High blood pressure, often called a “silent killer,” typically shows no symptoms until complications like stroke or heart attack arise. It is prevalent in Indonesia, with rates increasing. By 2018, one in three Indonesians aged 18 and older—and up to half of those over 40—had high blood pressure. This is an increase from one in four affected adults just five years prior. High blood pressure is associated with unhealthy diets, particularly those high in sodium. The World Health Organization advises consuming no more than 2000 mg of sodium (or five grams of salt) daily—equivalent to about a teaspoon—and at least 3510 mg of potassium per day.
A lack of potassium, often due to diets low in fruits and vegetables, raises the risk of high blood pressure. However, a national survey in Indonesia found that over half the population consumes more than five grams of salt daily, while another study indicates almost no one meets the recommended potassium intake. The 2023 WHO global report on hypertension highlights salt substitutes with reduced sodium and added potassium as a cost-effective strategy to combat high blood pressure.
Recent studies of randomized controlled trials show that these substitutes are effective in lowering blood pressure and reducing deaths from heart disease and stroke. Our study, published in The Lancet Regional Health – Southeast Asia, evaluated the potential benefits of switching from regular salt to a low-sodium, potassium-enriched salt substitute. We designed a simulation model to project the long-term effects of a government-led initiative to gradually replace salt containing 100% sodium chloride with a substitute containing 75% sodium chloride and 25% potassium chloride, mostly for home cooking and seasoning.
This transition was rolled out over five years, aiming for coverage similar to that of households using iodised salt in Indonesia. We assessed health benefits across the population and income levels, as well as the policy’s cost to the government and its economic value. According to our model, after ten years, switching to low-sodium potassium-enriched salt substitutes could prevent over 1.5 million non-fatal heart attack and stroke cases, avert 643,000 new chronic kidney disease cases, and delay or prevent over 200,000 deaths from heart disease, stroke, and chronic kidney disease. The switch would result in a gain of more than 880,000 health-adjusted life years within a decade, and up to 24.6 million over the lifespan of the Indonesian population, equating to about 92 healthy life years per 1,000 people.
The lowest-income group gained approximately 1.5 times more health benefits than the wealthiest group, primarily due to their higher average blood pressure levels. Considering program development, implementation, and salt reformulation, this salt switch would cost about US$2.1 billion (roughly IDR 29.7 trillion) over 20 years. However, these expenses are significantly offset by saving on health spending, estimated at US$7.3 billion (approximately IDR 103.2 trillion) over the same period. Similar modeling from China and India also reported considerable health benefits.
In places like Cameroon, Vietnam, and New Zealand, using salt substitutes would be a cost-saving measure against high blood pressure and its effects. The World Health Organization has urged nations to cut salt intake by 30% to manage noncommunicable diseases, a policy the Indonesian Ministry of Health supports. Yet, many countries, including Indonesia, are not on track to reach this target. Salt is a primary component of Indonesian cuisine, making it culturally challenging to reduce consumption. For Indonesia and nations where dietary sodium mainly comes from added cooking salt, replacing regular salt with substitutes can help people reduce sodium intake while increasing potassium, as these substitutes have a similar appearance and taste to regular salt, improving acceptability.
Financially, more than half of Indonesia’s rising health expenditure is due to noncommunicable diseases, particularly stroke and heart disease. The Indonesian government should consider reformulating regular salt with potassium-enriched alternatives and support nationwide supply chain enhancements to improve accessibility and affordability as part of its strategy to prevent and manage chronic diseases.