Low-salt

diet
for patients with hypertension
A noncommunicable disease education manual for primary health care professionals and patients
Low-salt
diet
for patients with hypertension
A noncommunicable disease education manual for primary health care professionals and patients
The Noncommunicable Disease Education Manual for Primary Health Care Professionals and Patients results from the contributions and hard work of many
people. Its development was led by Dr Hai-Rim Shin, Coordinator, and Dr Warrick Junsuk Kim, Medical Officer, of the Noncommunicable Diseases and Health
Promotion unit at the WHO Regional Office for the Western Pacific (WHO/WPRO/NCD) in Manila, Philippines.

WHO graciously acknowledges the intellectual contributions of Dr Jung-jin Cho, Co-director, Community-based Primary Care Project Committee and Professor,
Department of Family Medicine, Hallym University Sacred Heart Dongtan Hospital, Republic of Korea; Dr Hyejin Lee, Volunteer, WHO/WPRO/NCD (currently PhD
candidate, Department of Family Medicine, Seoul National University, Republic of Korea); Ms Saki Narita, Volunteer, WHO/WPRO/NCD (currently PhD candidate,
Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan); and Mr Byung Ki Kwon, Technical Officer, WHO/WPRO/NCD
(currently Director, Division of Health Promotion, Ministry of Health and Welfare, Republic of Korea).

Many thanks to Dr Albert Domingo, Dr Sonia McCarthy, Ms Marie Clem Carlos, Dr Katrin Engelhardt, Mr Kelvin Khow Chuan Heng and Dr Roberto Andres Ruiz
from the WHO Regional Office for the Western Pacific and Dr Ma. Charina Benedicto, Physician-in-Charge, Bagong Barangay Health Center & Lying-in Clinic,
Pandacan, Manila, Philippines for reviewing the draft publication.

Financial support for this publication was received from the Korea Centers for Disease Control and Prevention, Republic of Korea.

No conflict of interest was declared.

This is a translation of a manual published by the Ministry of Health and Welfare and Community-based Primary Care Project Committee in the Republic of Korea.
Some of the content has been adapted, with permission, to align with current WHO recommendations and policies. However, the views expressed in the manual
do not necessarily reflect the policies of the World Health Organization. The source publication was developed under the leadership of Dr Jung-jin Cho (also
mentioned above); Mr Hyunjun Kim, Co-director, Community-based Primary Care Project Committee and Director General, Bureau of Health Policy, Ministry of
Health and Welfare, Republic of Korea; and Dr Sunghoon Jung, Deputy Director, Division of Health Policy, Ministry of Health and Welfare, Republic of Korea.

All illustrations were provided by the source publication.

Photo credits
©WHO: pages 1, 2
©Shutterstock: pages 1, 2, 5-10, 19-22, 27, 28

ISBN 978 92 9061 800 3

© World Health Organization 2017
Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.
 Noncommunicable disease education manual
for primary health care professionals and patients

Part 1 Prevention and management of hypertension

Module 1 Diagnosis and management
Module 2 Healthy lifestyles
Module 3 Healthy eating habits
Module 4 Low-salt diet ◄ YOU ARE HERE
Module 5 Physical activity
Module 6 Medication and management of associated diseases
Module 7 Complication prevention

Part 2 Prevention and management of diabetes

Module 1 Diagnosis and management
Module 2 Healthy lifestyles
Module 3 Healthy eating habits 1
Module 4 Healthy eating habits 2
Module 5 Physical activity
Module 6 Taking care of yourself in daily life
Module 7 Complication prevention

Part 3 Quit smoking

 How to use this manual
This book is one of fifteen modules of the “Noncommunicable disease education manual for primary health
care professionals and patients”. This manual is intended to provide health information on the prevention and
control of hypertension and diabetes.

This will be used in the form of a flip chart for health professionals to educate their patients with either
hypertension or diabetes.

