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Potassium: The Little Element that Could (significantly reduce the cost of the global medical crisis)
Spring has sprung, the flowers are out, and if you’re not planning and planting your garden, stake out your local farmers’ markets. Of the myriad reasons to do so, chances are extremely high that you need some potassium. 93% of us do, according to the National Health and Nutrition Examination Survey (NHANES). No better way to get it than lots of fresh fruits and veggies. (Or avocado and coconut water -- my two favorite sources.)
For you skimmers, I’ll skip to the punchline of this ENL: If we had to pick one single, easy fix for the impending 47,000,000,000,000 US dollar global health care crisis it would be INCREASE FOOD SOURCE POTASSIUM. That’s it. We’d shave 20-30% right off the top of that debt. Done. And there would be a trickle-down effect of a healthy diet beyond that immediate savings, too.
Potassium giveth ...
Sodium taketh away...
Tell Me More….
Most famously, potassium works with its little brother sodium in a delicate ratio, getting pumped in and out of cells. It’s a part of the behind-the-scenes battery using energy (ATP) to generate the pulse of life. Thinking, feeling, heart beating, moving, tasting, breathing and on and on. Potassium is one of the most fundamental players in the game. Any activity requires the action potential that potassium generates as it is being pumped around.
For sake of simplicity, I’ll call the sodium/potassium/ATPase pump The Battery of Life.
See the movie: How the Sodium Potassium Pump Works
Historically, potassium was so ubiquitous in the food supply, deficiency through diet was rare. In fact, look at a Daily Recommended Intake (DRI) table for minerals and you won’t see potassium listed! (You don’t see your DRI for oxygen, either.)
But humans have a way of messing with the most fundamental rules of life, don’t we?
If you’re eating processed foods with any regularity, you’re ingesting too much salt and too little potassium. You’re messing with the Battery of Life. Here’s how bad it is: In the US, according to NHANES, we’re ingesting almost 250% of the DRI of sodium (men: 280%, women: 208%) and only 7% of the recommended amount of potassium.
Way too much, way too little, and way too imbalanced.
Humans are the only mammals to negatively flip the intake of sodium and potassium.
What are the ramifications of this flip?
When we were writing the Elements chapter from Laboratory Evaluations in Integrative and Functional Medicine, we came up with a novel idea: Let’s create a table of the association between essential element deficiencies and top causes of death in the US. We found that potassium deficiency was associated with heart disease, cerebrovascular disease (stroke) and essential hypertension. (What we feel as symptoms of deficiency are vague and widespread but could include muscle cramps, fatigue, slower reflexes.)
Potassium deficiency is associated with the top causes of death worldwide, including hypertension, stroke and heart disease.
About 25% of deaths globally are from heart disease and stroke alone, almost 14 million deaths annually. If we were potassium-replete, especially via fruits and veggies, how much could this number be reduced? How much money could be saved? I remember researching the global cost of hypertension and it alone was pegged at 10,000,000,000,000 US dollars annually. Hence my thesis from second paragraph above that potassium repletion through dietary intake could shave 20-30% off the impending 47 trillion US dollar global medical bill.
A note to a small subset of readers: Yeah, I know, correlation isn’t causation. It seems a pretty tight relationship to me, though. Better still: If we get our potassium from foods, that shift alone will improve morbidity and mortality.
So, in summary, increase potassium-containing foods. A lot. Reduce processed foods. A lot. It’s an easy fix to a longer and healthier life and ultimately will save a lot of money.
Part Two: Assessing potassium and sodium status
This April I was honored to be invited to lecture on allergic disease at the annual Orthomolecular Conference in Toronto, Canada (photos below). As with most good conferences, there are usually a couple “practice changers”; that is, ideas so relevant that they move one beyond just intellectual stimulation and into immediate action and change. For me, one of this year’s came from a lecture delivered by Saul Pilar, MD, a clinician from Vancouver, BC.
Dr Pilar’s simple but powerful take-home message? Measure 24-hour urine sodium (Na+) and potassium (K+) levels in yourself and your patients.
Ruling out confounding factors like Na+/K+-altering diseases and medication effects, urine Na+ and K+ reflect what we eat. Your ratio should be in the vicinity of 1:4 sodium to potassium (1500mg/day Na+ and 4700mg/day K+). And if it’s not? Too many processed foods, too little whole foods. Easy measure, easy fix. (Note: Depending on the reference, there is some disagreement around optimal Na+ and K+ intake, but generally speaking, ballpark is 1:3 to 1:5.)
