Wednesday, April 23, 2014

Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them - Part 1: Potassium Deficiency, Bone & Protein Loss, Stroke, Heart Disease & High Mortality

The fact that many Americans don't get enough of the "non-salt" electrolytes (calcium, magnesium, potassium) is also due to the fact that mineral water is still an exotic beverage in the US.
A recent paper by scientists from the Council for Responsible Nutrition in Washington (Wallace. 2014) says: Large portions of the population had total usual intakes below the estimated average requirement for vitamin A (35%), vitamin C (31%), vitamin D (74%), vitamin E (67%), choline (92%) and vitamin K (67%), as well as potassium (100%), calcium (39%) and, of course, magnesium (46%) - and that despite the fact that more than 50% of the US citizens consume a multivitamin and -mineral supplement of which probably 90% believe that it would balance their dietary shortcomings.

Reason enough to take another look at the possible health consequences and ways to fix these deficiencies by increasing the intake of certain foods or supplements.
There are more articles to come in this series, but you can use these to sugar the wait:

Pasta "Al Dente" = Anti-Diabetic

Vinegar & Gums for Weight Loss

Teflon Pans Will Kill You!

Yohimbine Burns Stubborn Fat

You Can Wash Pesticides Away

Milk = Poisonous Hormone Cocktail
Instead of tackling them in an alphabetical order, I would like to start with the two in my humble opinion most critical deficiencies - "critical", not necessarily because they entail the worst health consequences, but "critical", because no one appears to care about them:

You will probably think I am exaggerating (and in fact, I am), but if we are talking about America's Heart Disease Burden (CDC), i.e.
US "Heart Disease Map" (CDC)
  • about 600,000 deaths due to heart disease in the United States every year – that’s 1 in every 4 deaths,
  • heart disease being the leading cause of death for both men and women in the US,
  • 720,000 heart attacks with 515,000 "first timers" and 205,000 people who had at least one heart attack before, and 
  • a financial burden of $108.9 billion each year for heart disease and its consequences, alone, 
we cannot do so without talking about the insufficient potassium and choline intakes of the average American. Why? Well, because these constantly overlooked nutrients are at least as important for your heart as any of the overrated vitamins and the publicly transfigured alleged "supermineral" magnesium.
Today's episode will be about potassium - potassium and nothing but potassium! But don't worry we will deal with choline in the next episode and tackle all the non-significant rest in later episodes. Obviously I am exaggerating, but as mentioned before: I truly believe that choline and potassium are the most overlooked, yet crucially important nutrient deficiencies the average Westerner will have.
Table 1: Paleolithic nutriton according to Eaton (2000) - /1/ based on 3000 kcal/d, 35 % animal: 65 % plant subsistence; /2/ average of US men and women according to the Food and Nutrition Board (1989)
If you look at the Mediterranean diet, the DASH diet and, of course, the Paleo diet, you will find that there is more to it than olive oil, higher protein intakes and no grains. Let's take the Paleo diet, I mean, the half-science based version and not the strange amalgam of all sorts of dietary trends you will find in the blogosphere, as an example (see Table 1).

