Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses

Nancy J Aburto, Sara Hanson, Hialy Gutierrez, Lee Hooper, Paul Elliott, Francesco P Cappuccio, Nancy J Aburto, Sara Hanson, Hialy Gutierrez, Lee Hooper, Paul Elliott, Francesco P Cappuccio

Abstract

Objective: To conduct a systematic review of the literature and meta-analyses to fill the gaps in knowledge on potassium intake and health.

Data sources: Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, Latin American and Caribbean Health Science Literature Database, and the reference lists of previous reviews.

Study selection: Randomised controlled trials and cohort studies reporting the effects of potassium intake on blood pressure, renal function, blood lipids, catecholamine concentrations, all cause mortality, cardiovascular disease, stroke, and coronary heart disease were included.

Data extraction and synthesis: Potential studies were independently screened in duplicate, and their characteristics and outcomes were extracted. When possible, meta-analysis was done to estimate the effects (mean difference or risk ratio with 95% confidence interval) of higher potassium intake by using the inverse variance method and a random effect model.

Results: 22 randomised controlled trials (including 1606 participants) reporting blood pressure, blood lipids, catecholamine concentrations, and renal function and 11 cohort studies (127,038 participants) reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease in adults were included in the meta-analyses. Increased potassium intake reduced systolic blood pressure by 3.49 (95% confidence interval 1.82 to 5.15) mm Hg and diastolic blood pressure by 1.96 (0.86 to 3.06) mm Hg in adults, an effect seen in people with hypertension but not in those without hypertension. Systolic blood pressure was reduced by 7.16 (1.91 to 12.41) mm Hg when the higher potassium intake was 90-120 mmol/day, without any dose response. Increased potassium intake had no significant adverse effect on renal function, blood lipids, or catecholamine concentrations in adults. An inverse statistically significant association was seen between potassium intake and risk of incident stroke (risk ratio 0.76, 0.66 to 0.89). Associations between potassium intake and incident cardiovascular disease (risk ratio 0.88, 0.70 to 1.11) or coronary heart disease (0.96, 0.78 to 1.19) were not statistically significant. In children, three controlled trials and one cohort study suggested that increased potassium intake reduced systolic blood pressure by a non-significant 0.28 (-0.49 to 1.05) mm Hg.

Conclusions: High quality evidence shows that increased potassium intake reduces blood pressure in people with hypertension and has no adverse effect on blood lipid concentrations, catecholamine concentrations, or renal function in adults. Higher potassium intake was associated with a 24% lower risk of stroke (moderate quality evidence). These results suggest that increased potassium intake is potentially beneficial to most people without impaired renal handling of potassium for the prevention and control of elevated blood pressure and stroke.

Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: LH, FPC, and PE received funding from WHO to attend NUGAG Subgroup of Diet and Health meetings; PE receives support from the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London; FPC is an unpaid member of Consensus Action on Salt and Health and World Action on Salt and Health, an unpaid advisor to WHO and the PAHO, an individual member of the National Heart Forum, and a former member of the Executive Committee and trustee of the British Hypertension Society; PE is an unpaid member of CASH and WASH and an unpaid advisor to WHO; no further financial support from any organisation for the submitted work that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. NJA was a staff member of the WHO at the time this work was completed; the author alone is responsible for the views expressed in this publication, and they do not necessarily represent the views, decisions, or policies of WHO.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f1.jpg
Fig 1 Flow of studies through screening, inclusion, and exclusion. RCT=randomised controlled trial
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f2.jpg
Fig 2 Effect of increased potassium intake on resting systolic blood pressure in adults: by hypertension status and total
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f3.jpg
Fig 3 Effect of increased potassium intake on resting diastolic blood pressure in adults: by hypertension status and total
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f4.jpg
Fig 4 Association between higher potassium intake and risk of incident cardiovascular disease, stroke, and coronary heart disease in adults
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f5.jpg
Fig 5 Effect of increased potassium intake on blood lipid concentrations, catecholamine concentrations, and renal function in adults
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816263/bin/abun007498.f6.jpg
Fig 6 Effect of increased potassium intake on resting systolic blood pressure in children. Sinaiko 1993 reported results for boys and girls separately, and Wilson 1996 reported results for two groups separately on basis of their change in blood pressure between waking and sleeping hours during pilot phase of study

