Advertisement

Potassium Intake in India: Opportunity for Mitigating Risks of High-Sodium Diets

      Introduction

      Most Indians are vegetarian or eat very little meat, which could imply high potassium intake. Because a high-potassium diet could counterbalance the adverse health effects of high-sodium intake, this study aimed to describe potassium relative to sodium intake and investigate the relationship between blood pressure and potassium intake relative to sodium intake in rural and urban India.

      Methods

      Investigators collected 24-hour urines from 1,445 participants in a subset of 2 population-based surveys in North India in 2012–2013. Standardized questionnaires were used to collect information on demography, behaviors (tobacco, alcohol consumption, physical activity, and diet [food frequency and 24-hour recall]), and medical history. After evaluating expected versus measured creatinine excretion, the authors calculated median urine potassium excretion and sodium/potassium ratio, according to sex and urban or rural residence, and estimated least square means for the urine measures by participant demographics and comorbidities, after accounting for caloric intake. Two-year blood pressure follow-up data were available in the urban study, and ANCOVA regression was used to determine the association with urine measures. All the statistical analyses of the data were done in January 2019.

      Results

      Acceptable 24-hour urine collections were available in 1,397 participants (rural, n=730). Median urine potassium excretions were 1,492 (IQR=1,012−2,063) and 975 (615–1,497) mg/day; sodium/potassium ratios met the recommended target of <1 in 2.9% rural and 6.6% urban participants. Rural participants did not have higher potassium or lower (better) sodium/potassium ratios when diagnosed with hypertension or other cardiovascular conditions. Higher potassium excretion was associated with lower blood pressure during follow-up among the urban participants (mean systolic blood pressure, 129 vs 133 mm Hg in highest vs lowest potassium excretion tertiles; p=0.029).

      Conclusions

      Low potassium intake in India warrants dietary policies promoting intake of potassium-rich foods to improve heart health. This approach may be more acceptable than programs focused on sodium reduction alone.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Appel LJ
        • Brands MW
        • Daniels SR
        • et al.
        Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association.
        Hypertension. 2006; 47: 296-308
        • WHO
        Guideline: Sodium intake for adults and children.
        Published 2012
        • Cook NR
        • Obarzanek E
        • Cutler JA
        • et al.
        Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study.
        Arch Intern Med. 2009; 169: 32-40
        • O'Donnell M
        • Mente A
        • Rangarajan S
        • et al.
        Urinary sodium and potassium excretion, mortality, and cardiovascular events.
        N Engl J Med. 2014; 371: 612-623
        • Nohara-Shitama Y
        • Adachi H
        • Enomoto M
        • et al.
        Twenty-four-hour urinary potassium excretion, but not sodium excretion, is associated with all-cause mortality in a general population.
        J Am Heart Assoc. 2018; 7e007369
        • Adrogué HJ
        • Madias NE
        Sodium and potassium in the pathogenesis of hypertension.
        N Engl J Med. 2007; 356: 1966-1978
        • McDonough AA
        • Veiras LC
        • Guevara CA
        • Ralph DL
        Cardiovascular benefits associated with higher dietary K+ vs. lower dietary Na+: evidence from population and mechanistic studies.
        Am J Physiol Endocrinol Metab. 2017; 312: E348-E356
        • Powles J
        • Fahimi S
        • Micha R
        • et al.
        Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide.
        BMJ Open. 2013; 3e003733
        • Rodrigues SL
        • Baldo MP
        • Machado RC
        • Forechi L
        • Molina Mdel C
        • Mill JG
        High potassium intake blunts the effect of elevated sodium intake on blood pressure levels.
        J Am Soc Hypertens. 2014; 8: 232-238
      1. Tepper R. World's meat consumption: Luxemborg eats the most per person, India the least. Huffington Post. https://www.huffpost.com/entry/world-meat-consumption_n_1475760. Updated May 4, 2012. Accessed August 9, 2019.

        • Johnson C
        • Praveen D
        • Pope A
        • et al.
        Mean population salt consumption in India: a systematic review.
        J Hypertens. 2017; 35: 3-9
        • Yokoyama Y
        • Nishimura K
        • Barnard ND
        • et al.
        Vegetarian diets and blood pressure: a meta-analysis.
        JAMA Intern Med. 2014; 174: 577-587
        • Rizzo NS
        • Jaceldo-Siegl K
        • Sabate J
        • Fraser GE
        Nutrient profiles of vegetarian and nonvegetarian dietary patterns.
        J Acad Nutr Diet. 2013; 113: 1610-1619
        • Ophir O
        • Peer G
        • Gilad J
        • Blum M
        • Aviram A
        Low blood pressure in vegetarians: the possible role of potassium.
        Am J Clin Nutr. 1983; 37: 755-762
        • Nair M
        • Ali MK
        • Ajay VS
        • et al.
        CARRS Surveillance study: design and methods to assess burdens from multiple perspectives.
        BMC Public Health. 2012; 12: 701
        • Prabhakaran D
        • Roy A
        • Praveen PA
        • et al.
        20-year trend of CVDrisk factors: urban and rural national capital region of Delhi, India.
        Glob Heart. 2017; 12: 209-217
        • Johnson C
        • Mohan S
        • Rogers K
        • et al.
        Mean dietary salt intake in urbanand rural areas in India: a population survey of 1395 persons.
        J Am Heart Assoc. 2017; 6e004547
        • Ix JH
        • Wassel CL
        • Stevens LA
        • et al.
        Equations to estimate creatinine excretion rate: the CKD epidemiology collaboration.
        Clin J Am Soc Nephrol. 2011; 6: 184-191
        • HHS, U.S. Department of Agriculture
        Dietary Guidelines for Americans.
        6th ed. U.S. Government Printing Office, Washington, DC2005 (2005)
        • Buendia JR
        • Bradlee ML
        • Daniels SR
        • Singer MR
        • Moore LL
        Longitudinal effects of dietary sodium and potassium on blood pressure in adolescent girls.
        JAMA Pediatr. 2015; 169: 560-568
        • Zhang Z
        • Cogswell ME
        • Gillespie C
        • et al.
        Association between usual sodium and potassium intake and blood pressure and hypertension among U.S. adults: NHANES 2005–2010.
        PLoS One. 2013; 8: e75289
        • Bailey RL
        • Parker EA
        • Rhodes DG
        • et al.
        Estimating sodium and potassium intakes and their ratio in the American diet: data from the 2011–2012 NHANES.
        J Nutr. 2016; 146: 745-750
        • Huggins CE
        • O'Reilly S
        • Brinkman M
        • et al.
        Relationship of urinary sodium and sodium-to-potassium ratio to blood pressure in older adults in Australia.
        Med J Aust. 2011; 195: 128-132
        • Dixit AA
        • Azar KM
        • Gardner CD
        • Palaniappan LP
        Incorporation of whole, ancient grains into a modern Asian Indian diet to reduce the burden of chronic disease.
        Nutr Rev. 2011; 69: 479-488
        • Kehoe SH
        • Dhurde V
        • Bhaise S
        • et al.
        Barriers and facilitators to fruit and vegetable consumption among rural Indian women of reproductive age.
        Food Nutr Bull. 2019; 40: 87-98
        • Garg V
        • Shivashankar R
        • Kondal D
        • et al.
        Knowledge, attitudes and practices related to dietary salt intake among adults in North India.
        Public Health Nutr. 2019; 22: 1606-1614
        • Finzer LE
        • Ajay VS
        • Ali MK
        • et al.
        Fruit and vegetable purchasing patterns and preferences in South Delhi.
        Ecol Food Nutr. 2013; 52: 1-20
        • Cecchini M
        • Sassi F
        • Lauer JA
        • Lee YY
        • Guajardo-Barron V
        • Chisholm D
        Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.
        Lancet. 2010; 376: 1775-1784
        • Choi SE
        • Seligman H
        • Basu S
        Cost effectiveness of subsidizing fruit and vegetable purchases through the Supplemental Nutrition Assistance Program.
        Am J Prev Med. 2017; 52: e147-e155
        • An R
        • Patel D
        • Segal D
        • Sturm R
        Eating better for less: a national discount program for healthy food purchases in South Africa.
        Am J Health Behav. 2013; 37: 56-61
        • Waterlander WE
        • Steenhuis IHM
        • de Boer MR
        • Schuit AJ
        • Seidell JC
        The effects of a 25% discount on fruits and vegetables: results of a randomized trial in a three-dimensional web-based supermarket.
        Int J Behav Nutr Phys Act. 2012; 9: 11
        • Li N
        • Yan LL
        • Niu W
        • et al.
        The effects of a community-based sodium reduction program in rural China - a cluster-randomized trial.
        PLoS One. 2016; 11e0166620
        • Chang HY
        • Hu YW
        • Yue CS
        • et al.
        Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men.
        Am J Clin Nutr. 2006; 83: 1289-1296
        • D'Elia L
        • Barba G
        • Cappuccio FP
        • Strazzullo P
        Potassium intake, stroke, and cardiovascular disease a meta-analysis of prospective studies.
        J Am Coll Cardiol. 2011; 57: 1210-1219
        • Green R
        • Milner J
        • Joy EJ
        • Agrawal S
        • Dangour AD
        Dietary patterns in India: a systematic review.
        Br J Nutr. 2016; 116: 142-148
        • Day N
        • McKeown N
        • Wong MY
        • Welch A
        • Bingham S
        Epidemiological assessment of diet: a comparison of a 7-day diary with a food frequency questionnaire using urinary markers of nitrogen, potassium and sodium.
        Int J Epidemiol. 2001; 30: 309-317
        • Charlton K
        • Ware LJ
        • Baumgartner J
        • et al.
        How will South Africa's mandatory salt reduction policy affect its salt iodisation programme? A cross-sectional analysis from the WHO-SAGE Wave 2 Salt & Tobacco study.
        BMJ Open. 2018; 8e020404