If you’re wincing at the idea of an onerous 24-hour urine collection, a cursory search of the literature reveals that we can probably get away with this “gold standard” measurement in a 12-hour collection. This suggests that an overnight collection is adequate, too. And this test is routinely insurance-covered.
Generally speaking with regard to minerals, we want to see what’s going on inside the cell. This is usually accomplished by a red blood cell mineral assessment. Looking at intracellular potassium is a good thing, no doubt. However, given the gross imbalance in dietary intake in the case of sodium and potassium, the urine test is best.
Serum sodium and potassium are also routinely assessed; but these levels are so tightly regulated by the body, that you’ll rarely see a nutrient-induced abnormality. If K+ is abnormal in serum, evaluation for causes beyond the diet is essential.
91-year-old Prince Phillip is in the house!
And you can get a blurry glimpse of the proof in this photo. (Arrow provided for your viewing convenience.) Prince Phillip, Queen Elizabeth’s hubby, showed up at the Fairmont Royal York Hotel in Toronto, home of this year’s Orthomolecular Conference. Was he secretly hoping to catch some of the Conference? Maybe... he was in the room right next door!
Prince Phillip’s possee in the Royal York.
For all you Royal-ophiles, his full name is His Royal Highness The Prince Philip, Duke of Edinburgh, Earl of Merioneth and Baron Greenwich, KG (Knight of the Garter), KT (Knight of the Thistle), OM (Order of Merit), GBE (Knight Grand Cross of the Order of the British Empire), AC (Companion of the Order of Australia), QSO (Companion of The Queen’s Service Order), PC (Privy Counsellor). And we thought some integrative physicians have lengthy professional designations….
Also at the conference was Dr. Nicolas Gonzalez talking about Dr. John Beard, pictured on the screen. Dr Beard developed the trophoblastic theory of cancer and pioneered the use of pancreatic enzyme therapy. Very interesting.
Dr Lustig presented on sugar toxicity. Great lecture. See his video, “Sugar, the Bitter Truth,” on YouTube.
Nutra India Summit
I had the privilege of presenting an overview of Functional Medicine at the 8th annual Nutra India Summit in Mumbai, India, a few weeks ago, some of which is available on YouTube.
Dr. Kara Fitzgerald attended the Nutra India Summit in March.
It was an amazing experience. I was impressed with the level of scholarship and scientific inquiry. Very compelling research was presented on oligosaccharides (prebiotics), probiotics and fermented foods. There were meetings on integrating pharma and nutra. And it all took place against this wonderful backdrop that is Ayurveda, India’s 5000 year old system of medicine.
Dr. Fitzgerald speaks at summit.
Dr. V. Prakash, chairman of Nutra Summit, reminded the audience that the safety studies of today are sorely inadequate when compared to the rules of Ayurveda, where safety and efficacy of a compound require no less than a century of proof before it may enter circulation. Seems hard to believe; but if the system itself is 5K years old, those substances both safe and efficacious will indeed reveal themselves.
Jain temple seen on Dr. Fitzgerald's visit.
Unfortunately, along with India’s meteoric economic development comes the dark shadow of rising chronic disease, which has supplanted infectious disease as the top cause of mortality in India.
Dr. Fitzgerald with panel at summit.
India has one of the highest rates of diabetes world-wide (and it cuts across economic lines). In fact, data from Mumbai showed that a full 95% of its inhabitants had a least one metabolic syndrome biomarker, and about 80% of Mumbaikars are overweight. Food is more plentiful now, especially the fast, fried, simple carbohydrate variety….
An ox pulls a cart through the local streets.
I was pleased to see the same calling towards wellness, however, in my colleagues at the Nutra Summit. Everyone,it seems, is deeply committed to shifting the medical paradigm.
Bombay University.
I will return to India in June to present a day-long Introduction to Functional Medicine: Focus on Case Studies.
Dr. Fitzgerald plans to return to India in June.