References

    1. World Health Organization. Global status report on noncommunicable diseases. WHO, 2010:164.
    1. World Health Organization. World health statistics 2012. WHO, 2012:176.
    1. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. WHO, 2009:62 ().
    1. Mackay J, Mensah G. Atlas of heart disease and stroke. WHO, 2004.
    1. Murray CJL, Lauer JA, Hutubessy RCW, Niessen L, Tomijima N, Rodgers A, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003;361:717-25.
    1. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation 2008;117:3171-80.
    1. Young DB. Role of potassium in preventive cardiovascular medicine. Kluwer Academic Publishers, 2001.
    1. Cordain L, Eaton SB, Sebastian A, Mann N, Lindeberg S, Watkins BA, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr 2005;81:341-54.
    1. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ 1988;297:319-28.
    1. World Health Organization. Diet, nutrition and the prevention of chronic disease: report of a Joint WHO/FAO Expert Consultation. WHO, 2003.
    1. Federación Española de Sociedades de Nutrición, Alimentación y Dietética (FESNAD). Ingestas dietéticas de referencia (IDR) para la población Española. FESNAD, 2010.
    1. Bourges H, Casanueva E, Rosado J. Recomendaciones de ingestión de nutrimentos para la población Mexicana. Bases fisiológicas. Vitaminas e nutrimentos inorgánicos. Editorial Medica Panamericana, 2004.
    1. Hoge Gezondheidsraad. Voedingsaanbevelingen voor België. Hoge Gezondheidsraad, 2009. (Herziening 2009, Dossiernummer 8309.)
    1. Expert Group on Vitamins and Minerals. Revised review of potassium. 2002 (available at ).
    1. Ministry of Health and Welfare, Korean Nutrition Society, Korean Food and Drug Administration. Dietary reference intakes for Koreans, 1st revision. Korean Food and Drug Administration, 2010.
    1. Ministry of Health. Ordinance No23 from 19 July 2005 for physiological normative requirement (DRI) for nutrition of the population. In: State Gazzete 63. 2005.
    1. Institute of Medicine. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. National Academies Press, 2005.
    1. Dyer AR, Elliott P, Shipley M. Urinary electrolyte excretion in 24 hours and blood pressure in the Intersalt study. II. Estimates of electrolyte blood pressure associations corrected for regression dilution bias. Am J Epidemiol 1994;139:940-51.
    1. D’Elia L, Barba G, Cappuccio F, Strazzullo P. Potassium intake, stroke, and cardiovascular disease: a meta-analysis of prospective studies. J Am Coll Cardiol 2011;57:1210-9.
    1. Cappuccio FP, MacGregor GA. Does potassium supplementation lower blood pressure? A meta-analysis of published trials. J Hypertens 1991;9:465-73.
    1. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: a meta-regression analysis of randomised trials. J Hum Hypertens 2003;17:471-80.
    1. Whelton PK, He J, Cutler JA, Brancati FL, Appel LJ, Follmann D, et al. Effects of oral potassium on blood pressure: meta-analysis of randomized controlled clinical trials. JAMA 1997;277:1624-32.
    1. Dietary Guidelines Advisory Committee. What is the relationship between dietary potassium intake and blood pressure in adults? (available at ).
    1. Dickinson HO, Nicolson DJ, Campbell F, Beyer FR, Mason J. Potassium supplementation for the management of primary hypertension in adults. Cochrane Database Syst Rev 2006;3:CD004641.
    1. Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions, version 5.1.0. Cochrane Collaboration, 2011.
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700.
    1. Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003;7:1-173.
    1. Lau J, Ioannidis JP, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. BMJ 2006;333:597-600.
    1. Sterne JA, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. Clin Epidemiol 2001;54:1046-55.
