Nutrition, Metabolism & Cardiovascular Diseases (2024) 34, 903e910
Available online at www.sciencedirect.com

Nutrition, Metabolism & Cardiovascular Diseases

journal homepage: www.e lsev ie r .com/ locate/nmcd
Comparing a range of potassium-enriched low sodium salt
substitutes to common salt: Results of taste and visual tests in South
African adults

Simone H. Crouch a,*, Lisa J. Ware a, Shane A. Norris a,b, Aletta E. Schutte a,c,d

a SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the
Witwatersrand, South Africa
b School of Human Development and Health, University of Southampton, Southampton, UK
c School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, New South Wales, Australia
dHypertension in Africa Research Team (HART), MRC Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South
Africa
Received 14 June 2023; received in revised form 6 November 2023; accepted 18 December 2023
Handling Editor: A. Siani
Available online 20 December 2023
KEYWORDS
Sodium;
Potassium;
Salt;
Salt substitute;
Taste
* Corresponding author. SAMRC/Wits
tersrand, Chris Hani Baragwanath Acade

E-mail address: simone.crouch@wits.

https://doi.org/10.1016/j.numecd.2023.12.015
0939-4753/ª 2023 The Author(s). Published by
Human Nutrition and the Department of Clinica
org/licenses/by/4.0/).
Abstract Background and aims: Potassium-enriched low sodium salt substitutes (LSSS), which
replace a proportion of sodium chloride (NaCl) with potassium chloride (KCl), have been shown
to reduce blood pressure and offer a potential solution to address the high burden of hyperten-
sion in South Africa. However, it is unknownwhich proportions of KCl in LSSS are acceptable. We
compared the taste and visual acceptability of various LSSS in South African adults.
Methods and results: Fifty-six adults underwent double-blind taste and visual tests of four LSSS
(35%KCl/65%NaCl; 50%KCl/50%NaCl; 66%KCl/34%NaCl; 100%KCl) in comparison to 100%NaCl
(common salt). Participants scored each product by taste ranking, taste perception and likeliness
to use. Participants then visually inspected the five products and attempted to identify which
was which. Almost half (45 %) of participants ranked the taste of 50%KCl/50 %NaCl as fantastic
or really good. Furthermore, 62 % of participants liked and would be happy to use the 50 %
KCl/50 %NaCl or felt this tasted like common salt. Only 12 % rated the 100%KCl highly for taste,
and over half reported being unlikely to use this. Most participants (57.3 % and 36.4 %) were able
to visually identify 100%NaCl and 100%KCl, while identification of other blends was generally
poor. Responses were similar for 35%KCl/65%NaCl and 66%KCl/34%NaCl throughout.
Conclusion: Our findings suggest that the taste of the 50%KCl salt substitute would be well toler-
ated by South African adults, most of which could not visually differentiate between this salt sub-
stitute and common salt.
ª 2023 The Author(s). Published by Elsevier B.V. on behalf of The Italian Diabetes Society, the
Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the
Department of Clinical Medicine and Surgery, Federico II University. This is an open access article
under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwa-
mic Hospital, 26 Chris Hani Road Soweto Johannesburg, South Africa.
ac.za (S.H. Crouch).

Elsevier B.V. on behalf of The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of
l Medicine and Surgery, Federico II University. This is an open access article under the CC BY license (http://creativecommons.

http://creativecommons.org/licenses/by/4.0/
mailto:simone.crouch@wits.ac.za
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904 S.H. Crouch et al.
1. Introduction

The burden of non-communicable disease in Sub-Saharan
Africa has rapidly increased in recent years with raised
blood pressure (BP) being a key contributor to cardiovas-
cular disease and stroke [1,3]. In Africa, BP levels have risen
steadily, and are now amongst the highest in the world [2].
Dietary sodium is an established risk factor for the
development of hypertension and cardiovascular disease
[3,4]. Dietary potassium, on the other hand, has been
shown to have a lowering effect on BP [5,6,7]. With this
said, we have previously shown that more than two-thirds
of South African adults exceed the recommended daily
sodium intake (higher in young adults and urban pop-
ulations), while 91 % do not meet the daily recommended
minimum dietary potassium intake [8e10].