Diagnosis and management for patients with hypertension

FOR PATIENTS
Blood pressure target
On one side of the flip chart is the ‘For patients’ page. This side has simple
Systolic blood
pressure
Diastolic blood
pressure
images and key messages that are easy to understand. However, health
professionals may need to provide education for patients to fully understand the
content.
Under Under

140
mmHg
90
mmHg

*Age more than 80: blood pressure to be controlled below 150/90 mmHg

11 FOR PATIENTS

Diagnosis and management for patients with hypertension

FOR PHYSICIANS
Blood pressure target
Patient education Professional information
On the other side of the flip chart is the ‘For physicians’ page. This side
•

•
Blood pressure below 140/90 mmHg is
generally advised to prevent complications.
However, blood pressure targets can be
Target blood pressure

• According to the Eighth Joint National

includes information that the health professional can read out to the patient
during counselling. Professional information is also provided for further
adjusted according to age, number and type of Committee (JNC8), those over age 80 are
risk factors, and associated diseases. advised that their target blood pressure should
be below 150/90 mmHg.
• Therefore, if you have hypertension, you should
consult your physician to set a target after • Target blood pressure should be below

understanding. A small image of the ‘For patients’ side is included so that the
evaluating your current health status and risk 140/90 mmHg for hypertension combined with
factors. cerebrovascular disease and atherosclerosis.
Systolic blood Diastolic blood • For those under age 80 maintain below 140/90
pressure pressure

health professional is aware of what the patient is looking at.

mmHg; those over age 80 maintain below
150/90 mmHg.
Under Under

140
mmHg
90
mmHg

*Age more than 80: blood pressure to be controlled below 150/90 mmHg

REFERENCE:
James, Paul A., et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
JAMA, 2014, 311.5: 507-520.

12 FOR PHYSICIANS

This publication is intended to serve as a template to be adapted to national context. Images and graphs
that have been watermarked should be replaced with images or graphs that represent the national
situation. If assistance is required, or if you have any questions related to the publication, please contact
the Noncommunicable Diseases and Health Promotion unit at WHO Regional Office for the Western Pacific
(wproncd@who.int).
 Table of contents
Module 4
Low-salt diet for patients with hypertension

1 Benefits of healthy lifestyles

3 What is salt?
5 Health risks of eating too much salt
7 Salt (sodium) and hypertension
9 Effects of low-salt diet
11 Common sources of salt (sodium)
13 Foods high in sodium
15 Sodium in seasonings
17 Three steps toward a low-salt diet: choosing food
19 Sodium in processed food
21 Check nutrition labels for salt content
23 Three steps toward a low-salt diet: cooking
25 Three steps toward a low-salt diet: eat less salt
27 Reduce salt intake
29 Take-home message
 Low-salt diet for patients with hypertension

Benefits of healthy lifestyles

Daily Salt intake Physical 10 kg weight loss Avoid harmful Quit

medication reduction activity in obese person use of alcohol smoking

Maintain 2–8 mmHg 4–9 mmHg 5–20 mmHg 2–4 mmHg overall
target BP cardiovascular
risk reduction

1 FOR PATIENTS
 Low-salt diet for patients with hypertension

Benefits of healthy lifestyles

Patient education
• Controlling high blood pressure involves not only drug therapy, but also leading a healthy lifestyle.
• Taking medication daily is key to maintaining stable blood pressure in the target range.
• Healthy lifestyle including salt intake reduction, physical activity, weight control, lower alcohol consumption
and eating more fruits and vegetables helps maintain or decrease blood pressure.
• It is more effective if these lifestyle factors are controlled together.
• Smokers can reduce overall cardiovascular disease risk if they quit smoking.

Daily Salt intake Physical 10 kg weight loss Avoid harmful Quit

medication reduction activity in obese person use of alcohol smoking

Maintain 2–8 mmHg 4–9 mmHg 5–20 mmHg 2–4 mmHg overall
target BP cardiovascular
risk reduction

REFERENCE:
Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: 1206-1252.

2 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

What is salt?

1 g of table salt = 400 mg of sodium

Sodium (Na+)
40% increases blood pressure
60%
Chloride (Cl-)
makes food taste salty

1 g of sodium = 2.5 g of table salt

3 FOR PATIENTS
 Low-salt diet for patients with hypertension

What is salt?
Patient education Professional information
• Salt is composed of sodium and chloride. • One gram of salt contains 400 mg of sodium.
Chloride is what gives the salty taste, but only • Thus, the recommended 5 g of daily salt intake
in combination with sodium. is equivalent to 2 g of sodium.
• Sodium increases blood pressure.
• The adverse effects of salt on our body are
mainly caused by the sodium component.