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
    1. Stamler J, P Elliott P, Chan Q, for the INTERMAP Research Group. Intermap appendix tables. J Hum Hyper 2003;17:665-758.
    1. Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009;172:137-59.
    1. Higgins J, Thompson S, Deeks J, Altman D. Statistical heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practice. J Health Serv Res Policy 2002;7:51-61.
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539-58.
    1. Barros MA, Brito IM. Potassium in essential arterial hypertension. CCS (Universidade Federal da Paraiba, Centro de Ciências da Saúde) 1984;6:48-55.
    1. Morris R, O’Connor M, Forman A, Peeks R, Sebastian A. Supplemental dietary potassium with KHCO3 but not KCl attenuates essential hypertension [abstract]. J Am Soc Nephrol 1995;6:645.
    1. Kawano Y, Minami J, Takishita S. Effects of potassium, calcium and magnesium supplementation in patients with essential hypertension—assessment by blood pressure monitoring. Therapeutic Research 1997;18:44-7.
    1. Iimura O, Kijima T, Kikuchi K, Miyama A, Ando T, Nakao T, et al. Studies on the hypotensive effect of high potassium intake in patients with essential hypertension. Clin Sci 1981;61:77-80S.
    1. Hilary Green J, Richards JK, Bunning RL. Blood pressure responses to high-calcium skim milk and potassium-enriched high-calcium skim milk. J Hypertens 2000;18:1331-9.
    1. Cushman WC, Langford HG. Randomized controlled trial of potassium chloride versus placebo in mildly hypertensive blacks and whites. Circulation 1988;17:S370.
    1. Braschi A, Naismith DJ. The effect of a dietary supplement of potassium chloride or potassium citrate on blood pressure in predominantly normotensive volunteers. Br J Nutr 2008;99:1284-92.
    1. Tunstall-Pedoe H, Woodward M, Tavendale R, Brook R, McCluskey MK. Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish Heart Health Study: cohort study. BMJ 1997;315:722-9.
    1. Overlack A, Conrad H, Stumpe KO. The influence of oral potassium citrate/ bicarbonate on blood pressure in essential hypertension during unrestricted salt intake. Klin Wochenschr 1991;69:S79-83.
    1. Whelton PK, Kumanyika SK, Cook NR, Cutler JA, Borhani NO, Hennekens CH, et al. The effect of potassium supplementation in persons with a high-normal blood pressure: results from phase I of the Trials of Hypertension Prevention. Am J Clin Nutr 1995;65:S652-60.
    1. Valdés G, Vio CP, Montero J, Montero J, Avendaño R. Potassium supplementation lowers blood pressure and increases urinary kallikrein in essential hypertensives. J Hum Hypertens 1991;5:91-6.
    1. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase I. JAMA 1992;267:1213-20.
    1. Smith SJ, Markandu ND, Sagnella GA, MacGregor GA. Moderate potassium chloride supplementation in essential hypertension: is it additive to moderate sodium restriction? BMJ 1985;290:110-3.
    1. Siani A, Strazzullo P, Giacco A, Pacioni D, Celentano E, Mancini M. Increasing the dietary potassium intake reduces the need for antihypertensive medication. Ann Intern Med 1991;115:753-59.
    1. Siani A, Strazzullo P, Russo L, Guglielmi S, Iacoviello L, Ferrara LA, et al. Controlled trial of long term oral potassium supplements in patients with mild hypertension. BMJ 1987;294:1453-6.
    1. Richards AM, Nicholls MG, Espiner EA, Ikram H, Maslowski AH, Hamilton EJ, et al. Blood pressure response to moderate sodium restriction and to potassium supplementation in mild essential hypertension. Lancet 1984;1:757-61.
    1. Patki PS, Singh J, Gokhale SV, Bulakh PM, Shrotri DS, Patwardhan B. Efficacy of potassium and magnesium in essential hypertension: a double blind, placebo controlled, crossover study. BMJ 1990;301:521-3.
    1. Obel AO. Placebo-controlled trial of potassium supplements in black patients with mild essential hypertension. J Cardiovasc Pharmacol 1989;42:294-6.
