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The Effects of a Combined Low-Sodium, High-Potassium, High-Calcium Diet on Blood Pressure in Patients with Mild Hypertension

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The Effects of a Combined Low-Sodium, High-Potassium, High-Calcium Diet on Blood Pressure in Patients with Mild Hypertension Journal of Human Hypertension (1997) 11, 789–794 1997 Stockton Press. All rights reserved 0950-9240/97 $12.00 ORIGINAL ARTICLE The effects of a combined low-sodium, high-potassium, high-calcium diet on blood pressure in patients with mild hypertension E Grossman, A Vald, E Peleg, B Sela and T Rosenthal Chorley Hypertension Unit, Chaim Sheba Medical Center, Tel Hashomer, and Tel Aviv University Sackler School of Medicine, Israel Nutritional sodium, potassium and calcium are con- (P , 0.05). Eighteen patients did not comply with the sidered to be important regulators of blood pressure diet. Systolic BP (SBP) only slightly decreased, from 142 (BP). The present study evaluates the effects of com- mm Hg (95% CI, 137–146 mm Hg) to 138 mm Hg (95% bined low-sodium (LS), high-potassium (HK), high-cal- CI, 133–142 mm Hg); (P = 0.11). The change in SBP was cium (HCa) diet on BP in patients with mild essential related to the change in urinary sodium excretion hypertension. Thirty-six patients (26 M, 10 F), 24–67 (R = 0.46; P = 0.006). After 1 month of the HK diet, uri- years of age (mean 46 ± 8), participated in the study. nary potassium excretion increased by only Patients were divided into three groups and given a diet 5 mmols/day (P = NS). BP was unaffected by HK and consisting of three 1-month segments, which they fol- HCa diet. At the end of the study, urinary sodium lowed in different order. Group 1 (n = 11) received LS excretion decreased from 183 mmols/day (95% CI, 155– diet followed by the addition of HCa and then HK. The 211 mmols/day) to 148 mmols/day (95% CI, 131– order in Group 2 (n = 12) was HK-LS-HCa; and in 165 mmols/day); (P , 0.05), urinary potassium excretion Group 3 (n = 13) it was HCa-HK-LS. The third month of slightly increased from 75 mmols/day (95% CI, 68–82 the study all patients were eating a combined LS, HK mmols/day) to 85 mmols/day (95% CI, 76–94 and HCa diet. Urinary electrolytes were measured to mmols/day); (P = 0.09), and urinary calcium excretion confirm compliance with the diets. After 1 month of the remained unchanged. BP did not decrease. It is con- LS diet urinary sodium excretion decreased signifi- cluded that only the LS diet may be advantageous in cantly by 25 mmols/day (95% CI, 1–48 mmols/day); patients with mild essential hypertension. Keywords: sodium; potassium; calcium; diet; blood pressure Introduction Patients and methods Nutritional sodium, potassium and calcium are con- Patients sidered to be important regulators of blood pressure Thirty-six patients (26 M, 10 F), from our out-patient (BP). Some studies have shown that sodium restriction ± 1–5 clinic, 24–67 years of age (mean 46 8 years) par- lowers BP while others have found no effect. Pot- ticipated in the study. The relevant clinical data at assium and calcium supplementation was also con- 6–12 enrolment in the study are given in Table 1. sidered beneficial in lowering BP, although the All participants had essential hypertension and finding on the value of manipulating these electro- = 13–18 were either on no drug therapy (n 20), or treated lytes in hypertension are controversial. Each with a b-blocker (n = 7), or a calcium channel dietary manipulation has been evaluated as a sole blocker (n = 9) as a single agent throughout the intervention in these various studies, but the combi- study. Patients were included only if they stated nation of all three has seldom been studied. their willingness to maintain the diet. Excluded The present study was undertaken to assess from the study were patients with secondary hyper- whether a combined low-sodium (LS), high-potas- tension, ischaemic heart disease, congestive heart sium (HK), high-calcium (HCa) diet is achievable, failure, renal failure (creatinine .1.5 mg/dL) and and whether it affects BP in patients with mild treated diabetes mellitus. essential hypertension. Study design Patients were divided into three groups and given a diet which they followed in different order, as illus- Correspondence: Dr Ehud Grossman, Hypertension Unit, Chaim = Sheba Medical Center, Tel Hashomer 52621, Israel trated in Figure 1. Group 1 (n 11) began with the Received 29 November 1996; revised and accepted 5 May 1997 LS diet followed by the addition of HCa and HK Sodium, potassium and calcium in hypertension E Grossman et al 790 Table 1 Patients characteristics at time of enrolment in the study (mean 6 s.d.) Group 1 Group 2 Group 3 Number 11 12 13 Height (cm) 168 ± 10 174 ± 9 175 ± 5 Weight (kg) 76 ± 10 89 ± 13 85 ± 12 BMI (kg/m2) 26.8 ± 