High Potassium Foods

High potassium foods, low potassium foods and associated potassium symptoms info

 

Potassium Enriched Salt Study

The convenience of processed foods plays a big role in their popularity. And it is rare that a processed food is also a high potassium food. But some nations have sought to reduce their rate of cardiovascular disease by changing the way their food is processed, resulting in an improved potassium sodium ratio of the food. Finland started a program in the 1970s which has been very successful in reducing its rate of strokes and cardiovascular disease. In Finland they instructed people about how to change their diet, and they convinced the manufacturers of food to change the composition of the salt they used as preservative. The manufacturers used a potassium enriched salt that was lower in sodium and higher in potassium. Read about it here.

Potassium enriched salt v Normal salt260 Potassium Enriched Salt StudyPotassium Enriched Salt Study

Others have looked at changing the composition of the salt used in food also. Studies have been done with salt that has less sodium and more potassium to determine if it results in changes in cardiovascular disease.

In Taiwan, researchers did such a study (1) on 1981 men in veteran retirement homes. One group used normal salt for cooking and at the table. The other group used a combination potassium enriched salt. Half of the combination salt was a salt of potassium and half was a salt of sodium.

The researchers took one month to gradually transition the experimental group to the new potassium enriched salt. This was to allow for the change in taste from the new salt. They did not modify soy sauce or any other potential sources of sodium.

The groups were very similar in composition. The age distribution of each group was similar. Each group was composed of World War II veterans. And both groups had a 40% rate of hypertension at the beginning of the study.

The diet of the two groups was very similar except for the types of salt. The researchers could control the diets because the residents ate their meals at the retirement homes.

Study Results

The researchers were able to confirm the change in potassium and sodium consumption by studying how much of each was excreted. Sodium was reduced by 17% and potassium increased by 76% in the combination salt group. Sodium and potassium remained almost the same in the normal salt group.

The study period lasted 31 months. After 31 months, the researchers saw a big difference in the rate of cardiovascular death between the two groups. In the potassium enriched salt group there were 13 deaths per thousand persons from cardiovascular disease. In the control group that continued to use the normal salt there were 21 deaths per thousand persons from cardiovascular disease. The deaths in the potassium enriched salt group are the dashed line and the normal salt deaths are the solid line in the graph on this page.

The beauty of this study is the uniformity of the participants and of their diet. There are fewer variables requiring statistical manipulations. Many studies have a wider variety of people, lifestyles and diets. These studies require statistical adjustments which may be inadequate.

Food Tables

To find links to tables of the potassium and sodium content of both processed and natural food, use the List of Posts tab at the top of the page.
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1. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Chang HY, Hu YW, Yue CS, Wen YW, Yeh WT, Hsu LS, Tsai SY, Pan WH. Am J Clin Nutr. 2006 Jun;83(6):1289-96.

Low Sodium Diet Dangers?

Periodically studies are mentioned in the popular press from the medical literature saying you don’t need to reduce the sodium in your diet. They try to convey the idea that you can take in any amount of sodium and it will make no difference to your health. This is based on a relatively small number of studies. And the studies have a lot of problems. In 2012 (1) a study came out analyzing some recent studies supporting the idea that a low sodium diet can be dangerous.

LowSodiumDiet240x411 Low Sodium Diet Dangers?Danger In A Low Sodium Diet

There are two relatively recent studies that claim getting sodium below 1500 to 3000 mg is dangerous and makes you more likely to die. These two studies describe what has become a popular concept concerning the danger of a low sodium diet. They claim there is a J-shaped or U-shaped relationship between sodium intake and serious health problems.

Both studies have serious design problems. The studies were done in patients who were at high risk of stroke, cardiovascular disease (CVD), kidney disease and other disease. The studies determined dietary sodium by collecting a 24 hour urine sample for sodium in the first study, and a single morning spot urine sample for sodium in the second study. Such sampling methods are not as accurate as methods using multiple collections, since day to day intake of sodium varies a lot.

The first study (2) was a 10 year follow-up of over 2800 Finnish adults. The researchers found a J-shaped survival curve in relation to sodium. From their graph, survival improved as daily sodium was lowered until it reached somewhere between 1200 and 1700 mg per day. Survival then worsened at lower sodium levels, implying danger for a low sodium diet.

For 75% of the participants the rate of death from all causes increased proportionally to sodium. For the 25% taking in a lower amount of sodium an uptick in deaths occurred. The researchers did not report separately on cardiovascular events and deaths, or stroke events and deaths.

Problems With First Study

The biggest problem with the study is that it was in high risk patients. This is done in many medical studies so enough adverse events can occur to make the findings significant. This is a valid method for determining how to medically manage high risk patients. It is not valid for studies of prevention. The object of prevention studies is to find what can allow people to avoid becoming a high risk patient.

The participants at the time of entry into the study already had diabetes for a median of 20 years duration. 47% had hypertension, and 30% were spilling albumin (protein) in their urine.

The protein in the urine indicates some degree of kidney disease. The low sodium group had more participants with very poor kidney function. The high sodium group had some participants with kidney disease, but kidney function was better than in the low sodium group.

In this study, as the sodium in the urine (assumed in the proper situation to be proportional to how much is consumed) went down, the function of the participants’ kidneys was worse. This means that many of the participants already had damaged kidneys. The low sodium group had more people with very poor kidney function.

Age 39 – 8% Died In 10 Years!