Viva la Commensal Biofilm
Gastrointestinal biofilms are an important topic, and those comprised of pathogenic microbes are getting much well-deserved attention in the integrative medical community. However, in keeping with the sIgA topic, I want to give a shout-out to commensal biofilms, which are vital to GI health and deserve similar attention.
Biofilms are everywhere, allowing bacteria to survive -- good or bad. They are found at the solid-liquid interface in most environments. Indeed, dental plaque is a biofilm, as is the slime on an icky bathtub. Biofilms are comprised of bacteria (and/or other microbes) and an extracellular matrix of excreted polymeric polysaccharides.
Simply put: bugs + goo = slime (biofilm).
Slime is nothing to joke about! Biofilms allow pathogenic organisms to be antibiotic resistant, up to 1000-fold by one estimate. But biofilms comprised of commensals can be our friends, modulating our immune response, supporting GI integrity and reducing inflammation.
Research on commensal GI biofilm shows that E. coli , bifidobacteria and L. reuteri are apparently efficient producers, with the former mediated by sIgA and mucin. Research suggests commensal biofilms may be anti-inflammatory, modulate cytokine production and crowd out pathogenic biofilms.
One study in rats with human-type flora showed improved bifidobacteria biofilm, mucus thickness, villous height, crypt depth, and mucin-producing goblet cell numbers when supplemented with inulin-type fructans. How cool is that?
How can we tell if our GI commensal biofilm is healthy?
On a stool test, I would be concerned if I didn’t see enough bifidobacteria, lactobacillus, commensal E. coli or sIgA. Glutamine, vitamin A and S. boulardii support sIgA production; whereas the inulin mentioned above, plus probiotic supplementation, will help facilitate commensal bacterial growth. Finally, treating inflammation and minimizing unwarranted antibiotic use should also benefit biofilm status.
I think we can say that biofilms are little ecosystems unto themselves, where "the sum is greater than the parts.” And when we’re thinking about protection of our all-important GI microbiota, the commensal biofilm is once slimy surface we don’t want to slip away!
Metabolic Syndrome: The Deadly Quartet
The four horsemen of the apocalypse, AKA the deadly quartet
In a moment, I’m going to throw out a few rather depressing statistics about metabolic syndrome (MetS) and the state of health in the U.S. These stats need articulating. Over and over and over, until we get it.
We also need to be very clear on the driving forces behind our rapid descent into a disease culture. I’ll mention a couple in this blog. If we understand the root problems, chances are much higher we’ll be motivated and empowered to embrace solutions. (Perhaps only because we’re angered by the extent to which -- yet again -- health is a distant runner up to profit.)
But there are do-able solutions, which I’ll also mention shortly. And what’s particularly wonderful about the solutions is that they help not just you, your family, your neighbors, your community, but also the planet.
Doable solutions for all!
Once called “The Deadly Quartet,” MetS is comprised of elevated blood sugar, blood fat (triglycerides), blood pressure and weight (abdominal adiposity). We’re not talking that elevated, though. Take blood sugar, for instance. For a fasting blood sugar to be in the MetS range, it need only hit 100 mg/dL. But 100 mg/dL is actually considered a normal result by many laboratories! (Laboratory reference ranges are based on the population as a whole. So if everyone goes up, the reference range for normal will generally go up, too. An interested future blog: Understanding Reference Ranges. I tussled with the reference range conundrum in the B12 blog, also.) The point is this: You won’t always see fasting blood sugar flagged “high” on your lab report to draw attention to the number. And unfortunately, a level of 100 mg/dL doesn’t alert many doctors either.
Do you know your fasting blood sugar number? To be sure, it’s not the whole story, but it’s arguably more important than the vaunted “total cholesterol” number that gets far more P.R. High blood sugar is the third leading cause of death in the world!1
Dig into the research a little bit further -- scientists in Texas looked at blood sugar and heart disease and found that levels above 86 mg/dL were associated with increased risk for heart disease. That’s quite a bit below 100.2
Note to self: A really good fasting blood sugar is around 86 mg/dL (or lower). Not a whole lot of folks actually clock in at 86.
We’re a culture whose “normal” promotes disease.
How about weight? 70% of us are overweight. Along with elevated blood sugar, it’s part of the deadly quartet. And obesity is the number one risk factor for Type II diabetes.3,4 Obesity is the first leading cause of death in the world, and hypertension is the fifth leading cause of death in the world. Along with elevated blood sugar, that means three of the deadly quartet are leading causes of death.
