The Perils of Potassium, part 2.

A while back I wrote a blog post on the perils of potassium.  At the time, my blood had been tested in the office of my family doctor and my potassium reading was 5.1 which is about .1 above the highest end of the range.  The doctor was concerned about this and I remember she instructed me to stop eating things like bananas, avocados, and potatoes.
 
At the time it seemed like a simple thing to do in order to get the reading back to the normal range.  Thankfully the next reading 2 weeks later was back in the normal range at the high end.   I was able to reduce the level by cutting the consumption of the food items the doctor warned me about.  I only had a banana several times a week, and they were smaller bananas.  As for things like potatoes and avocados, while I did not totally cut them out, I definitely made sure they were rare items in my diet.  This approach seemed to keep my potassium in check.

But at about the same time, I also remembered an earlier episode in 2016 when my potassium level had been much more elevated – to 5.5.  When this occurred, one of the nurses in the heart failure doctor’s office called to alert me to the abnormal result.  My doctor was out of the office at the time.  But his colleague suggested that I reduce my dose of a drug known as spironolactone (brand name aldactone) . This is because spironolactone is referred to as a “potassium sparing” diuretic.  This drug is also used to treat low potassium levels and conditions in which the body is making too much of a natural chemical known as aldosterone.  Of course we had clearly established that a shortage of potassium was not my issue, so cutting the dose back some was appropriate.  As a heart failure patient, I needed some spironolactone so I could not eliminate it from my medication list

Just to recap for those who have not seen the prior post or forgot it, what follows is the reason I needed to cut back and why potassium consumption monitoring is so important.  According to the Harvard Health website, the mineral potassium helps control the electrical balance of your heart as well as metabolize carbohydrates and build muscle.  As you may recall, my heart failure began with an issue with the electrical side of my heart.  It turns out that both low and high potassium are issues – with low potassium levels causing heart rhythm disturbances, while high potassium causes dangerous heartbeat irregularities and even sudden death.  Obviously none of these results, especially sudden death, is a good thing.

When my family doctor raised the concern about potassium, it made sense for me to also get some guidance from a nutritionist who worked at the heart failure doctor’s office.  I set up an appointment, and she schooled me on the ins and outs of potassium consumption.  She gave me some handouts with potassium amounts listed for vegetables and fruits, which all contain some level of potassium.  I used them to guide me in reducing my potassium level got to the point that I hoped it would never be over the acceptable range again.

But then this year the shark appeared again.  In the beginning of January I had a blood test at the heart failure doctor's office.  The lab results came back with a potassium level of 5.4!  The first thing the nurse wanted to know was what was I eating that was different.  Being Melanie, I just got this really shocked look on my face and probably started to stutter.  You see I was perplexed, even frustrated, because I am the most predictable person in the world with the  most predictable diet.  I had not changed anything in the last  few years, except maybe adding some bran cereal.  I was eating the same things.  The nurse rattled off a few of the foods that I already knew were triggers, like avocados and bananas.  I eat avocados rarely and I found it hard to believe that the sole trigger was something like a small banana that I didn't eat every day.  So I told her I thought I needed another consultation with the nutritionist.  Plus we both agreed I needed to do another blood test in about a week.

I hung up the phone feeling defeated.  Yet again, my body needed to get with the heart failure program and stop working against me.  Whatever it was doing to upset the potassium applecart, it needed to stop!  So I went to my desk drawer and started to search for  my potassium handouts.  But then I also had a thought strike me like lightning.  I was on new heart failure drug Entresto.  I had been on it for over a month, and I was doing well enough that the doctor and I had just agreed that I should increase the dosage.  But I had this gnawing feeling that Entresto might impact one’s potassium level. 

So I pulled out the file of information that I have received from the Entresto Central Support Program.  And there it was – a statement on side effects that included:  “Increased amount of potassium in your blood.  Your doctor will check your potassium level during your treatment with Entresto.”  Yep – there definitely had been an increase.  I started to get nervous because this was the night I was to begin the increased dose.  But it made sense to me to hold off on this until I checked with the nurse/doctor about the plan to increase and make sure it was still a go.

I e-mailed the nurse with my question the next morning.  She confirmed that the doctor wanted me to go ahead and increase the dose of Entresto.  I was happy about this, because I see Entresto as the best shot to proactively manage my  heart failure.  But I also realized that given the potential of increased potassium retention, I needed to really revamp my diet.  I set to work and encountered a number of obstsacles.  Happily, I found an ally in the nutritionist.

Here are some of the things that are frustrating about potassium – other than the fact that high amounts exist in some of my favorite foods.  At first blush, it looks like potassium would be no problem to control, as the recommended daily allowance is anywhere from a range of 3600 to 4700 milligrams (depending on your source).  However, if you have one banana, that is a 10th or more of your allowance already.  Have one baked potato and it is over 900 milligrams – a significant slice of your daily allowance.

It is hard for me to figure out portion sizes for my favorite vegetables.  For example, the instructions are things like 1 cup of raw broccoli or raw cauliflower.  Think about your typical broccoli and cauliflower florets, and now you have to try to easily fit them into a 1 cup measuring cup.  Are you supposed to take off the stem part of the floret?   The potassium allowance for a cup is about 150 milligrams, so even though these two vegetables are lower in potassium, it can start to add up depending on how much you eat.  I also have seen information on various websites that seem to indicate that boiled veggies have less milligrams than raw.