The mean age of the participants was only 39 at the beginning of the study, and yet 8% of them died and 4.5% developed end stage kidney disease in the following 10 years. This is way more than would occur in this age group.

Certainly this study group cannot be considered representative of a general population. The most likely reason for the worse survival in the low sodium group is that the sickest participants had been put on a low sodium diet. In other words, the high risk of serious illness and death prompted the participants to be on a low sodium diet, either because their doctor put them on it or because they did it themselves.

Reverse Causality

This is called reverse causality. They were not sick because they went on a low sodium diet. They went on a low sodium diet because they were sick (at high risk).

Second Study

Another study in 2011 (3) showed a J-shaped relationship between urinary sodium and the combined outcome of stroke and CVD. The researchers combined non-fatal and fatal heart attacks, stroke and hospitalization for heart failure as an outcome measure. They showed a greater likelihood of these outcomes when sodium consumption was estimated to be less than 3000 mg a day.

One of the problems with this study is that it was a secondary look at a pair of studies designed for entirely different purposes, so that a great deal of needed information was not collected. As with the first study, it had a great many participants who had damage to their organs already. Almost half had already had a previous heart attack, more than 20% had a previous stroke, 40% had diabetes, and 70% had hypertension. Hardly representative of the general public.

The low sodium group had a higher percentage of people with prior heart disease, hypertension, and a sedentary lifestyle. They also had a higher percentage on diuretics (water pills).

A high percentage of this low sodium group was likely to have been put on a low sodium diet because of their health problems. Furthermore, they had distortion of the sodium in their urine because so many were using medications that affect sodium excretion into the urine. Another example of reverse causation.

Be Skeptical

These studies provide good examples of what to look out for when you hear about medical studies that you should be skeptical of. Reverse causation is a common mistake made when there is an association. Very few people can be made to think that evening cooling causes the sun to go down. But many can be fooled by claims of salt consumption below 3000 mg causing cardiovascular death. Only a few people will question the results. Especially when the study is presented by experts.

Food Tables

Find the posts with food tables listed with other posts under the List of Posts tab at the top of the page.
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1. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Whelton PK, Appel LJ, Sacco RL, Anderson CA, Antman EM, Campbell N, Dunbar SB, Frohlich ED, Hall JE, Jessup M, Labarthe DR, MacGregor GA, Sacks FM, Stamler J, Vafiadis DK, Van Horn LV. Circulation. 2012 Dec 11;126(24):2880-9. doi: 10.1161/CIR.0b013e318279acbf. Epub 2012 Nov 2.

2. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Thomas MC, Moran J, Forsblom C, Harjutsalo V, Thorn L, Ahola A, Waden J, Tolonen N, Saraheimo M, Gordin D, Groop PH; FinnDiane Study Group. Diabetes Care. 2011;34:861– 866.

3. Urinary sodium and potassium excretion and risk of cardiovascular events. O’Donnell MJ, Yusuf S, Mente A, Gao P, Mann JF, Teo K, Sleight P, Sharma AM, Dans A, Probstfield J, Schmieder R. JAMA. 2011;306:2229–2238.

Sodium Potassium Ratio – Important?

I always love it when two examinations of the identically same data set come to opposite conclusions. It shows how easy it is to go wrong when relying on statistics. In today’s pair of studies, one group of researchers decided that lowering sodium makes no difference in cardiovascular health. The other group found that lowering sodium did improve cardiovascular health. They also gave a good explanation of how the first study slipped up. And they emphasized the importance of the sodium potassium ratio.

Previously we discussed a different pair of contradictory studies that used the same data set here. In that particular case one way of looking at the data set showed vegans did better than non-vegetarians. Another way of dividing the identically same data set gave a different result. It showed that those vegetarians who also ate fish or consumed milk and eggs did better than vegans.

RutherfordQuote280x367 Sodium Potassium Ratio   Important?The Sodium Potassium Ratio

The researchers in today’s pair of studies used the sodium potassium ratio instead of the potassium sodium ratio. The sodium potassium ratio is used more commonly in the medical literature than the potassium sodium ratio. It is simply the inverse of the potassium sodium ratio.

I prefer the potassium sodium ratio because as the number gets larger, you are doing better and better. With the sodium potassium ratio as the number gets larger, you are doing worse and worse. I prefer for a larger number to mean that you are doing better. For most games and sports a larger number is better. An exception is golf. And I am horrible at golf.

The First Study

In 2008 (1), the researchers looked at data in the Third National Health and Nutrition Examination Survey (NHANES III). They included 8699 people over the age of 30 that they recruited between 1988 and 1994 in their study. Based on a single 24 hour dietary recall questionnaire, they divided the people into 4 groups according to their sodium intake.

They then determined how many in each group had died by the year 2000 from cardiovascular disease or from any cause. They concluded that those who took in more sodium had fewer deaths. They did not study potassium at all.

The Second Study

In 2011 (2), a different set of researchers used the same data set (NHANES III), but included 12,267 participants over the age of 20. The researchers also obtained a second 24 hour dietary recall in 8% of the participants. They used this second questionnaire to better estimate sodium and potassium intake in the entire group.

They then looked at the sodium potassium ratio and deaths through 2006. This gave an average follow-up period of 14.8 years. They found the sodium potassium ratio had a significant association with death from cardiovascular death and death from any cause.