With these stats, we can’t possibly be surprised that the incidence of type II diabetes increased in the U.S by a whopping 83% between 1995 and 2010, can we? (At 226%, Oklahoma is the state with the dubious honor of highest increase in diabetes.)3,4
I’ll say it again: We’re a culture whose “normal” promotes disease.
While MetS is under-addressed by doctors, it’s well understood to be the “gateway disease,” leading to increased risk of type II diabetes, heart disease, kidney disease, cancers, dementia, autoimmune disease. Pretty much every chronic disease to confront us is promoted by the inflammation-driven effects of MetS. A look at top causes of death in the U.S. -- most of them can be traced to the Deadly Quartet. Here’s the Center for Disease Control’s 2010 list.
Number of deaths for leading causes of death
1 *Heart disease: 597,689
2 *Cancer: 574,743
3 *Chronic lower respiratory diseases: 138,080
4 *Stroke (cerebrovascular diseases): 129,476
5 Accidents (unintentional injuries): 120,859
6 *Alzheimer's disease: 83,494
7 *Diabetes: 69,071
8 *Nephritis, nephrotic syndrome, and nephrosis: 50,476
9 *Influenza and Pneumonia: 50,097
10 Intentional self-harm (suicide): 38,364
* Diseases directly or indirectly influenced by MetS. Even suicide, which is often associated with depression, could be driven by MetS via inflammation.5
A couple of driving forces behind our descent into a disease-centered culture.
Junk food. Michael Moss’s brilliant article from Sunday’s New York Times Magazine, called: “The Extraordinary Science of Addictive Junk Food” says it better and with greater depth than anything I could say.
“The public and the food companies have known for decades now — or at the very least since this meeting — that sugary, salty, fatty foods are not good for us in the quantities that we consume them. So why are the diabetes and obesity and hypertension numbers still spiraling out of control? It’s not just a matter of poor willpower on the part of the consumer and a give-the-people-what-they-want attitude on the part of the food manufacturers. What I found, over four years of research and reporting, was a conscious effort — taking place in labs and marketing meetings and grocery-store aisles — to get people hooked on foods that are convenient and inexpensive.”
Pesticides. Other potent and often overlooked drivers of MetS and obesity are the pesticides on our foods.
A little-acknowledged study by Lee that was released in 2006 (using National Institute of Health data) noted that exposure to six pesticides (called POPs -- persistent organic pollutants) resulted in up to a 38-fold risk for developing type II diabetes in certain individuals!6 (Where’s the publicity on this study?) By comparison, a study looking at women smokers with a 40-year history found “a mere” 27-fold increased risk for developing lung cancer.7
Obese people were particularly vulnerable to the effects of POPs. POPs are known to accumulate in adipose and cause massive, metabolic disruption.
It’s not just about eating JUNK. It’s the TOXIC JUNK that’s particularly horrific.
The do-able solutions? Here’s a few. Pick a couple:
● Plant a garden and don’t use pesticides. (even a little garden pot on the porch with a few basils and tomatoes- you’ll love it!)
● Buy local food. Where is your farmers market?
● Exercise. (My goal: Commuting by bike to work 3 days a week).
● Stop most sugar, and especially the processed stuff
● Buy food from the perimeter of the grocery store- fresh veggies and fruits; lean, clean proteins
● Don’t buy food with chemical names in the ingredient list
● Eat more greens, beans, lean poultry.
● Read Mark Hyman’s “Blood Sugar Solution.”
When I was in medical school, a professor told us that sugar was a drug, and should be regulated as such. Her statement was an awakening for me. It was a radical idea at the time, but the time has come, hasn’t it?
1. Gray LJ, Khunti K, Williams S, et al. Let's prevent diabetes: study protocol for a cluster randomised controlled trial of an educational intervention in a multi-ethnic UK population with screen detected impaired glucose regulation. Cardiovasc Diabetol. 2012;11:56.
2. Hoogwerf BJ, Sprecher DL, Pearce GL, et al. Blood glucose concentrations < or = 125 mg/dl and coronary heart disease risk. Am J Cardiol. Mar 1 2002;89(5):596-599.
3. Centers for Disease Control and Prevention. Atlanta GUSDoHaHS, Centers for Disease Control and Prevention, 2011. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. 2011.
