Protocol
Sodium reduction to under 2,300 mg/day
Randomized trials pooled in two large meta-analyses A study that pools the numbers from several trials into one combined estimate. show that reducing sodium lowers blood pressure, with larger reductions giving larger falls and more effect in people with hypertension; DASH-Sodium shows the fall continuing below the 2,300 mg level.
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How this letter has changedLatest: October 2026 · Corrected.
The name and description implied a benefit at a 2,300 mg threshold; the pooled trials (He et al., BMJ, 2013; PMID PubMed ID: the permanent number the US National Library of Medicine gives a published paper. Each one links to that paper's record on PubMed. 23558162) tested an average 75 mmol/day reduction regardless of end level, with a larger fall in hypertensive than normotensive people, and DASH-Sodium (Sacks et al., N Engl J Med, 2001; PMID 11136953) shows the fall continuing below 2,300 mg. Added: the 133-trial dose-response meta-analysis (Huang et al., BMJ, 2020; PMID 32094151) and the Cochrane review of cardiovascular events (Adler et al., 2014; PMID 25519688), which is imprecise and explains why the letter stops at B. Potassium-enriched salt substitutes are named as a different intervention. B unchanged. Applied the written grade definition under the editor's standing instruction of October 2026 (Arnold Sandlow, D.C.).PMID 11136953 PMID 23558162 PMID 25519688 PMID 32094151
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This is about eating less salt, down to under 2,300 mg of sodium a day. Large reviews of many trials found that cutting sodium lowers blood pressure. Bigger cuts gave bigger drops, and the effect was larger in people with high blood pressure. One trial showed the drop kept going below 2,300 mg. The trials tested cuts of a set size, not that exact number. Trials on heart and blood vessel events and deaths are too unclear to show fewer events.
Randomized trials pooled in two large meta-analyses show that reducing sodium lowers blood pressure, with larger reductions giving larger falls and more effect in people with hypertension; DASH-Sodium shows the fall continuing below the 2,300 mg level. The trials tested reductions of a given size, not a 2,300 mg cut-off. Blood pressure is a surrogate, so the grade is B; randomized evidence on cardiovascular events is imprecise and does not confirm event reduction.
Why this gradeThe reasoning, and what the grade does not cover.
Grade B on blood pressure. Two large meta-analyses of randomized trials show sodium reduction lowers blood pressure with a dose-response (He et al., 2013; PMID 23558162, 34 trials; Huang et al., 2020; PMID 32094151, 133 trials), and DASH-Sodium shows the fall continuing below 2,300 mg/day (Sacks et al., 2001; PMID 11136953).
WHY NOT Ablood pressure is a validated surrogate, and the randomized evidence on cardiovascular events and mortality (Adler et al., Cochrane, 2014; PMID 25519688) is imprecise and does not confirm event reduction.
WHAT THIS GRADE DOES NOT COVERthe 2,300 mg figure as a threshold, since the trials tested reductions of a given size rather than a cut-off and larger reductions gave larger falls; cardiovascular events or mortality; and potassium-enriched salt substitutes, a different intervention with its own trials.
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The evidence, in fullFour papers, each linked to its PubMed record.
He, Li and MacGregor (BMJ, 2013; PMID 23558162): Cochrane systematic review A review that searches for every study on a question using a method set in advance, then assesses them together. and meta-analysis of 34 randomized trials, 3,230 participants, modest salt reduction sustained four weeks or longer; a mean 75 mmol/day fall in urinary sodium (4.4 g of salt) lowered blood pressure by 4.2/2.1 mm Hg, 5.4 mm Hg systolic in hypertensive and 2.4 in normotensive people, with a dose-response across trials. Huang et al. (BMJ, 2020; PMID 32094151): 133 randomized trials, 12,197 participants; each 50 mmol reduction in 24-hour urinary sodium associated with about 1.1 mm Hg lower systolic pressure, larger in older and hypertensive people. Sacks et al. (New England Journal of Medicine, 2001; PMID 11136953), DASH-Sodium: randomized crossover A trial design in which each participant receives both the treatment and the comparison, one after the other, and serves as their own control. of three sodium levels within two diets, blood pressure falling at each step down, including below 2,300 mg. Adler et al. (Cochrane, 2014; PMID 25519688): trials of reduced dietary salt with mortality or cardiovascular event data; estimates imprecise and not confirming event reduction. Graded B: blood pressure is a validated surrogate; the randomized hard-outcome evidence does not reach A.
Measured outcome: systolic and diastolic blood pressure over four weeks or longer, which is the minimum trial duration the cited meta-analysis included. The cited evidence reports blood pressure only.
Evidence notes: meta-analysis of randomized trials, randomized trial
Endpoint The outcome a trial measures to decide whether the treatment worked, such as heart attacks, blood pressure or a symptom score. graded: Systolic and diastolic blood pressure (Cochrane meta-analysis) (surrogate)
Last reviewed: August 2026
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