In low sodium salt substitutes (LSSS), a proportion of
sodium chloride (NaCl) is typically replaced with potas-
sium chloride (KCl). In the landmark Salt Substitute and
Stroke Study (SSaSS) in China, salt substitutes reduced the
risk of major adverse cardiovascular events (rate ratio,
0.87; 95%CI 0.80 to 0.94; P < 0.001), stroke (rate ratio,
0.86; 95%CI 0.77 to 0.96; PZ 0.006), and led to a reduction
in BP (mean difference in systolic BP; �3.34 mm Hg (95 %
CI �4.51 to �2.18) over 5 years [11]. Similar BP reductions
were shown in a salt substitute trial in India [12]. However,
these trials used salt substitutes with different formula-
tions, for instance, a 25%KCl; 75%NaCl formulation in
China, whereas in India a formulation of 30 %KCl; 70 %NaCl
was used.

Systematic reviews have shown that potassium sup-
plementation can have the greatest BP lowering effects on
individuals with low potassium intakes and high sodium
intakes [13], such as those observed in South Africa [9].
However, with median potassium intakes at approxi-
mately only one-third of the current dietary recommen-
dations [10], a higher proportion of KCl in a salt substitute
may be necessary. As people of African descent have a
greater likelihood of having raised BP due to sodium
sensitivity [14,15], a salt substitute containing more po-
tassium and less sodium may have profound effects on
reducing BP in Africa. However, it is unknown whether
formulations with higher proportions of KCl would be
acceptable to the South African population based on taste
and visual inspection. We, therefore, compared the taste
and visual acceptability of 35 %, 50 %, 66 % and 100%KCl
salt substitute formulations to common salt (100 %NaCl) in
urban South African adults.

2. Methods

2.1. Study population

Fifty-six (N Z 56) individuals were recruited through a
youth community centre based in the Soweto area of
Johannesburg. Adults, aged 18 years or older, with no self-
reported previous diagnosis of kidney disease, diminished
kidney function or food allergies, residing in the local
urban area were purposively sampled, with additional
participants that met the eligibility criteria recruited
through snowball sampling. Trained researchers who
spoke the participant’s home language explained the study
and all participants provided written informed consent
prior to participation. The study was conducted according
to the principles of the Declaration of Helsinki [16] and the
Human Research Ethics Committee (Medical) of the Uni-
versity of the Witwatersrand approved the protocol
(M220652).

2.2. Study approach

Double-blinded taste and visual tests were conducted over
2 h. Participants were each provided with five sets of
commercially available water crackers (sodium �18mg/
cracker; potassium �7mg/cracker) accompanied by four
sets of LSSS and usual table salt. Water crackers were
chosen as they have no strong taste of their own. The salt
formulations included (i) Cerebos (RSA) 100%NaCl, (ii) a
Cerebos (RSA) 35%KCl; 65%NaCl blend, (iii) a Cerebos (RSA)
50%KCl; 50%NaCl blend, (iv) a Lo Salt (UK) 66%KCl; 34%
NaCl blend and (v) a Nature’s Source (RSA) 100%KCl. Each
salt was alliquoted into clear packaging, sealed and
labelled using only a coloured sticker. For the taste test
only, the five salts were all ground to the same texture
prior to packaging so as not to influence taste perceptions
through differences in appearance.

Participants were asked to place a small pinch of each
salt onto different water crackers. Participants were
randomly assigned by a researcher present on the day to
each station in a different order to negate influence from
the order of testing. Participants were asked to provide
feedback on rank, and compare the taste of each salt using
a provided survey and score sheet. Between each station,
participants were provided with a lemon-lime palette
cleanser drink (the Vita-Sun Zero Sugar lemon-lime
concentrate drink was mixed according to manufacturer
guidelines in a ratio of 1L of concentrate to 4L of water)
and were requested to wait 2 min before moving to their
next assigned station. Following the taste test participants
were informed of the differences between samples. Par-
ticipants were then given the five salt samples to visually
inspect and asked to determine if they could correctly
identify all five samples. Questionnaires were adminis-
tered to rank the perceived taste of the five versions of salt
as well as the perceived salt content of each of the five
formulations based on visual assessment. Additional
questionnaires were administered to determine percep-
tions of typical salt use and nutritional habits related to
typical salt use. Although the process of the taste test was
fairly complex and the generally low education levels in
South Africa [17], participants had not received any specific
health literacy training. However, the full procedure was
explained to participants during the consenting process
and all participants were given the opportunity to ask
questions. Instructions were reiterated at the start of the
taste test and researcher assistants, who were blind to