4. MMWR. Increasing Prevalence of Diagnosed Diabetes - United States and Puerto Rico, 1995-2010. November 16, 2012 / 61(45);918-921.
5. Silic A, Karlovic D, Serretti A. Increased inflammation and lower platelet 5-HT in depression with metabolic syndrome. J Affect Disord. Dec 1 2012;141(1):72-78.
6. Lee DH, Lee IK, Song K, et al. A strong dose-response relation between serum concentrations of persistent organic pollutants and diabetes: results from the National Health and Examination Survey 1999-2002. Diabetes Care. Jul 2006;29(7):1638-1644.
7. Kligerman S, White C. Epidemiology of lung cancer in women: risk factors, survival, and screening. AJR Am J Roentgenol. Feb 2011;196(2):287-295.
OMG, I have the flu!!
“The flu vaccine is the best way to protect against flu.” Nancy Cox, PhD, Center for Disease Control Influenza Division chief.5 
For the Twelve Days of Christmas My True Love Challenged the Conclusion of the 2012 JAMA Meta-Analysis, Which Implied That Omega 3 Fish Oil was Basically Useless
On the first day of Christmas, my true love pondered...
Of all the supplements out there, fish oils are one of the best accepted and most widely used because the research on it is so plentiful and compelling. Modern man has flipped the intake of “good” anti-inflammatory omega 3 fatty acids with “bad” pro-inflammatory omega 6 fatty acids, not unlike how we’ve negatively flipped intake of potassium and sodium. (We’re the only mammals to accomplish this feat!) In 2009 Harvard School of Public Health estimated that omega 3 deficiency contributed to 84,000 US deaths per year!1 And interestingly, according to CDC/NHANES data, those most likely to be severely deficient are heart failure patients!
And on the seventh day of Christmas, my true love mentioned that it is also interesting that the P value used in the meta-analysis was set at an inexplicably low 0.0063. (This basically means it’s needle-in-the-haystack hard for this study to have achieved significance. Generally, p-values are 0.05, which is a whole order of magnitude higher!) As the National Lipid Association pointed out, “There really isn’t a good discussion as to why the authors made this choice, which makes accepting the conclusions difficult.” The Weight Loss Miracle?
I was reading an enewsletter on weight loss recently. They were recommending a very sexy-sounding supplement that suggested the pounds would melt away like bacon fat in a hot skillet. I looked at the ingredients -- most were old favorites that are found in most weight loss blends from time immemorial. In general, we know these products have very limited efficacy (unless appropriately prescribed, more on that in a second); but sales are huge for them, given the promise of rapid weight loss.
I remember thinking that every single person in the testimonial group who needed to lose weight did so. And the weight loss wasn’t a central focus of our work together for any of them, rather it was a byproduct of the restoration of health.
Photo credits: Flickr.com: Noodles and Beef, jackiebese
Cesium: Coming to a fish near you?
As with most patients, I wanted to take a look at JT’s potential toxin exposures. The flag for me with JT was the fact that she relied heavily on sushi for her protein.
If not careful, we can exceed the EPA limit for mercury exposure with the intake of certain fish.
Naked Mole Rat, You’re My Detox Hero!
There’s no disputing these guys are homely at best, hideous at worst. They’re wrinkled, beady-eyed, hairless (except for whiskers), subterranean rodents with massive protruding front teeth. When one was spotted in Africa in 1842 by German naturalist, Eduard Ruppell, he mistakenly described it as diseased. Poor little NMR! 
A farm-raised tale about farm-raised salmon
I was at Whole Foods Market (WFM) last night. It was the grand-opening day. Kind of embarrassing to admit such a thing would get me going, but it did. Finally, one opened in Connecticut near enough to me where it might actually be a realistic shopping option.
- Antibiotics, parasiticides, hormones, and genetically modified organisms (GMOs), are prohibited in feed.
- Stringent water and food quality guidelines.
- All farmed salmon must contain at least 1,820 mg of combined EPA and DHA per eight ounce piece of uncooked salmon.
- Maximum allowable contaminant levels (including PCBs and mercury) are set by WHO--2.16pg/g TEQ (toxic equivalent). The above figure shows suggests some farm-raised salmon clocks in up to 55pg/g.