2.9 28.6 ± 3.9 28.1 ± 3.8 Waist/Hip 0.94 ± 0.12 1.04 ± 0.08 1.03 ± 0.05 MAP (mm Hg) 103 ± 4 112 ± 11 112 ± 13 HR (beats/min) 76 ± 14 73 ± 11 79 ± 11 Urinary sodium (mmols/day) 143 ± 58 194 ± 96 219 ± 78 Urinary sodium (mmols/gr 138 ± 77 151 ± 71 180 ± 50 creatinine) Urinary potassium (mmols/day) 76 ± 22 75 ± 29 77 ± 12 Urinary potassium (mmols/gr 75 ± 35 56 ± 12 68 ± 24 creatinine) Urinary calcium (mg/day) 128 ± 63 185 ± 106 121 ± 83 Energy intake (Kcal) 2260 ± 765 2467 ± 1130 2600 ± 509 Carbohydrate intake (g/day) 282 ± 92 308 ± 120 330 ± 85 Fat intake (g/day) 81 ± 46 97 ± 59 92 ± 35 Protein intake (g/day) 114 ± 31 105 ± 44 115 ± 27 Calcium intake (mg/day) 1115 ± 129 985 ± 175 710 ± 94 BMI = body mass index; MAP = mean arterial pressure; HR = heart rate. diets. Group 2 (n = 12) began with HK followed by (Version 6 Copyright 1990, N-Sgeared Company, LS and HCa diets. Group 3 (n = 13) started on the USA). HCa diet followed by HK and LS diets. The third BP, heart rate, body weight, waist and hip circum- month of the study all patients were eating a com- ference and 24 h urinary electrolytes were measured bined LS, HK and HCa diet. at baseline and monthly for 3 months. BP was meas- Recommendations for the diets were: 50 mmols ured with a sphygmomanometer three times in the sodium per day for the LS diet, supplementation of sitting position after 5 min rest; phases 1 and 5 of 30–60 mmols potassium per day for the HK diet, and the Korotkoff sounds were used to determine the 1000 mg calcium per day for the HCa diet. systolic and diastolic BPs (SBP/DBP), respectively. LS diet was attained by cooking without adding Sodium and potassium in urine were measured with salt, and using low-sodium substitutes to the regular a flame photometer, and calcium was measured diet, such as fresh vegetables and fish instead of spectrophotometrically on a monarch 2000 analyser olives, sour cucumbers and tuna. The HK diet was with the indicator methylthymol blue reagent of attained by increasing the consumption of veg- bioMe´rieux (France). To confirm complete urine col- etables and legumes and by moderately increasing lection the values were also corrected for creatin- the consumption of fresh fruits. Suggestions for food ine excretion. preparation were also given, in particular, subjects were encouraged to steam rather than boil legumes Data analysis and vegetables. A compensatory moderate reduction ± in the intake of animal protein (meat) and total fat Values are presented as mean s.d. Analysis of vari- (olive oil) was suggested, however, to keep the total ance (ANOVA) for repeated measurements (Statview + energy and macronutrient intake unchanged. HCa 512 , Brainpower Inc, Calabasas, CA, USA) was diet was attained by increasing the consumption of used to compare values at baseline with those at dairy products, such as milk and cheese, sesame, each diet manipulation. Pearson’s correlation was and fish. Patients were asked to alter only electrolyte used to test the relationship between changes in BP intake and to avoid changes in other dietary habits and urinary electrolytes, and between the estimated and lifestyle during the study. A nutritional coun- electrolyte intake and the 24-h urinary excretions. A selor was provided to help subjects maintain the P value of less than 0.05 defined statistical signifi- prescribed diet. To monitor compliance patients cance. were seen frequently by the dietitian who calculated the electrolyte intake. Dietary intake was assessed at Results each clinic visit using a recall questionnaire that Nutrient analysis was filled by the patient under the supervision of the dietitian. Foods were then coded for computer Energy intake remained unchanged during the study analysis by using a Nutritionist 3 computer program (baseline value, 2424 kcal/day [95% CI, 2147– Sodium, potassium and calcium in hypertension E Grossman et al 791 (Figure 2). Among the 18 who did comply, 11 exhib- ited a decrease in SBP (Figure 2) while seven showed no change or even an increase in this para- meter. These patients were probably salt-resistant subjects. The change in SBP was related to the change in urinary sodium excretion (Figure 2, R = 0.46, P = 0.006). Eliminating the seven salt-resistant sub- jects from the calculation further strengthened this correlation (Figure 2, R = 0.64, P = 0.0003). The rate of compliance and the rate of response to LS diet were not affected by age, sex, BMI, and waist/hip ratio. Salt sensitivity was unrelated to age. Urinary sodium excretion increased over time in patients who started the study on LS diet (Group 1, Figure 3). The effects of a high potassium diet After 1 month of HK diet, urinary potassium excretion increased by only 5 mmols/day from 82 mmols/day (95% CI, 71–92 mmols/day) to 87 mmols/day (95% CI, 76–97 mmols/day); (P = 0.27).
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