How could this be?  Well nutrition websites told me that the water in the boiling process leaches the nutrient potassium out of the vegetable.  Additionally, I learned that steaming vegetables actually makes the potassium content higher.  That made no sense to me that boiling reduced it but steaming added to it.  But the same nutrition websites said that the steaming process enhances nutrients like potassium.  This was a real bummer because I steamed all of my vegetables.  It is no longer my preferred method of preparation.

I started to notice that grapes and plums were decent choices, between 115 and 140 milligrams per serving.  But raisins and prunes were high potassium fruits.  Tomatoes are not the best choice, especially if you are dealing with the sun-dried variety.  Also, you are much better off with fresh green beans than dried beans.  It appears that the process of drying out the fruit or vegetable is the culprit, plus the fact that you  just eat more raisins, prunes and sun-dried tomatoes per serving than you do fresh grapes, plums and tomatoes.

I also find some of the health benefits of certain foods defeat the goal of a low potassium diet.  For example, for years I have been encouraged to eat brown rice, whole wheat and whole grain breads over white rice and white bread, and to prefer bran and oat and whole wheat cereals.  Now I am being told I need to be careful with those “healthy” foods because they have more potassium.  I love quinoa and some of the newer grains, but am better off with white rice and couscous when it comes to the potassium hit.

The nutritionist and I had a number of chats.  We talked about the very delicate balance that needs to be maintained between sodium, potassium and fluids, and she sent me some articles at my request so I could become more at ease with this balance.  She also went over a typical day of eating with me, and made some suggestions that might facilitate that sodium and potassium balance.  She also encouraged my habit of reading food labels diligently.

But it was at the door of the food label where I almost met my match.  I was stunned to find that potassium does not appear on many labels.  I thought at first that maybe it just meant that there was no potassium in the product.  But I began to find this hard to believe if the product contained a fruit or vegetable that I knew was a source of potassium.  After doing some research, I found out that the Food and Drug Administration had issued a new Nutrition Facts label for package foods.  The intent is to make it easier for the consumer to make informed food choices. 

So you’re asking me what the problem is.  Well it is this:  The change was announced by the FDA on May 2, 2016 (yes, really that long ago).  In the Q&A section of the relevant guidance, included the following exchange:

• Why are vitamin D and potassium being added to the Nutrition Facts label?  Vitamin D and potassium are nutrients Americans don’t always get enough of, according to nationwide food consumption surveys  *** and when lacking, are associated with increased risk of chronic disease. 

It would have been nice if the guidance had recognized that some of us poor schmucks actually get too much of potassium.  But why quibble when at least the requirement to report potassium is there?  Actually that is just a small quibble when it comes to the immediate impact of the guidance.  Or maybe I should say lack of immediate impact of the guidance.  By this I mean that the FDA has issued a ton of documents on nutrition labeling, and if I follow the documents correctly, the initial change to the labels was issued in May 2016.  The compliance date for the change was set for July 26, 2018, with an additional year to comply for manufacturers with annual food sales of less than $10 million.

However, the FDA says that after those rules were finalized, industry and consumer groups provided the FDA with feedback regarding the compliance dates. As a result, the FDA provided manufacturers covered by the rule with necessary guidance to help them complete and print updated nutrition facts panels for their products before they were expected to be in compliance. 

In other words, new dates for compliance were set.  So what are those new dates?  January 1, 2020, for manufacturers with $10 million or more in annual food sales. And until January 1, 2021 for manufacturers with less than $10 million in annual food sales.  I don’t know what the consumer group feedback was, and whether it was for extending the time frame.  I would think that the most important consideration should have been to get correct information out as soon as possible.  But maybe there is something I am missing.

I have found that some manufacturers have moved forward and have potassium listed on their labels.  And some may not have it on their labels but you can find it on their websites.  But I do have a caveat.  Even in some cases where there is package labeling that contains potassium, it might just have a percentage rather than the level of milligrams.  I mean, who has the time or the patience to do the math from percentages to milligrams when you’re standing in the grocery store aisle.  Or you might find that a manufacturer lists 0% on the box label, but may put 80 milligrams on the individual product label inside the box.  I don’t know about you, but I fail to see how something can have 0% when there are actually milligrams in the product.  I mean when you have been placed on a low anything diet, milligrams (or whatever the relevant measurement is) add up.

With a lot of frustration, I was able to get the potassium down to somewhere in the middle part of the standard range.  My goal now is to keep the number consistent.  The nutritionist says that 2,300 mg of potassium a day is a good target for me.  This means I am tracking everything I eat carefully for sodium and potassium using a handy app that my nutritionist suggested.  This means that for the time being, I will stay away from products where the manufacturer either doesn’t have the potassium information on the label or on a website.  Sorry manufacturer who needs more time to comply, but this is something I have to get under control NOW and so I need the clearest information I can find.

​The bottom line for me is that I need to convert potassium from a peril and make it nothing more than a pesky but necessary fact of my life.