1 g of table salt = 400 mg of sodium

Sodium (Na+)
40% increases blood pressure
60%
Chloride (Cl-)
makes food taste salty

1 g of sodium = 2.5 g of table salt

4 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Health risks of eating too much salt

high sodium intake = disease burden

Hypertension
Angina
Stroke
Cancer
Heart attack
Dementia
Kidney disease

5 FOR PATIENTS
 Low-salt diet for patients with hypertension

Health risks of eating too much salt

Patient education
• Consuming too much sodium can cause various diseases.
• It increases the risk of not only hypertension and cardiovascular diseases, but also chronic kidney
disease, osteoporosis, and gastric cancer.
• Risk rises as intake increases.
• Salt works on your kidneys to make your body hold on to more water.
• This extra stored water raises your blood pressure and puts strain on your kidneys, arteries, heart and brain.

high sodium intake = disease burden

Hypertension
Angina
Stroke
Cancer
Heart attack
Dementia
Kidney disease

REFERENCE:
James, Paul A., et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
JAMA, 2014, 311.5: 507-520.

6 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Salt (sodium) and hypertension

For every 5 g reduction

of daily salt intake:
• Cardiovascular mortality decreases
by 17%.
• Stroke mortality decreases by 23%.

7 FOR PATIENTS
 Low-salt diet for patients with hypertension

Salt (sodium) and hypertension

Patient education
• When we eat salty food, sodium enters the
blood vessels and increases blood volume
which results in higher blood pressure.
• Controlling salt intake is vital.
• Reducing daily intake of salt by 5 g cuts
cardiovascular mortality by 17% and stroke
mortality by 23%.

For every 5 g reduction of

daily salt intake:
• Cardiovascular mortality decreases by 17%.
• Stroke mortality decreases by 23%.

REFERENCE:
Strazzullo, Pasquale, et al. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ, 2009, 339: b4567.

8 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Effects of low-salt diet

• Average life expectancy increases by five

years when sodium intake is reduced by
one third for 30 years.
• Reducing daily salt intake by 1–3 g is
more effective than antihypertensive
drugs.
• The risk of hypertension is reduced by
30% and the benefit of medication is
doubled when daily salt intake is reduced
by 4.6 g.

9 FOR PATIENTS
 Low-salt diet for patients with hypertension

Effects of low-salt diet

Patient education
• Average life expectancy increases by five years
when sodium intake is reduced by one third for
30 years.
• Reducing daily salt intake by 1–3 g is more
effective than antihypertensive drugs.
• The risk of hypertension is reduced by 30% and
the benefit of medication is doubled when daily
salt intake is reduced by 4.6 g.

REFERENCES:
Karppanen H. et al. Sodium intake and hypertension. Prog Cardiovasc Dis, 2006.
Bibbins-Domingo K. et al. Reductions in cardiovascular disease projected from modest reductions in dietary salt. N Engl J Med, 2010, 362(7): 590-599.
Joffres MR et al. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol, 2007, 23(6): 437-443.

10 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Common sources of salt (sodium)

Rice
6%
Snacks
14%
No. 1 source of
Soup,
Noodles
sodium in the
D ATA
T rce o f
:
31% Republic of
R
SEin sou ium iny
INm a sod ntr
t u
Korea:
sal ur co
Kimchi y o
instant noodles
23%
and soup
Others
26%

REFERENCE:
Korean National Health and Nutrition Examination, 2011.

11 FOR PATIENTS
 Low-salt diet for patients with hypertension

Common sources of salt (sodium)

Patient education
• What are the main sources of sodium in Korea?
Rice
• Koreans consume 50% of their total sodium 6%
intake just by eating pickled cabbage, soup,
and instant noodles whereas people in other Snacks
countries consume much of their salt from 14%
Soup,
processed foods and bread. Noodles
:
TA 31%
T DAe of r
E R ourc you
INS in s m in
ma diu ry t
t so coun
sal
Kimchi
23%

Others
26%

No. 1 source of sodium in the

Republic of Korea: instant noodles and soup

REFERENCE:
Korean National Health and Nutrition Examination, 2011.

12 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Foods high in sodium

4,000 mg
3,396 mg 3,221 mg
3,152 mg
2,875 mg 2,853 mg 2,813 mg

A:
INSERT DATin your country
in sodium
main foods high

Spicy Chinese Pickled Cold Kimchi Spicy Spicy

noodles udon crabs noodles udon soup rice
(100 g) (100 g) (100 g) (100 g) (100 g) (100 g) (100 g)

55%–75% of the sodium in a noodle soup dish

is contained in the broth.
13 FOR PATIENTS
 Low-salt diet for patients with hypertension

Foods high in sodium

Patient education
• If you just eat the noodles and other ingredients in a bowl of noodle soup and leave the broth, you can
reduce your sodium intake by half to three quarters.

