in vegetables, fruits, and legumes remains the basis. For people at risk of hyperkalemia, especially those with impaired renal function, potassium-containing salt substitutes require individual medical evaluation. [59]

Thus, the publication suggests a new public health formula: "reduce sodium while simultaneously correcting potassium deficiency." If this approach is consistently reflected in the food industry, labeling, and recommendations, the authors believe that the impact of nutrition on hypertension control may be greater than with the current almost exclusive focus on salt. [60]

News source

Fukagawa NK, Welling PA, Johnson J, Reimers K, Lee S-Y, Zecca P. Rethinking the impact of dietary sodium and potassium on blood pressure to advance public health. The American Journal of Clinical Nutrition. 2026;124(2):101396. The article was first published online June 13, 2026, in the journal issue August 2026.

DOI: 10.1016/j.ajcnut.2026.101396.