Comparing a range of potassium-enriched 905
product allocations, were available to clarify any in-
structions in multiple languages and guided participants
step by step through the testing process.

2.3. Statistical analyses

Study data were collected by trained researchers and
captured into and managed using REDCap electronic data
capture tools hosted at The University of the Witwa-
tersrand [18]. Statistical data analysis was conducted in
SPSS 28.0. Data was assessed for normality using visual
inspection of histograms and skewness and kurtosis, with
continuous data reported as the median and interquartile
range (IQR). Categorical data were presented as absolute
numbers and percentages. Percentage was calculated for
each possible response for all likert scales. The top-2-box
and bottom-2-box scores were calculated for each likert
scale indicating the highest and lowest-ranking potas-
sium-enriched LSSS. The top-2-box and bottom-2-box
scores were used to conduct two proportion Z-tests to
examine the difference between NaCl as a reference and
the four various LSSS.

To determine the sample size needed for this crossover
randomized study to detect a 20 % difference (D) in taste
with a power of 80 % and an alpha significance level of
0.05, we used the formula for crossover design for
proportions:

nZ2Z2
1�a

2
:Pð1� PÞ�D2

Where Z is the Z-score, P is the estimated proportion in
the population, and D is the desired proportion Z-score
difference. Based on this calculation we required a mini-
mum of 48 participants.

3. Results

The final sample included n Z 56 participants with a
median age of 21, of which 45.6 % were male and 54.4 %
female (Table 1). Participants were asked to score salt
formulations on taste ranking, perception and likeliness to
use.

3.1. Taste ranking

NaCl (100 %) had the highest top-2-box score for taste
ranking (54.9 %) and taste perception (69.6 %) but not for
likeliness to use. In terms of taste ranking of the salt
substitutes (Fig. 1A), 45 % of participants ranked 50%KCl as
Table 1 Participant characteristics.

Characteristics Total (n Z 56)

Age, years (Median, IQR) 21 (19.5e24.0)
Sex, n (%)
Male 26 (45.6)
Female 31 (54.4)
either fantastic or really good. Only 12 % indicated the
same for 100%KCl respectively. In contrast (Fig. 1B), 51 % of
participants indicated they found the 100%KCl not very
good or awful while only 22 % reported the same for 50%
KCl. Responses were similar on either side for 35%KCl and
66%KCl. Top-2-box score proportions (Table 2) for 50%KCl
(p Z 0.30) did not differ significantly from NaCl while 35 %
(p Z 0.012), 66 % (p � 0.001) and 100%KCl (p � 0.001) did.
Only 100%KCl (p � 0.001) differed from NaCl on the bot-
tom-2-box score.

3.2. Taste perception

When examining taste perceptions of the salt substitutes
(Fig. 2A) 62 % of participants indicated they liked and
would be happy to use it or felt the 50 %KCl tasted like
normal seasoning. Conversely (Fig. 2B), 71 % of participants
indicated they would eat but did not like or would not eat
the 100%KCl. Responses for 35%KCl and 66%KCl were split
equally. For both top- and bottom-2-box scores (Table 2)
proportions 35 % (Top: pZ 0.034; Bottom pZ 0.034), 66 %
(Top: p Z 0.034; Bottom: p Z 0.034) and 100%KCl (Top:
p � 0.001; Bottom: p � 0.001) differed significantly from
NaCl while 50%KCl did not (Top: p Z 0.38; Bottom
p Z 0.39).