It is of course higher in calcium, in magnesium folate, B1, B2, vitamin A and vitamin E than the current US diet, but those are nutrients everyone thinks about. Copper (10x higher!) and not even in the list Wallace et al. present in their recent paper in the Journal of the American College of Nutrition (Wallace. 2014), potassium (4.2x higher) and manganese (3.8x higher) are micronutrients no one ever talks about.
Urinary potassium excretion vs. food logs: In subjects who are not on diuretics or other medications that would influence the urinary potassium excretion, the urinary potassium excretion is not necessarily a more accurate, but certainly a more reliable and objective measure of an individual's total potassium intake.
The FDA in their infinite wisdom even limits the maximal amount of potassium in dietary supplements to 99mg - i.e. ~2% of their own recommended daily allowance and the prescribed potassium intake on the DASH diet (4,700mg/day for adults (18y+, breastfeeding women "may" consume an extra 500mg/day). If we take the potassium intake of the average Cretan iteration of the Mediterranean (according to Kafatos. 2000) diet or the Paleo diet (according to Eaton. 2000) as a reference it would be as a reference that's 1.8% and 0.8%, respectively. That's unquestionably much less than you would need to double the pathetic 2500mg/day of potassium the average American gobbles down with a 3,000kcal/day diet (Eaton. 2000) - bad news, in view of the fact that insufficient potassium intakes are associated with...
  • 29% higher all-cause mortality risk in the 1,448 randomly selected healthy subjects in the Rotterdam Study (Geleijnse. 2007)
  • 20% increased higher all-cause-mortality risk in the 12,267 participants of the Third National Health and Nutrition Examination Survey Linked Mortality File (1988-2006), a prospective cohort study of a nationally representative sample (Yang. 2011) 
  • 36% increased CVD risk (stroke, myocardial infarction, coronary revascularization, or CVD mortality) for the subjects with the lowest (vs. highest) urinary potassium excretion in 2,275 adults with prehypertension aged 30 to 54 year (Cook. 2009)
Table 2:  Estimated Usual Intakes of Sodium, Potassium, and Calories and Sodium-Potassium Ratio at Baseline by Sex, NHANES IIII Linked Mortality Filea (Yang. 2011)
Even exercise won't save your ass, if you don't get enough potassium! That's at least what the results of Yang's analysis of the data from the shows. The increased mortality risk did after all not differ significantly by sex, race/ethnicity, body mass index, hypertension status, education levels, or physical activity (Yang. 2011).
Furthermore, the difference in all-cause mortality risk between participants with low (Q1) intakes and those who approached "paleo" or at least "Mediterranean" potassium intakes was even large: 39% even after full adjustment!
  • 38% increased total stroke and ischemic stroke in among 43,738 US men, 40 to 75 years old, without diagnosed cardiovascular diseases or diabetes, who completed a semi-quantitative food frequency questionnaire in 1986 (Ascherio. 1998) 
  • Figure 1: Potassium intake and adjusted risk of stroke among 43,738 US men aged 40 to 75 years followed for eight years. Risk was adjusted for age, total energy intake, smoking, alcohol consumption, history of hypertension, history of hypercholesterolaemia, parental history of myocardial infarction before age 65 years, profession, and quintiles of body mass index and physical activity (He. 2001)
    28% increased ischemic stroke risk in the 85,764 women in the Nurses’ Health Study cohort, aged 34 to 59 years and free of diagnosed cardiovascular disease and cancer who completed the dietary questionnaires of scientists from the Brigham and Women’s Hospital and Harvard Medical School in 1980 (Iso. 1999)
  • 50% increased total stroke risk in the 5,600 men and women older than 65 years and free of stroke at enrollment in The Cardiovascular Health Study (Green. 2002)
  • 28% increased total stroke risk according to a 2001 (re-)analysis of data from 9805 US men and women who participated in the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-Up Study (Bazzano. 2001) 
  • significantly lower bone mineral density (BMD) in elderly men and women with per unit differences that were significantly higher than for magnesium (~30%) and total fruit and vegetable intake alone (+400%; cf. Tucker. 1999)
  • higher protein loss due to low-grade acidity; just like the bone loss (Dawson-Hughes. 2000) the loss of nitrogen can be countered by potassium bicarbonate supplements (~4-6g per day lead to a 86.4% reduction in urinary nitrogen excretion in postmenopausal women; cf. Frassetto. 1997 | learn more)
Sociodemographic and -economic studies show that older men and women and people from lower socioeconomic groups are at particularly  high risk of low potassium (and high sodium) intakes (Loftfield. 2013).
Figure 2: Graphs showing age-adjusted death rates in the US from cerebrovascular accidents, 1968 through 1988, by socioeconomic quintiles, i.e. median income and high school completeion (Modan. 1992)
No wonder that their risk of hypertension-related diseases is significantly higher than that of their better-off peers. Needless to say, as well, that a low potassium and high sodium intake are inevitable consequences of the standard American convenience diet with lot's of high salt, low potassium processed foods and few minimally / unprocessed low salt, high potassium foods.
Figure 3: Low carb, low fat, vegetarian, vegan, low glycemic, Mediterranean, balanced and palolithic diets, they may be based on different premises, but the food recommendations are the same (Katz. 2014).
A pattern of which the diet overview in Katz' and Meller's recent paper "Can We Say What Diet Is Best for Health?" indicates that it one of the few criteria all the en-vogue diets from low-carb to paleo have in common.