They also found an association of sodium with cardiovascular death for people with a normal blood pressure, but a reverse association if they were hypertensive. The researchers concluded that the reason for low sodium seeming to be harmful was that the low sodium group had many hypertensive patients. The hypertensive patients may have been put on a reduced sodium diet. This is commonly done by doctors for their heart patients.

Which Study Is Right?

A commentary after the 2011 study sums up the two studies well (it is after the citations at the same link). It states that the methodology in the 2011 study was superior. The 2011 study also concurs with the basic science of the cell. The sodium potassium ratio is critical to cellular function.

How can you tell which study is right when two contradictory studies are reported? It seems that every week there are news reports with a new contradictory result. Sadly, you need to have a bit of knowledge about the subject. Hill’s criteria are a good place to start.

There are two criteria that are the most important. You should have enormous differences between the test group and the control group. And basic science studies should be consistent with the results.

When you are improving your potassium sodium ratio realize that the importance of the ratio is not based on just a few observational studies. There is a huge underpinning of basic science studies supporting the importance of the potassium sodium ratio to cardiovascular health at the cellular level.

Tables Of Sodium And Potassium In Food

Looking to improve your potassium sodium ratio? Find a listing of tables with the potassium and sodium content of thousands of foods by clicking the List of Posts tab at the top of the page.
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1. Sodium intake and mortality follow-up in the Third National Health and Nutrition Examination Survey (NHANES III). Cohen HW, Hailpern SM, Alderman MH. J Gen Intern Med. 2008 Sep;23(9):1297-302. doi: 10.1007/s11606-008-0645-6. Epub 2008 May 9.

2. Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey. Yang Q, Liu T, Kuklina EV, Flanders WD, Hong Y, Gillespie C, Chang MH, Gwinn M, Dowling N, Khoury MJ, Hu FB. Arch Intern Med. 2011 Jul 11;171(13):1183-91. doi: 10.1001/archinternmed.2011.257.

Potassium Sodium Guidelines

High potassium foods are a great way to reduce blood pressure, combat osteoporosis, and prevent kidney stones. They all have a high ratio of potassium to sodium. However most Americans eat foods loaded with sodium and with little potassium. Such foods have a horrible potassium sodium ratio. Recommendations by medical institutions to get more potassium and less sodium have had little effect. The Institute of Medicine (IOM) has produced potassium sodium guidelines on how much potassium and sodium to get daily. A recent medical publication (1) tried to satisfy the IOM’s guidelines for sodium and potassium using the typical American diet, but could not meet the guidelines using the typical American diet.

NIH280 Potassium Sodium GuidelinesIOM Potassium Sodium Guidelines

The IOM advises getting 4700 mg of potassium daily. They recommend less than 2300 mg of sodium for healthy individuals, and less than 1500 mg for those over 50 years of age or those with cardiovascular risk factors. Using linear programming, the researchers (1) were unable to satisfy both of these criteria simultaneously using the typical American diet.

The researchers tried to maximize sodium reduction to reach the goal amount and found that the potassium goal could not be reached when they did so. They also tried to maximize potassium intake to reach the goal amount and found the sodium goal could not be reached. This was even when they made an assumption of a 10% reduction of sodium in processed food.

Such a result is expected if there is no change in diet. But more than a 10% reduction of sodium in processed food is possible. And other changes in diet make it completely possible to reach both goals of the Institute of Medicine.

Following Potassium Sodium Guidelines Improves Health

And such changes can make remarkable improvements in health. Even fairly small changes in diet can have dramatic health effects. Finland reduced their average citizen’s sodium intake by slightly more than 10%. When Finland reduced the average salt intake from 12.7 g per day to 11.1, they saw a dramatic reduction in deaths from stroke and cardiovascular disease (2). Both fell by over 50%. And the average diastolic blood pressure in Finland fell from 92.8 to 84.2 in men and from 91.8 to 79.6 in women.

In Finland they achieved part of this change by a change in the salt used in processed food. In the 1980s, food manufacturers changed the salt used from sodium chloride to a combination salt of sodium chloride, potassium chloride, magnesium sulfate, and lysine. Other dietary changes included less use of salt at the table and less use in cooking.

How To Meet Guidelines

But an even greater change in blood pressure can be achieved by shifting away from typical American food. Americans today eat a lot of junk food loaded with sodium and no nutritional value. By including more foods that have a high potassium to sodium ratio, the potassium sodium guidelines can be met with relatively minimal change in the diet.

My wife and I exceed the IOM recommended potassium sodium guidelines every day. Many others other have been able to improve their potassium sodium ratio. Dr. Moore had hundreds of readers of his book (the one in the upper left corner of the page) write to him about how they had improved their ratio and had lowered their blood pressure.

The Biggest Hurdle

The biggest hurdle to overcome is the change in the taste of food. American processed food has become more and more salty and sweet. American taste buds are accustomed to excessive salt and sugar.

When you improve the ratio of your diet, your tongue will take about two to four weeks to get used to the taste of less salt. This is probably the greatest hurdle to overcome. However once the taste buds have adjusted, the true flavor of food becomes more intense. No longer do all foods seem to have the same kind of taste.

Books And Tables

To find out how easy it is to change your own diet you can read either of the two books recommended in the upper left-hand corner. They both show ways to obtain a high potassium sodium ratio in your diet. If you want to do it on your own, you can look at the tables that we have throughout this website to find foods that will provide a favorable ratio. The List of Posts tab has a listing of all the tables.
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1. Food pattern modeling shows that the 2010 Dietary Guidelines for sodium and potassium cannot be met simultaneously. Maillot M, Monsivais P, Drewnowski A. Nutr Res. 2013 Mar;33(3):188-94. doi: 10.1016/j.nutres.2013.01.004. Epub 2013 Feb 12.