3.3. Likeliness to use

Participants ranked salt substitutes on likeliness to use
(Fig. 3A), 57 % ranked 50% KCl the most or second most
likely to use. While 56 % of participants ranked the 100%
KCl and 54 % ranked the 66 %KCl as the least or second
least likely to use (Fig. 3B). Both top- and bottom-2-box
score (Table 2) proportions for 66 % (Top: p Z 0.001;
Bottom: p � 0.001) and 100 % KCl (Top: p Z 0.001; Bot-
tom: p Z 0.001) differed significantly from NaCl while
neither 35 % (Top: p Z 0.056; Bottom p Z 0.11) or 50 %KCl
differed (Top: p Z 0.92; Bottom p Z 0.68).

3.4. Visual identification

Participants were also asked to attempt to visually iden-
tification of the various salt formulations (results shown in
Fig. 4). Most participants (57.3 % and 36.4 %) were able to
accurately identify 100 %NaCl and 100 %KCl. As for the salt
substitute blends 35 %KCl, 50 %KCl, and 66 %KCl accurate
visual identification was generally poor.

4. Discussion

In this study, we asked 56 individuals to conduct a
double-blind comparison of a range of potassium-
enriched LSSS with common salt as a reference both
visually and by taste. When examining potassium-
enriched LSSS taste across three categories: taste
ranking, taste perception and use ranking the 50%KCl
performed the best. In all three categories for both the
top-2-box score and bottom-2-box score proportions, the



Figure 1 A. Top and B. bottom-2-box score of taste ranking of various salt formulations.

Table 2 Two Proportion Z-Test between the top-2-box score and bottom-2-box score of NaCl and various salt formulations.

NaCl (Reference) 35 % KCl 50 % KCl 66 % KCl 100 % KCl

Top-2-Box Score
Taste Ranking e z Z 2.510 z Z 1.037 z Z 3.520 z Z 4.837

p [ 0.012 p Z 0.30 p £ 0.001 p £ 0.001
Taste Perception e z Z 2.115 z Z 0.865 z Z 2.115 z Z 4.340

p [ 0.034 p Z 0.38 p [ 0.034 p £ 0.001
Likeliness to use e z Z 1.908 z Z �0.096 z Z 3.228 z Z 3.228

p Z 0.056 p Z 0.92 p [ 0.001 p [ 0.001
Bottom-2-Box Score
Taste Ranking e z Z �1.794 z Z �1.096 z Z �1.096 z Z �4.219

p Z 0.073 p Z 0.27 p Z 0.27 p £ 0.001
Taste Perception e z Z �2.115 z Z �0.869 z Z �2.115 z Z �4.340

p [ 0.034 p Z 0.39 p [ 0.034 p £ 0.001
Likeliness to use e z Z �1.602 z Z �0.412 z Z �3.456 z Z �3.255

p Z 0.11 p Z 0.68 p £ 0.001 p [ 0.001

P values typeset in bold indicate statistical significance.

906 S.H. Crouch et al.
50%KCl did not differ significantly from common salt.
Common salt (reference) scored higher than all the LSSS
on taste perception and ranking. This may be as a result
of the familiarity of the taste of common salt or the
absence of a metallic taste reported to be associated with
some LSSS [19]. While salts were ground to the same
consistency prior to the taste tests, this was not the case
for the visual tests and visually participants were able to
accurately identify common salt most often followed by
the 100 %KCl, while accurate identification of the 35 %, 50
% and 66%KCl was low and varied minimally.

As mentioned, researchers in China [11] and India [12]
have conducted trials comparing the effects of salt sub-
stitutes to traditional table salt (100 %NaCl) to lower blood
pressure in large populations. However, these trials made
use of salt substitutes with different formulations. Salt
substitutes were effective in reducing blood pressure in
these populations that are estimated to consume at least
50 % of their sodium intake through discretionary use, (i.e.
at the table or during food preparation). A systematic re-
view estimated China and India’s average discretionary
salt use to be 69 % and 86 %, respectively [20]. In South
Africa, approximately 33e46 % of salt intake is from
discretionary use [21]. It may thus be more appropriate to
use a salt substitute with a higher proportion of KCl for
discretionary use to offset the higher percentage of the
population’s salt intake from non-discretionary use.
However, since it is unknown whether there is user pref-
erence for certain formulations in how these salt sub-
stitutes look or taste, our study in a local South Africa
population provides important insights relevant to future
implementation of salt substitutes.