Being based on a limited amount of refined starches, added sugars, processed foods; limited intake of certain fats and emphasizing whole plant foods, with or without lean meats, fish, poultry, seafood. They are all well capable of providing the RDA 4,700mg/day of potassium so few of the modern convenient food buyers are consuming on a daily basis.
Potassium: Why and from where?
  • Increasing potassium intake lowers blood pressure in both hypertensive and normotensive people. 
  • Increasing potassium intake and reducing sodium intake are additive in lowering blood pressure High potassium intake reduces the risk of stroke and prevents renal vascular, glomerular, and tubular damage
  • Increasing potassium intake reduces urinary calcium excretion, which reduces the risk of kidney stones and helps prevent bone demineralisation.
  • Increasing serum potassium concentrations reduces the risk of ventricular arrhythmias in patients with ischaemic heart disease, heart failure, and left ventricular hypertrophy.
The best way to increase potassium intake is to eat more fresh fruit and vegetables and the list on the left gives you an idea which of them contain particularly high amounts of this essential electrolyte. On a whole foods diet supplements shouldn't be necessary.
In the end, things could be so easy: Whether you are consuming high carb, low carb, no carb, high protein, low protein, or even vegetarian diet - there is no reason any of you would have to be taking potassium supplements.

So don't fret about the FDAs unquestionably inexplicable conclusion to prohibit the inclusion of more than 99mg of potassium in dietary supplements, but make sure that you get add at least one of the fruit and vegetable items from the following list of high potassium foods in each of your meals
Fruits ★★★
Apricots
Avocados
Bananas
Dates
Figs
Kiwi
Mangos
Melons
Nectarines
Oranges
Papayas
Peaches, fresh
Pears, fresh
Prunes
Vegetables ★★★
Artichokes
Beans: kidney, lima, pinto, red, white, etc.
Greens: beet, chard,
collard, kale, mustard,
spinach, turnip
Parsnips
Potatoes: sweet, white
French fries, chips, etc.
Pumpkins
Tomatoes: fresh, canned, paste, etc.
Winter squash
Yams
Zucchini
Other ★★
Chocolate
Cocoa
Custard
Lentils
Milk
Milk drinks
Milkshakes
Nut butters
Nuts
Peanut butter
Peanuts
Pudding
Salt Substitutes
Yogurt
And what about hyperkalemia? Potassium balance is normally maintained by precise physiological mechanisms that match potassium excretion to intake, mainly through the kidney but also through the gastrointestinal tract. Large loads of potassium are excreted rapidly with only a minimal increase in plasma potassium concentration (He. 2001). A high food and even oral suppplement intake is thus not an issue for people with healthy kidneys who don't have to take potassium sparing diuretics or similar meds.
References:
  • Ascherio, A., et al. "Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men." Circulation 98.12 (1998): 1198-1204.
  • Bazzano, Lydia A., et al. "Dietary potassium intake and risk of stroke in US men and women National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study." Stroke 32.7 (2001): 1473-1480.
  • CDC. Heart Disease Fact Sheet. < www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm > visited on March 20, 2014.
  • Cook, Nancy R., et al. "Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study." Archives of internal medicine 169.1 (2009): 32-40. 
  • Dawson-Hughes, Bess, et al. "Treatment with potassium bicarbonate lowers calcium excretion and bone resorption in older men and women." Journal of Clinical Endocrinology & Metabolism 94.1 (2009): 96-102.
  • Geleijnse, Johanna M., et al. "Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam Study." European journal of epidemiology 22.11 (2007): 763-770.
  • Green, D. M., et al. "Serum potassium level and dietary potassium intake as risk factors for stroke." Neurology 59.3 (2002): 314-320.
  • He, Feng J., and Graham A. MacGregor. "Fortnightly review: beneficial effects of potassium." BMJ: British Medical Journal 323.7311 (2001): 497.
  • Iso, Hiroyasu, et al. "Prospective study of calcium, potassium, and magnesium intake and risk of stroke in women." Stroke 30.9 (1999): 1772-1779.
  • Kafatos, Anthony, et al. "Mediterranean diet of Crete: foods and nutrient content." Journal of the American Dietetic Association 100.12 (2000): 1487-1493. 
  • Katz, D. L., and S. Meller. "Can We Say What Diet Is Best for Health?." Annual Review of Public Health 35.1 (2014).
  • Loftfield, Erikka, et al. "Potassium and fruit and vegetable intakes in relation to social determinants and access to produce in New York City." The American journal of clinical nutrition 98.5 (2013): 1282-1288. 
  • Modan, Baruch, and Diane K. Wagener. "Some epidemiological aspects of stroke: mortality/morbidity trends, age, sex, race, socioeconomic status." Stroke 23.9 (1992): 1230-1236. 
  • Wallace, Taylor C., Michael McBurney, and Victor L. Fulgoni III. "Multivitamin/Mineral Supplement Contribution to Micronutrient Intakes in the United States, 2007–2010." Journal of the American College of Nutrition 33.2 (2014): 94-102.
  • Yang, Quanhe, et al. "Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey." Archives of internal medicine 171.13 (2011): 1183-1191.