2. Do changes in cardiovascular risk factors explain changes in mortality from stroke in Finland? Vartiainen E, Sarti C, Tuomilehto J, Kuulasmaa K. BMJ. 1995 Apr 8;310(6984):901-4.

Mediterranean Diet Reduces Inflammation

The established medical community feels there are a few diets that have health value. The two main ones are the DASH diet and the Mediterranean diet. There have been multiple studies showing that the Mediterranean diet results in a better cardiovascular risk profile than the Western diet. A recent study (1) out of Italy examined how the Mediterranean diet affects some of the inflammatory markers in the blood. Other medical studies have shown that increased inflammatory markers in the blood are associated with more cardiovascular risk.

Mediterranean280 Mediterranean Diet Reduces InflammationMediterranean Diet Reduces Inflammation

The researchers commented that the diet of the typical Italian has been changing from a traditional Mediterranean diet to a more Western diet. They studied 131 subjects in southern and central Italy to determine how much adherence to the Mediterranean diet influenced these inflammatory markers. They measured many of the micronutrients that the medical literature has considered antioxidants. This study came out about the time that the traditional measure of antioxidant capacity was found to have little value.

In this study the researchers defined Mediterranean diet based on four criteria: 1. having increased fruits and vegetables 2. having olive oil as the main source of fat 3. having a low meat and dairy intake 4. having a moderate consumption of wine. Of course there are multiple Mediterranean diets that differ according to the specific geographic location. However these criteria do tend to be relatively common to all Mediterranean diets.

They divided their subjects into 3 categories according to a Mediterranean diet score that weighed the diet according to these criteria. They found that the higher the level of adherence to the Mediterranean diet, the better the blood inflammatory markers were. So the Mediterranean diet reduces inflammation. They speculated on the various traditional antioxidants present in the Mediterranean diet, but did not consider potassium and sodium.

Potassium Content

They reported the average potassium content of the participants’ diet. But they did not report the difference in potassium content of those adhering to the Mediterranean diet versus those not adhering. Also they did not report on the sodium content of either diet.

The overall average of potassium intake was quite low. However if they had examined the potassium and sodium content of those adhering to the Mediterranean diet versus those not adhering, they would probably have found a significant difference. The higher fruit and vegetable content of the Mediterranean diet would likely have resulted in a much higher potassium and lower sodium content.

This is one of the problems with these kinds of studies. As reported in this post, potassium was shown to be a strong antioxidant inside of cells over 20 years ago. Other researchers have since confirmed the finding. Yet potassium intake is not examined in studies of inflammation.

Antioxidant Value Of No Value

Other more popular antioxidants are studied because they have shown antioxidant qualities in the test tube. But the test tube antioxidant values (ORAC) have been shown to have no correlation with antioxidant activity in the body. See this post for a discussion about the lack of correlation. What matters is the antioxidant activity inside the cell, not the activity in the test tube.

The problem in Italy is similar to the problem throughout the world. As more and more people move into cities, their diet and lifestyle changes to an urban diet and lifestyle. The change in diet is one that consists of a diet much higher in sodium and lower in potassium. This results in the cells in our body being too imbalanced to eliminate excessive free radicals. This leads to more inflammation, and will lead to more hypertension and cardiovascular disease throughout the world.

Find Tables Of Potassium Content

However by getting more high potassium foods and less sodium you can prevent the damage from a more Western diet. To find the potassium and sodium content of different foods you can click on the List of Posts tab at the top of the page. From there find a link to a table with your food of interest to find the potassium and sodium content.
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1. Mediterranean Diet Effect: an Italian picture. Azzini E, Polito A, Fumagalli A, Intorre F, Venneria E, Durazzo A, Zaccaria M, Ciarapica D, Foddai MS, Mauro B, Raguzzini A, Palomba L, Maiani G. Nutr J. 2011 Nov 16;10:125. doi: 10.1186/1475-2891-10-125.

Optimize Cell Restoration

High potassium foods can protect against a number of diseases. Hypertension is the disease most strongly shown to be prevented by high potassium foods. By getting a proper ratio of potassium to sodium in your food you provide an electrochemical balance within your cells. This balance provides cell restoration quickly so the cell can function optimally. For your cells to function best, potassium and sodium must pass through multiple channels in the membranes of the cell. If these channels do not allow potassium and sodium to pass properly, cell restoration occurs slowly and disease will result. The last post discussed how the malfunction of some genes that produce the proteins of these channels is associated with hypertension. Another way the channels can function poorly depends on the lipids (fats) that the membranes are composed of.

Excessive saturated fat makes the membranes too stiff, so the channels do not open and close as well as they should. Polyunsaturated and monounsaturated fats make the membranes more fluid. They allow the channels to function better, and allow certain cell messages to be transmitted more easily within the cell. The cell does its work better and restores itself better.

PotassiumChannel Optimize Cell Restoration

Potassium Channel

PIP2

One particular lipid of great interest is PIP2. More and more publications are showing how important it is. It is best known for its role in cell signaling, being split into two molecules that are secondary messengers within the cell. A recent publication (1) reviewed another important function of PIP2. Although PIP2 regulates multiple types of ion channels, the review limited its discussion. It only discussed how PIP2 controls a certain small group of potassium channels.