4,000 mg
3,396 mg 3,221 mg
3,152 mg
2,875 mg 2,853 mg 2,813 mg

A:
INSERT DATin your country
in sodium
main foods high

Spicy Chinese Pickled Cold Kimchi Spicy Spicy

noodles udon crabs noodles udon soup rice
(100 g) (100 g) (100 g) (100 g) (100 g) (100 g) (100 g)

14 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Sodium in seasonings
(mg) 2000 1 tablespoon (15 ml) 1 teaspoon (5 ml)
1800

1600

1400

1200
INSERT DATA:
um in your country
high in sodi
1000 main seasonings

800

600

400

200

lt
pa per
up

ce

rs
e

rd

ce

so

Sa
ais

he
sta

au

Mi

au
tch

ep
ste
nn

Ot
rs

ys
Mu
Ke

Seasoning
dp
yo

ste

So
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Ma

Oy

15 FOR PATIENTS
 Low-salt diet for patients with hypertension

Sodium in seasonings
Patient education
• Below is a comparison of sodium content in seasonings, by teaspoon.
• Miso, red pepper paste and oyster sauce are especially high in sodium.

(mg) 2000 1 tablespoon (15 ml) 1 teaspoon (5 ml)

1800

1600

1400

1200
TA:
INSERT DAium in your country
high in sod
1000 main seasonings

800

600

400

200

lt
pa per
up

rs
ise

rd

ce

so

ce
Sa

he
sta

au

Mi

au
tch

na

ep
ste

Ot
rs

ys
Mu
on
Ke

Seasoning
dp
ste

So
y

Re
Ma

Oy

16 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: choosing food

• Step 1: Five tips for choosing food

a. Raw or steamed fish rather than fried fish.

b. Fresh food rather than processed food.

c. Check nutrition labels and choose the one with the lowest
sodium (target daily sodium intake: 2000 mg).
d. Choose low-sodium seasonings, including low-sodium salt.

e. Avoid preserved food.

• Step 2: Five tips for cooking

• Step 3: Five ways to eat less salt

17 FOR PATIENTS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: choosing food

Patient education
Five steps for choosing food:

a. Raw or steamed fish rather than fried fish.

b. Fresh food rather than processed food.
c. Check nutrition labels and choose the one with the lowest sodium (target daily sodium intake: 2000 mg).
d. Choose low-sodium seasonings, including low-sodium salt.
e. Avoid preserved food.

REFERENCE:
McGuire, Shelley. U.S. Department of Agriculture and U.S. Department of Health and Human Services (United States), Dietary Guidelines for Americans, 2010. Advances in Nutrition: an international
review journal, 2011, 2.3: 293-294.

18 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Step 1: Five tips for choosing food

Sodium in processed food

How much sodium is added when food is processed?

x 117 x 713

Potatoes 100 g Fries and chips Flour 100 g Instant noodles

Na+ 4 mg 100 mg Na+ 3 mg with soup
Na+ 469 mg Na+ 2140 mg

x 259

Tomatoes 100 g Ketchup 100 g

Na+ 5 mg Na+ 1295 mg

19 FOR PATIENTS
 Low-salt diet for patients with hypertension

Step 1: Five tips for choosing food

Sodium in processed food

Patient education
• When fresh food products are processed, sodium content generally increases – salt and other sodium
products are added for many reasons including longer shelf life and increased flavour.

x 117 x 713

Potatoes 100 g Fries and chips Flour 100 g Instant noodles

Na+ 4 mg 100 mg Na+ 3 mg with soup
Na+ 469 mg Na+ 2140 mg

x 259

Tomatoes 100 g Ketchup 100 g

Na+ 5 mg Na+ 1295 mg

20 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Step 1: Five tips for choosing food

Check nutrition labels for salt content

Check nutrition labels for salt

content before purchasing:
An example of what one serving
(1 oz. or 28 g) of chips may include:

• 160 kcal
• 15 g of carbohydrates (5%)
• 2 g of protein
• 10 g of fat (16%)
• 170 mg of sodium (7%) (0.4 g of salt)
• 350 mg of potassium (10%)

* % indicates percentage of daily values based on a

2000 kcal diet

21 FOR PATIENTS
 Low-salt diet for patients with hypertension

Step 1: Five tips for choosing food

Check nutrition labels for salt content

Patient education
• This nutrition label shows, for example, that
one serving (1 oz. or 28 g) of chips may include
160 kcal.
• In one serving of chips, you are eating 15 g of
carbohydrates, 2 g of protein, 10 g of fat, 170
mg of sodium (0.4 g of salt) and 350 mg of
potassium.