Minimal research into taste perceptions of LSSS is
available and to the best of our knowledge none within a



Figure 2 A. Top and B. bottom-2-box score of taste perception of various salt formulations.

Comparing a range of potassium-enriched 907
South African context. Studies have suggested the gene
Transient Receptor Potential Vanilloid 1 (TRPV1)
rs8065080 may play a role in salt taste perceptions and
preference. [22,23] Given the potential for unknown
ethnic or regional differences in the expression of TRPV1, it
is important to understand taste perceptions of LSSS
within a South African context. A study conducted in Peru
made use of a triangle method (a method in which par-
ticipants are given three samples, two identical and one
different, and asked to determine the odd one out) to
determine whether LSSS were distinguishable from com-
mon salt [24]. They found that 25%KCl salt was indistin-
guishable from common salt with 63/156 participants
Figure 3 A. Top and B. bottom-2-box score of l
accurately identifying it, while 33 % and 50%KCl were
found to be significantly distinguishable from common salt
with 69/156 and 82/156 participants accurately identifying
the potassium-enriched salt substitute [24]. While statis-
tically significant this does still indicate that almost half
were unable to accurately identify the various substitutes.
Furthermore, Saavedra-Garcia et al. [24] showed of those
who correctly identified the LSSS, only 12.7, 5.8 and 6.1 %
reported a high degree of difference for the 25 %, 33 % and
50%KCl with the majority reporting a moderate taste dif-
ference for all three. However, the ability to perceive a
taste difference does not equate to acceptability or
perception of taste [24]. This highlights the need for
ikeliness to use of various salt formulations.



Figure 4 The percentage of participants who accurately identified salt
formulations based on visual inspection.

908 S.H. Crouch et al.
studies to investigate acceptability, taste perception and
willingness to use various LSSS.

A study in China assessed the changes in perceptions of
saltiness, flavour and acceptability of home-cooked foods
and a standard salt-seasoned soup between a control
group provided with common salt and an intervention
group provided with a salt substitute (65%NaCl; 25 %KCl;
10 % magnesium sulphate) for use in all cooking, pickling
and other uses within the household over a 12 month
period [25]. They found that changes in the perceptions of
saltiness, flavour and overall acceptability did not differ
between groups [25]. However, secondary analysis did
show rating of flavour was lower in the salt substitute
group, this did not appear to discourage the use of the
potassium-enriched salt substitute [25]. In contrast, a
study conducted by Braschi et al. in the United Kingdom,
examined perceptions of appearance, odour, texture,
aftertaste, flavour and overall acceptability of standard
bread and bread made with a 50 %KCl substitute [26]. They
found that while scores varied across test factors, the
overall acceptability of bread made with a 50 %KCl sub-
stitute did not differ significantly from the breads scored
as non-acceptable [26]. This difference in findings within
studies as well as between studies conducted in different
populations, highlights the need not only for investigation
into this topic but for population-specific investigation.
Amongst other things, patterns of salt usage, cooking
patterns and preferences as well as potential genetic dif-
ferences may all contribute to differences in response to
various LSSS.