PIP2 binds strongly to a part of these potassium channels that controls their opening and closing. It causes the channel to open or close depending on the difference in electrical charge (voltage) between the inside and outside of the cell. This difference in charge depends on how much sodium and potassium are inside and outside the cell. And how much sodium and potassium are inside and outside depends on how much are in the food you eat.

Cell Restoration

These particular channels are the ones that are involved in cell restoration. They help the cell restore itself to a resting state after the cell has performed its function. For example, these channels allow a nerve cell that has discharged and sent a message somewhere in your body to restore itself. This allows the cell to send another message all over again – many times a second. If the channel opens and closes too slowly, the nerve cell will not restore itself fully and the nerve will not function as well as it could.

Of course, this is true for every cell in the body. All cells use similar channels. The specific cells already shown to be affected by this small subset of channels are heart rhythm cells, nerve cells and cells of the inner ear. So considering all the channels that PIP2 regulates, all cells (heart, lung, liver, kidney, immune, etc.) in the body will not function as well as they could if potassium and sodium were in balance.

This may be a part of the reason polyunsaturated and monounsaturated fat are better for heart and blood vessel health than saturated fat. They increase the fluidity of the cells’ membranes. This allows PIP2 to open and close channels better. Quick restoration of the cell to its resting state means the cell is quickly ready to get back to work again. The cell can perform more work in a given amount of time.

Potassium Sodium Food Tables

How can you be sure your cells are functioning optimally? Get the right ratio of potassium and sodium in your diet. Links to tables with the potassium and sodium content of many foods can be found here.

There is little reason to be concerned about getting enough PIP2. It is made in our bodies from its precursor phosphotidylinositol. Phosphotidylinositol is found widely in a variety of foods. It is a component of lecithin and phytate. Phytate is a less absorbable form than lecithin. However, if you are getting a variety of high potassium foods, you are getting plenty of PIP2 precursor.
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1. PIP2 regulation of KCNQ channels: biophysical and molecular mechanisms for lipid modulation of voltage-dependent gating. Zaydman MA, Cui J. Front Physiol. 2014 May 27;5:195. doi: 10.3389/fphys.2014.00195. eCollection 2014.

Hypertensive Genes And Potassium Sodium

Genetics are involved in hypertension. There are a few conditions that only require the presence of one gene to result in hypertension. These are very rare. Most of the hypertensive genes require multiple factors to result in hypertension. Some of these factors may be multiple other genes. Some may be environmental factors such as food or exercise. A recent review (1) looked at 130 genes that are commonly associated with hypertension.

MaleKaryotype Hypertensive Genes And Potassium SodiumPrimary Hypertension

In the article, the authors refer to hypertension as essential hypertension. This is a term that is still commonly used, but it is an old term that should be abandoned in favor of the term primary hypertension. There is nothing essential about hypertension.

Although somewhat technical, the study is the most up-to-date review concerning genetic and epigenetic changes associated with hypertension. It does not review those hypertensive genes that are monogenic. These are genes that have a change in just one gene causing hypertension. They are extremely rare.

This was a review article that compiled many other articles that were Genome Wide Association Studies (GWAS). Such studies look at thousands of genes at a time to find genes that occur more often in people with a particular disease than people who do not have the disease. In this particular case, they compiled GWA studies that found associations between genes and hypertension.

Hypertensive Genes

The study found that the hypertensive genes had multifactorial inheritance. None of those studied had Mendelian inheritance (like blue eyes, brown eyes). The authors found none of the extremely rare genes leading to monogenic hypertension.

They were able to come up with a list of 130 hypertensive genes. Not all of the genes had known functions. However of those with known functions, a great many involved sodium and potassium, either directly or indirectly.

To see what functions were involved was very interesting. Many of them involved the RAAS pathway. This is the pathway that involves hormones affecting blood pressure. Also many of the genes were those affecting how the kidney handles sodium and potassium. At the cellular level, many genes affected the potassium channels, the sodium channels, and the calcium channels one way or another. And many genes involved enzymes associated with balancing potassium and sodium.

Epigenetic Changes

The authors also considered epigenetic changes. Epigenetic changes are changes in gene expression caused by mechanisms other than changes in the DNA sequence itself. These are changes such as microRNA, methylation of specific genes or changes in histones (proteins associated with DNA).

This is a more recent area of study that is less developed, so there were fewer studies. Nonetheless, the researchers found some epigenetic overlap with genes affecting potassium and sodium balance. And they also found epigenetic changes influencing genes involved with the results of potassium sodium imbalance, such as nitric oxide and fibrosis.

The authors did emphasize that there was much yet to be discovered and there was no clear set of genetic pathways evident yet. Their hope was that knowing the various genes involved would allow for better design of medications to provide a personal level of prescription.

Lifestyle Changes?

They felt that discovering genetic pathways would provide little help in determining lifestyle changes. In their view, the lifestyle recommendations to eat better and exercise more would apply to anyone.

However, their study shows that the most common hypertensive genes are highly involved in controlling potassium and sodium. This throws more weight behind specific recommendations concerning potassium and sodium in the diet. When these types of genetic studies are combined with epidemiological and physiological studies, the importance of the potassium sodium ratio in the diet becomes harder to ignore.