22 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: cooking

• Step 1: Five tips for choosing food

• Step 2: Five tips for cooking
a. Season your food at the last minute.

b. Use herbs and vegetables for additional flavour.

• Savoury: spring onion, garlic, onions, pepper.
• Sour and sweet: vinegar, lemon zest.
c. Use less seasoning when cooking processed foods.

d. Grill fish without salt.

• Step 3: Five ways to eat less salt

23 FOR PATIENTS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: cooking

Patient education
Five tips for cooking:

a. Season your food at the last minute.

b. Use herbs and vegetables for additional flavour.
• Savoury: spring onion, garlic, onions, pepper.
• Sour and sweet: vinegar, lemon zest.
c. Use less seasoning when cooking processed foods.
d. Grill fish without salt.

REFERENCE:
McGuire, Shelley. U.S. Department of Agriculture and U.S. Department of Health and Human Services (United States), Dietary Guidelines for Americans, 2010. Advances in Nutrition: an international
review journal, 2011, 2.3: 293-294.

24 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: eat less salt

• Step 1: Five tips for choosing food

• Step 2: Five tips for cooking
• Step 3: Five ways to eat less salt
a. Eat fresh vegetables rather than pickles.

b. Do not add sauce or salt to fried foods.

c. Avoid soups high in salt and use low-salt stock when cooking
them.
d. Use spring onion/garlic or pepper for seasoning soups.

e. Choose low-salt options when eating out.

25 FOR PATIENTS
 Low-salt diet for patients with hypertension

Three steps toward a low-salt diet: eat less salt

Patient education
Five ways to eat less salt:

a. Eat fresh vegetables rather than pickled.

b. Do not add sauce or salt to fried foods.
c. Avoid soups high in salt and use low-salt stock when cooking them.
d. Use spring onion/garlic or pepper for seasoning soups.
e. Choose low-salt options when eating out.

REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
James, Paul A., et al. w-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 2014,
311.5: 507-520.Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute (United States). Your guide to lowering your blood pressure with
DASH. DASH eating plan, 2006.

26 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Reduce salt intake

Reduce salt, soy sauce Remove the salt shaker Use spices instead of
to HALF. from your table. salt and soy sauce.

Steam or grill Reduce pickled Eat the solid ingredients,

instead of salting or vegetables and leave the broth.
simmering in soy sauce. salted/dried fish.

27 FOR PATIENTS
 Low-salt diet for patients with hypertension

Reduce salt intake

Patient education
• Most people eat too much salt.
• However, the recommended level is less than
5 grams per day.
• Eating salty food increases your blood pressure
and appetite.
Reduce salt, soy sauce Remove the salt shaker
• Reducing salt intake prevents blood pressure to HALF. from your table.
from rising and reduces your appetite, making it
easier to eat healthy.
• If you have kidney failure, it is even more
important to strictly control your salt intake.
• Try to eat only the solid ingredients in soups
and reduce consumption of processed food Steam or grill Use spices instead of salt
(instant noodles, ham, canned food, snacks, instead of salting or and soy sauce.
bread). simmering in soy sauce.

REFERENCES:
Diabetes basic nutrition course. Centers for Disease Control and Prevention, Republic of
Korea. 2016. (http://www.kncd.org/down/sub09/01/9_1_2_4.pdf, accessed 28 September
2016).
American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care,
2015.
International Diabetes Federation. Global guideline for type 2 diabetes. Brussels: IDF Clinical
Guidelines Task Force, 2012. Reduce pickled vegetables Eat the solid ingredients,
Scottish Intercollegiate Guidelines Network. Management of diabetes. Edinburgh. 2011. and salted/dried fish. leave the broth.

28 FOR PHYSICIANS
 Low-salt diet for patients with hypertension

Take-home message
Low-salt diet

Shopping Dining
Check the Ask for low-salt
sodium content in options when
ingredients list. eating out.

Buy fresh food Remove salt from

instead of the dining table.
processed foods. :
O TO
H a
RT Pof howl would
E le a
INSxampcal mleayed
Ordering Snacks e l lo sp
p ica be di
ty
Ask about low-salt Eat vegetables,
food options. fruits and milk.

29 FOR PATIENTS