One important factor to acknowledge when evaluating
potassium-enriched LSSS is chronic kidney disease (CKD).
In South Africa, the prevalence of CKD is estimated to be
around 6.4e8.7 % [27], however the prevalence of undi-
agnosed CKD is high in many LMICs [28]. While higher
potassium LSSS may compensate for the lower discre-
tionary salt use in countries such as South Africa (as
currently LSSS are available for consumer purchase but
rarely used in product manufacturing), higher potassium
levels may pose a risk in undiagnosed CKD patients [29].
However, a recent study has shown kaliuresis not to be
correlated to eGFR in stage 1e4 CKD patients, not sup-
porting the need for strict dietary potassium control in the
regulation of kalemia in CKD patients [30]. With this said,
as potassium handling may differ between various pop-
ulations [31], it remains important to ensure adequate
screening and evaluation in high-risk populations. CKD
patients are also advised to moderate sodium intake and
as such, both sodium and potassium may pose individual
risks [29]. The LSSS in this study are not iodised. Iodine is
important for fetal and child growth, neurological and
motor development [32]. To counter iodine deficiencies,
the World Health Organisation endorsed universal salt
iodisation for all salt consumed by humans and animals
[33,34]. In 1995 South Africa implemented mandatory salt
iodisation replacing voluntary iodisation [35]. Charlton el
al. [36], suggested South Africa’s salt reduction strategies
may impact the adequacy of iodine supplementation
strategies and recommended iodine status of populations
undergoing salt reduction strategies should be closely
monitored. As such, if LSSS are rolled out on a population
level, iodisation of the LSSS would be required.

Our study should be interpreted within the context of
its strengths and limitations. This study included a con-
venience sample of South African adults, where samples
were tasted in a random order to ensure no consistent
influence of the order of tasting. However, participants
may have experienced sensory overload or taste fatigue. In
an attempt to counter this participants were provided with
a lemon-lime drink between salt samples and were
requested to wait 2 min between each tasting. This taste
test was conducted using water crackers as they served as
a flavour neutral option. However, this may not reflect
typical scenarios where LSSS are used, such as in cooking
and the response to LSSS in other food combinations may
differ. Due the young age of the participants (median 21
years), taste perceptions may differ from that of older
adults, however, literature has suggested that perceived
taste intensity decreases with age, though research in Af-
rican populations is limited [37]. It is unknown whether
iodisation of LSSS may result in changes in taste percep-
tions and ranking. As such, taste testing would need to be
repeated.

Our findings suggest that the 50%KCl salt substitute
would be well tolerated from a taste perspective within a
South African context. In addition, the 50%KCl was not
visually distinguishable by the majority of participants and
as such would be well suited for general home use.
Acknowledgements

The authors acknowledge the support of the Wits Health
Hubb in the collection of this data.



Comparing a range of potassium-enriched 909
Funding

This study was supported by a Strategic Hires and Reten-
tion Pathways (SHARP) Fellowship awarded to AES by the
University of New South Wales, Sydney, Australia. The
Wits Health HUBB youth community health work training
programme (https://www.witshealthhubb.org/) is
supported by Wits Health Consortium and through
development funding from the Development Bank of
Southern Africa. AES is supported by a National Health
and Medical Research Council (NHMRC) Leadership
Investigator Grant (Application ID 2017504). LJW is
supported by a Strategic Grant [Ref. STRATGNT2023-01]
from the DSI-NRF Centre of Excellence in Human Devel-
opment. SHC is supported by the Joint Global Health Trials
(UK). SAN is supported by the South Africa Medical
Research Council (SAMRC) and DSI-NRF Centre of Excel-
lence in Human Development at the University of Wit-
watersrand, Johannesburg, South Africa.
Authors’ contributions

The authors confirm contribution to the paper as follows:
study conception and design: SHC, LJW, SAN and AES; data
collection and management: SHC and LJW; analysis and
interpretation of results: SHC and SAN; draft manuscript
preparation: SHC; critical review of manuscript: LJW, SAN
and AES. All authors reviewed the results and approved
the final version of the manuscript.
Conflict of interest

None to declare.

Appendix A. Supplementary data

Supplementary data to this article can be found online at
https://doi.org/10.1016/j.numecd.2023.12.015.
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	Comparing a range of potassium-enriched low sodium salt substitutes to common salt: Results of taste and visual tests in So ...
	1. Introduction
	2. Methods
	2.1. Study population
	2.2. Study approach
	2.3. Statistical analyses

	3. Results
	3.1. Taste ranking
	3.2. Taste perception
	3.3. Likeliness to use
	3.4. Visual identification

	4. Discussion
	Acknowledgements
	Funding
	Authors’ contributions
	Conflict of interest
	References