    1. Matlou SM, Isles CG, Higgs A, Milne FJ, Murray GD, Schultz E, et al. Potassium supplementation in blacks with mild to moderate essential hypertension. J Hypertens 1986;4:61-4.
    1. MacGregor GA, Smith SJ, Markandu ND, Banks RA, Sagnella GA. Moderate potassium supplementation in essential hypertension. Lancet 1982;11:567-70.
    1. Kawano Y, Minami J, Takishita S, Omae T. Effects of potassium supplementation on office, home and 24-hour blood pressure in patients with essential hypertension. Am J Hypertens 1998;11:1141-6.
    1. Kaplan NM, Carnegie A, Raskin P, Heller JA, Simmons M. Potassium supplementation in hypertensive patients with diuretic-induced hypokalemia. N Engl J Med 1985;312:746-9.
    1. He FJ, Marciniak M, Carney C, Markandu ND, Anand V, Fraser WD, et al. Effects of potassium chloride and potassium bicarbonate on endothelial function, cardiovascular risk factors, and bone turnover in mild hypertensives. Hypertension 2010;55:681-8.
    1. Gu D, He J, Wu X, Duan X, Whelton PK. Effect of potassium supplementation on blood pressure in Chinese: a randomized, placebo-controlled trial. J Hypertens 2001;19:1325-31.
    1. Grobbee DE, Hofman A, Roelandt JT, Boosma F, Schalekamp MA, Valkenburg HA. Sodium restriction and potassium supplementation in young people with mildly elevated blood pressure. J Hypertens 1987;5:115-9.
    1. Fotherby MD, Potter JF. Potassium supplementation reduces clinic and ambulatory blood pressure in elderly hypertensive patients. J Hypertens 1992;10:1403-8.
    1. Forrester TE, Grell GA. Changes in red cell sodium content and blood pressure levels with potassium supplementation in black hypertensive patients. West Indian Med 1988;37:92-6.
    1. Chalmers J, Morgan T, Doyle A, Dickson B, Hopper J, Mathews J, et al. Australian National Health and Medical Research Council dietary salt study in mild hypertension. J Hypertens 1986;4:S629-37.
    1. Bulpitt CJ, Ferrier G, Lewis PJ, Daymond M, Bulpitt PF, Dollery CT. Potassium supplementation fails to lower blood pressure in hypertensive patients receiving a potassium losing diuretic. Ann Clin Res 1985;17:126-30.
    1. Berry SE, Mulla UZ, Chowienczyk PJ, Sanders TA. Increased potassium intake from fruit and vegetables or supplements does not lower blood pressure or improve vascular function in UK men and women with early hypertension: a randomised controlled trial. Br J Nutr 2010;104:1839-47.
    1. Barden A, Vandongen R, Beilin LJ. Increases in urinary kallikrein activity and prostanoid synthesis after dietary potassium supplementation. Clin Exp Pharmacol Physiol 1987;14:565-72.
    1. Weng LC, Yeh WT, Bai CH, Chen HJ, Chuang SY, Chang HY, et al. Is ischemic stroke risk related to folate status or other nutrients correlated with folate intake? Stroke 2008;39:3152-8.
    1. Umesawa M, Iso H, Date C, Yamamoto A, Toyoshima H, Watanabe Y, et al. Relations between dietary sodium and potassium intakes and mortality from cardiovascular disease: the Japan Collaborative Cohort Study for Evaluation of Cancer Risks. Am J Clin Nutr 2008;88:192-202.
    1. O’Donnell MJ, Yusuf S, Mente A, Gao P, Mann JF, Teo K, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA 2011;306:2229-37.
    1. Larsson SC, Virtanen MJ, Mars M, Männistö S, Pietinen P, Albanes D, et al. Magnesium, calcium, potassium, and sodium intakes and risk of stroke in male smokers. Arch Intern Med 2008;168:459-65.
    1. Khaw KT, Barrett-Connor E. Dietary potassium and stroke-associated mortality: a 12-year prospective population study. N Engl J Med 1987;316:235-40.
    1. Iso H, Stampfer MJ, Manson JE, Rexrode K, Hennekens CH, Colditz GA, et al. Prospective study of calcium, potassium, and magnesium intake and risk of stroke in women. Stroke 1999;30:1772-9.