The key to controlling blood pressure is controlling the potassium and sodium balance in your body’s cells. This can be done by controlling how much potassium and sodium you get in your diet.
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1. Elevated blood pressure: Our family’s fault? The genetics of essential hypertension. Natekar A, Olds RL, Lau MW, Min K, Imoto K, Slavin TP. World J Cardiol. 2014 May 26;6(5):327-37. doi: 10.4330/wjc.v6.i5.327.

Exercise And Leanness – Enough To Prevent Hypertension?

There are several factors that can help protect against hypertension. But when the potassium to sodium ratio of your diet is poor, these factors are of little help. Some recent posts (1, 2) discussed how normally protective fruits and vegetables can be made to fail by a poor ratio. Exercise and leanness are usually felt to prevent hypertension. But they too can be undermined by a poor dietary ratio of potassium to sodium.

SheepIran280 Exercise And Leanness   Enough To Prevent Hypertension?An Old Classic

A recent article (3) brought back memories of a classic article (4) from 1981. This spring there was an article (3) concerning hypertension in Yazd. This is an urban center close to a rural area in Iran that had a high incidence of hypertension in a 1981 report.

What was unique about the rural group, the Qash’qai, was that they remained lean and very physically active into old age. Nonetheless they had a high incidence of hypertension, although not as high as the thin, physically active tea garden workers of India (1) discussed a few weeks ago.

Exercise and leanness usually protect against hypertension. They are associated with lower blood pressure. However, if the basic principle of having a high potassium to sodium ratio in your food is not followed, you will still have a strong chance of developing hypertension.

Exercise And Leanness Are Not Enough

In the 1981 report (4) researchers discussed how blood pressure in the Qash’qai went up with age the same as in a typical urban Western society. The Qash’qai however were nomads who remained lean throughout their life, traveling great distances on foot while shepherding their herds of sheep and goats. Even so, they had an incidence of hypertension of over 20%.

The researchers determined the diet of the Qash’qai by a food frequency questionnaire. But they also confirmed the sodium and potassium content of the diet with measurement of urinary potassium and sodium, which correlates well with the dietary content. The urinary ratio was 0.28 in men and 0.31 in women.

Examination of their diet showed they added salt to almost all of their food, either during preparation or at the table. 100% of the subjects ate bread. For many it was all they ate for at least one meal. Approximately half of the nomads ate rice, 37% ate vegetables and only about 28% ate meat, with 17% eating dairy and 17% eggs.

The researchers measured the sodium and potassium content of the bread and rice. They found very high ratios of sodium to potassium in each of their samples. Also they noted that salt was added to almost every dish.

Exercise And Leanness And No Salt

This is in great contrast to the centenarians that we have discussed in the past. In Sicani (5) and in Sardinia there are a great number of centenarians. They also remain physically active in a mountainous region and maintain a normal weight. However, in contrast, they do not add salt to their food.

In the Qash’qai report the researchers correlated blood pressure with age and body weight. They found that body weight did not increase with age as it does in the West, even though blood pressure increased the same as in the West. Leanness and physical activity do not fully protect against the hypertension resulting from a poor ratio diet.

Rural And Urban Diet With Same Ratio

In the more recent report about Yazd (3) it appears that the sodium and potassium in the diet have not changed. This was an urban environment in which the amount of dietary sodium and potassium had remained in the same ratio as in the rural population.

The percentage of hypertension was twice as great in the Yazd participants as it had been in the Qash’qai. In Yazd, 40% of people were hypertensive (with more than half of them previously undiagnosed). In the Qash’qai, hypertension had been present in at least 22% of men and 29% of women. The Yazd study did not report on physical activity or leanness, but urban dwellers are generally less active and less lean than rural nomads.

The Yazd study included more young people than old (as did the Qash’qai study), but did not report blood pressure by age group. This lack of age group information and the 33 years between reports make it difficult to compare the two groups. Nonetheless, the Qash’qai study shows that exercise and leanness are not enough to fully prevent hypertension. Compared to an urban lifestyle, the leanness and physical activity of a rural nomad lifestyle may cut in half the chance of hypertension.

Prevent Hypertension

But a poor potassium sodium ratio will still lead to hypertension for many who exercise and stay lean. The first and most basic way to prevent hypertension and its associated cardiovascular problems is to eat a diet with a high potassium to sodium ratio.

Exercise and maintaining a normal weight can help when the diet is right. With a high ratio diet, normal blood pressure can be maintained into old age, as with many rural indigenous people (6). When the diet is not right, exercise and weight control will help only a little.
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1. http://www.highpotassiumfoods.org/potassium-symptoms/vegetarian-hypertension-india

2. http://www.highpotassiumfoods.org/potassium-symptoms/kimchi-pickling-blood-pressure

3. Sodium and potassium intake of urban dwellers: nothing changed in Yazd, Iran. Mirzaei M, Soltaniz M, Namayandeh M, GharahiGhehi N. J Health Popul Nutr. 2014 Mar;32(1):111-7.

4. Blood pressure of Qash’qai pastoral nomads in Iran in relation to culture, diet, and body form. Page LB, Vandevert DE, Nader K, Lubin NK, Page JR. Am J Clin Nutr. 1981 Apr;34(4):527-38.

5. http://www.highpotassiumfoods.org/high-potassium-foods/longevity-sicani

6. http://www.highpotassiumfoods.org/high-potassium-foods/changes-in-diet-leading-to-hypertension

The Potassium Sodium Ratio. Really?

I don’t understand why the potassium sodium ratio is so important. My doctor tells me to reduce my salt and to eat more fruits and vegetables. Isn’t that enough? Depends. What else do you eat? How do you prepare it? How much sodium does it really contain?FruitsVegs280x206 The Potassium Sodium Ratio. Really?

This website has emphasized the potassium sodium ratio in many of its posts. Medical guidelines discuss reducing sodium and talk about eating more fruits and vegetables as a way to reduce hypertension and cardiovascular disease. However the guidelines don’t explain why to eat the fruits and vegetables or what is important about them.

Why Fruits And Vegetables Are Important

Although fruits and vegetables have many admirable qualities, such as fiber, antioxidants, phytochemicals, and polyunsaturated fats, their most important quality is that they have a high potassium to sodium ratio. This has been shown indirectly in many studies. Many studies show that decreasing sodium improves blood pressure. Almost as many studies show that increasing potassium improves blood pressure. But there have been only a few that have directly studied the ratio.

It’s The Ratio

The report (1) that we will be discussing today directly studied the potassium to sodium ratio. It found that the ratio had the strongest fit to cardiovascular disease. The ratio was stronger than sodium by itself or potassium by itself. It found that there was an effect on cardiovascular disease even after statistical adjustments for blood pressure.

How To Go Wrong Eating Fruits And Vegetables

It is important to understand the potassium sodium ratio because just eating vegetables and fruits is not the key to reducing cardiovascular disease. Increasing the potassium to sodium ratio is the key. The last 2 posts showed some societies that eat more fruits and vegetables than the average Western society. Yet these societies have just as much hypertension as a Western society.

The reason is that they add sodium in the form of salt to the vegetables. Kimchi is a pickled vegetable that is the national food of Korea. Korea has just as much hypertension as Western societies. India is composed of 30 to 50% vegetarians and even non-vegetarians eat very little animal food. However their hypertension is the same as any Western society and they have pockets with a much higher percentage of hypertensive people than the average Western society.

I’m Vegan. Why Are My Blood Tests Bad?

I have vegan friends who do not understand why their cardiovascular biomarkers are so poor. They avoid all animal food. However they eat a great deal of processed food made from plants. Many of the processed foods, such as the veggie burgers, cocoa and sugar products, and the vegan pasta, have a poor ratio. Eating too many of the processed veggie foods and not enough vegetables and fruits as they come from the ground will be counterproductive to being a vegan, if being vegan is done for health reasons.

There have been a great many studies of reduced sodium in the diet. There also have been a great many studies of fruits and vegetables, especially vegans versus omnivores. Most of the studies are done with food frequency questionnaires, which are a good first start.

More Rigor Is Needed

However a more rigorous study would involve measuring urinary sodium and potassium and this is rarely done. Usually when it is done, it is only done once. Because of the variability of what people eat, the amount of sodium and potassium on any given day will be highly variable.

The study we are discussing today did multiple measurements over several years. This gives a much better idea of the average sodium and potassium that someone consumes than a single measurement.

The Study

This study (1) actually included participants and data from 2 studies. The first one was 18 months and the second was 3 years in duration. The average number of sodium measurements and of potassium measurements over these periods was 4.8 each. The study included over 2200 participants.

The researchers did a follow-up at approximately 15 years after the first study and 10 years after the second. They examined the number of deaths that were due to cardiovascular disease and the number of nonfatal cardiovascular events.

The result was that there were fewer and fewer cardiovascular deaths and events in participants as the ratio of potassium to sodium got larger and larger. The ratio provided a better fit to the data than did sodium alone or potassium alone. This was even true when they adjusted results for blood pressure.

The Potassium Sodium Ratio Is Basic

Hypertension is a sign of a basic cellular disease. It is very similar to the sign of fever indicating an infection. Fever is not the disease. Hypertension is not the disease. This basic cellular disease is an imbalance of potassium to sodium. It affects every cell in the body, including the heart and blood vessels. The more rigorous the study, the more likely it is to demonstrate the importance of the ratio.
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1. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study. Cook NR, Obarzanek E, Cutler JA, Buring JE, Rexrode KM, Kumanyika SK, Appel LJ, Whelton PK; Trials of Hypertension Prevention Collaborative Research Group. Arch Intern Med. 2009 Jan 12;169(1):32-40. doi: 10.1001/archinternmed.2008.523.

Vegetarian Hypertension In India

We’ve reported on several studies showing vegetarians have a lower incidence of hypertension than consumers of the Western diet. This is because vegetables and fruits have a high potassium to sodium ratio. If you don’t add salt to the vegetables, a vegetarian diet will have a high potassium to sodium ratio. You will be unlikely to develop hypertension. But there are occasional reports of eating more vegetables and fruits leading to hypertension, such as last week’s report from Korea. When you read such a report you need to look deeper.

India Vegetarian Hypertension In IndiaThis week’s post is about two more such reports. The first (1) reports that a non-vegetarian diet is more protective against hypertension than a vegetarian diet. The second (2) reports that  an urban group of Indians (a group associated with more hypertension) ate approximately 50% more fruits and vegetables than a matched rural group (a group associated with less hypertension).

The reports are out of India, which is a country with more vegetarians than any other nation. Estimates are that between 30 and 50% of the total population are vegetarian.

India is involved at present in a large migration of its populace from rural to urban locations. Concurrent with this migration has been an increase in hypertension.

It’s Not Just Migration

But the increase in hypertension has not been due only to the urban transition. In 1949 the prevalence of hypertension in urban populations was only 1.24%. It rose to 36% in 2003 (1). In rural India, the prevalence also rose. It went from 1.99% in 1958 to 21% in 1994 (1). There is something changing in both rural and urban India to account for this rise in both urban and rural hypertension.

Fried Fish Protective?

The first study (1) looked at the diet in urban Malda in eastern India. It concluded that being non-vegetarian protected against hypertension. The non-vegetarians had a lower prevalence of hypertension than vegetarians. The researchers felt fish consumption and the cooking oil used (mustard oil) may be why the non-vegetarians had less hypertension. However the researchers did only a limited investigation of dietary factors and food preparation. They did not consider sodium or potassium content at all.

The second study (2) compared the diet of urban and rural populations from several areas of India. They found that the urban group ate more fruits and vegetables. Like the first study they did not consider the sodium or potassium content of the diet.

Non-vegetarian. Really?

The second study compared vegetarians to non-vegetarians (the group in the first study found to have less hypertension). The non-vegetarians ate only a minimal amount more meat and fish than the vegetarians. The non-vegetarians ate 19 to 28 g of meat daily and approximately 6 g fish daily. This is an average of only 2/3 to 1 oz. of meat a day and an ounce of fish every 4 to 5 days. The non-vegetarians were almost vegetarian.

A more likely reason for urban dwellers to be hypertensive is related to urban lifestyle. Urban lifestyle has been associated with an increased prevalence of hypertension in a large number of studies. These studies have found an association of hypertension with less physical activity and increased weight in urban migrants.

But the most glaring problem with the first and second studies is not looking at the sodium and potassium content of the study subjects’ diets. Multiple studies have shown an increase in sodium intake and a drop in potassium intake when populations move from a rural to an urban location. This is especially important since salt is added to a great many dishes in India. The daily salt consumption varies from 5 grams a day to 30 grams a day among differing populations in India.

Other studies about Indian hypertension have looked at salt intake. A study (3) of sodium in the urine (and thus the diet) of research participants from a state in southern India showed a significant increase of sodium in the hypertensive group compared to the normal pressure group.

Tea Garden Workers

An especially revealing study (4) was done of tea garden workers in northeast India. It showed a much higher prevalence of hypertension than is generally present in India. This is despite the tea garden workers in the study being more physically active and thinner than other Indians, which is opposite the usual findings associated with hypertension.

Hypertension in these tea garden workers showed a prevalence of 61% among the adults. Other studies of tea garden workers, however, put the prevalence in the range of 46%. In either case, this is much more than the average rate in India, which a recent meta-analysis (5) put at approximately 33% of urban and 25% of rural adults.

30 Grams Of Salt A Day

What is unique about the tea garden workers is their high intake of sodium. In one study (6) they were found to consume from 20 to 30 grams of salt a day. This is compared to the average intake by Indians of approximately 10 grams a day.

Just as in Korea, eating more fruits and vegetables will not protect against hypertension when a great deal of sodium is consumed along with the fruits and vegetables. The protective aspect of fruits and vegetables is primarily their high potassium and low sodium content. Other factors such as polyphenols, antioxidants, and polyunsaturated fats may help. But the epidemiological studies and basic science studies of how these factors protect have not yielded the clear picture that the dietary potassium sodium ratio has.

Tables

Tables of potassium and sodium content can be found for high potassium fruits here and high potassium vegetables here. Links to tables for other foods can be found by clicking the List of Posts tab at the top of the page.
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1. Study of urban community survey in India: growing trend of high prevalence of hypertension in a developing country. Das SK, Sanyal K, Basu A. Int J Med Sci. 2005;2(2):70-78. Epub 2005 Apr 1.

2. Dietary intake and rural-urban migration in India: a cross-sectional study. Bowen L, Ebrahim S, De Stavola B, Ness A, Kinra S, Bharathi AV, Prabhakaran D, Reddy KS. PLoS One. 2011;6(6):e14822. doi: 10.1371/journal.pone.0014822. Epub 2011 Jun 22.

3. Relationship of sodium and magnesium intakes to hypertension proven by 24-hour urianalysis in a South Indian population. Chidambaram N, Sethupathy S, Saravanan N, Mori M, Yamori Y, Garg AK, Chockalingam A. J Clin Hypertens (Greenwich). 2014 Aug;16(8):581-6. doi: 10.1111/jch.12361. Epub 2014 Jun 17.

4. Hypertension and its risk factors in tea garden workers of Assam. Hazarika NC, Biswas D, Narain K, Kalita HC, Mahanta J. Natl Med J India. 2002 Mar-Apr;15(2):63-8.

5. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, Prabhakaran D. J Hypertens. 2014 Jun;32(6):1170-7. doi: 10.1097/HJH.0000000000000146.

6. Prevalence of modifiable cardiovascular risk factors among tea garden and general population in Dibrugarh, Assam, India. Mahanta TG, Joshi R, Mahanta BN, Xavier D. J Epidemiol Glob Health. 2013 Sep;3(3):147-56. doi: 10.1016/j.jegh.2013.04.001. Epub 2013 May 25.

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Recommended

Two excellent books about high potassium foods and blood pressure reduction are available on Amazon. The first is a practical guide to changing your diet to a high potassium foods diet. It is helpful even if you do not have hypertension. The second is a scientific explanation of the diet. It discusses the changes to your body that occur with high potassium foods.

Practical Guide

Scientific Explanation

RSS National Library Of Medicine

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