    1. Green DM, Ropper AH, Kronmal RA Psaty BM, Burke GL. Serum potassium level and dietary potassium intake as risk factors for stroke. Neurology 2002;59:314-20.
    1. Geleijnse JM, Witteman JC, Stijnen T, Kloos MW, Hofman A, Grobbee DE. Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam Study. Eur J Epidemiol 2007;22:763-70.
    1. Cook NR, Obarzanek E, Cutler JA, Buring JE, Rexrode KM, Kumanyika SK, et al, for the Trials of Hypertension Prevention Collaborative Research Group. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the trials of hypertension prevention (TOHP) follow-up study. Arch Intern Med 2009;169:32-40.
    1. Bazzano LA, He J, Ogden LG, Loria C, Vupputuri S, Myers L, 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 2001;32:1473-80.
    1. Ascherio A, Rimm EB, Hernán MA, Giovannucci EL, Kawachi I, Stampfer MJ, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198-204.
    1. Sinaiko AR, Gomez-Marin O, Prineas RJ. Effect of low sodium diet or potassium supplementation on adolescent blood pressure. Hypertension 1993;21:989-94.
    1. Geleijnse JM, Grobbee DE, Hofman A. Sodium and potassium intake and blood pressure change in childhood. BMJ 1990;300:899-902.
    1. Wilson DK, Sica DA, Devens M, Nicholson SC. The influence of potassium intake on dipper and nondipper blood pressure status in an African-American adolescent population. Blood Press Monit 1996;1:447-55.
    1. Miller JZ, Weinberger MH, Christian JC. Blood pressure response to potassium supplementation in normotensive adults and children. Hypertension 1987;10:437-42.
    1. Vasan RS. Biomarkers of cardiovascular disease: molecular basis and practical considerations. Circulation 2006;113:2335-62.
    1. Desai M, Stockbridge N, Temple R. Blood pressure as an example of a biomarker that functions as a surrogate. AAPS J 2006;8:E146-52.
    1. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, for the Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13.
    1. Energy and nutrient intake in the European Union. Ann Nutr Metab 2004;48(suppl 2):1-16.
    1. Van Mierlo LAJ, Greyling A, Zock PL, Kok FJ, Geleijnse JM. Suboptimal potassium intake and potential impact on population blood pressure. Arch Intern Med 2010;170:1501-2.
    1. Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med 1995:155:701-9.
    1. McPherson K, Britton A, Causer L. Coronary heart disease: estimating the impact of changes in risk factors. National Heart Forum, 2002.
    1. Saggar-Malik AK, Cappuccio FP. Potassium supplements and potassium-sparing diuretics: a review and guide to appropriate use. Drugs 1993;46:986-1008.
    1. Hathcock JN. Potassium. In: Vitamin and mineral safety. 2nd ed. Council for Responsible Nutrition, 2004.
    1. Rabelink TJ, Koomans HA, Hene RJ, Dorhout Mees EJ. Early and late adjustment to potassium loading in humans. Kidney Int 1990;38:942-7.
    1. EFSA Panel on Dietetic Products, Nutrition and Allergies. Opinion of the Scientific Panel on Dietetic Products, Nutrition and Allergies (NDA) related to the tolerable upper intake level of sodium (Request EFSA-Q-2003-018). European Food Safety Authority Journal 2005;193:1-19.
    1. World Health Organization. Guideline: sodium intake for adults and children. WHO, 2012.
    1. Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol 2009;38:791-813.
    1. Kawasaki T, Itoh K, Kawasaki M. Reduction in blood pressure with a sodium-reduced, potassium- and magnesium-enriched mineral salt in subjects with mild essential hypertension. Hypertens Res 1998;21:235-43.
    1. Chang HY, Hu YW, Yue CS, Wen YW, Yeh WT, Hsu LS, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr 2006;83:1289-96.
    1. World Health Organization. Guideline: potassium intake for adults and children. WHO, 2012.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться