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WHO| Guideline Potassium intake for adults and childreni

Guideline:

Potassium intakefor adults andchildren


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WHO| Guideline Potassium intake for adults and childrenII

WHO Library Cataloguing-in-Publication Data

Guideline 1: Potassium intake or adults and children.

1.Potassium. 2.Potassium de ciency prevention and control. 3.Chronic disease prevention and control.4.Guideline. I.World Health Organization.

ISBN 978 92 4 150482 9 (NLM classi cation: WD 105)

World Health Organization, 2012

All rights reserved. Publications o the World Health Organization are available on the WHO web site

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The designations employed and the presentation o the material in this publication do not imply theexpression o any opinion whatsoever on the part o the World Health Organization concerning thelegal status o any country, territory, city or area or o its authorities, or concerning the delimitation o itsfrontiers or boundaries. Dotted lines on maps represent approximate border lines for which there maynot yet be ull agreement.

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All reasonable precautions have been taken by the World Health Organization to veri y the in ormationcontained in this publication. However, the published material is being distributed without warranty o any kind, either expressed or implied. The responsibility or the interpretation and use o the material lieswith the reader. In no event shall the World Health Organization be liable or damages arising rom its use.

Design and layout: Alberto MarchPrinted by the WHO Document Production Services, Geneva, Switzerland

WHO.Guideline: Potassium intake for adults and children.Geneva, World Health Organization (WHO), 2012.

1 This publication is a World Health Organization (WHO) guideline. A WHO guideline is any document, whateverits title, containing WHO recommendations about health interventions, whether they be clinical, public health orpolicy interventions. A recommendation provides in ormation about what policy-makers, health-care providers orpatients should do. It implies a choice between diferent interventions that have an impact on health and that haverami cations or the use o resources. All publications containing WHO recommendations are approved by the WHOGuidelines Review Committee.

Suggested citation
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WHO| Guideline Potassium intake for adults and childrenIII

Contents Acknowledgements V

Abbreviations and acronyms VI

Executive summary 1

Introduction 4

Scope and purpose 4

Background 4

Justi cation 6

Guideline development process 7

Advisory groups 7 Advisory guideline group 7

Panel 7

Scoping o the guideline, evidence appraisal and decision-making 8

Management o con icts o interest 9

Summary o evidence 10

Evidence base 10

Adults 10

Blood pressure in adults 10

All-cause mortality, cardiovascular disease, stroke,

and coronary heart disease in adult s 11

Potential adverse efects in adults 12

Children 13

Blood pressure in children 13

Final considerations o the evidence 14

Recommendations and remarks 16

Recommendations 16

Remarks 16

Translation and implementation 18

Research gaps and uture initiatives 18

Implications or uture research 18

Dissemination 18

Updating the guideline 19


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WHO| Guideline Potassium intake for adults and childrenIV

Annex 1 GRADE summary o ndings tables 20Annex 2 Examples o oods that contain potassium, and their approximate

potassium content 23

Annex 3 WHO Secretariat 24

Annex 4 Members o the WHO Steering Committee or Nutrition

Guideline Development 2010 - 2011 25

Annex 5 Members o the NUGAG Subgroup on Diet and Health and external

resource persons 2010 - 2011 26Annex 6 External Expert and Stakeholder Panel 28

Annex 7 Priority questions in the ormat o population, intervention, control

and outcomes (PICO) 31

Annex 8 Summary o considerations or determining the strength o

the recommendations 33

Annex 9 Management o con ict o interest 35

Re erences 39


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WHO| Guideline Potassium intake for adults and childrenV

This guideline was coordinated by Dr Nancy Aburto under the supervision o Dr ChizuruNishida. The World Health Organization (WHO) grate ully acknowledges the technicalinput and expert advice provided by the members o the WHO Nutrition GuidanceExpert Advisory Group Subgroup on Diet and Health, and by the external experts andresource persons involved in the development o this guideline.

Thanks are due to the members o the WHO Steering Committee or NutritionGuidelines Development, and the sta o the WHO Guidelines Review CommitteeSecretariat or their support and guidance throughout the process. We also expressour deep appreciation o Mr Issa Matta rom the WHO Ofce o the Legal Counsel

or his support and valuable guidance in the management o the con icts o interestprocedures. Special acknowledgement is made to Ms Emma Kennedy rom the NutritionPolicy and Scienti c Advice Unit, Department o Nutrition or Health and Development,

or providing administrative and logistic support. Special thanks are given also to HialyGuiterrez, Sara Hanson and Anna Ziolkovska or their work on data collection andextraction or the systematic reviews that in ormed this guideline.

Acknowledgement is also made to Dr Hilary Cadman rom Cadman Editing Servicesin Australia or technical editing o this guideline and Mr Alberto March rom Gra macInc in USA or the cover design and layout.

WHO expresses special appreciation to the Ministry o Health, Labour and Wel are o the Government o Japan, the Korea Food and Drug Administration, the Korea HealthIndustry Development Institute, and the International Kidney Evaluation AssociationJapan or providing nancial support or this work.

Technical support

Financial support

Acknowledgements


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WHO| Guideline Potassium intake for adults and childrenVI

Abbreviations and acronyms

AUB American University o Beirut

CDC Centers or Disease Control and Prevention

CI con dence interval

FAO Food and Agriculture Organization o the United Nations

FSANZ Food Standards Australia New Zealand

GRADE Grading o Recommendations Assessment,

Development and Evaluation

HDL high-density lipoprotein

IAEA International Atomic Energy Agency

KFDA Korea Food and Drug Administration

KHIDI Korea Health Industry Development Institute

LDL low-density lipoprotein

MD mean di erence

NCD noncommunicable disease

NUGAG Nutrition Guidance Expert Advisory Group

NZFSA New Zealand Food Sa ety Academy

PICO population, intervention, control and outcomes

RCT randomized-controlled trial

RR risk ratio

UN United Nations

UNU United Nations University

USA United States o America

WASH World Action on Salt and Health

WHO World Health Organization

Symbols> greater than

< less than

equal to or greater than

equal to or less than


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WHO| Guideline Potassium intake for adults and children1

Noncommunicable diseases (NCDs) are the main contributor to mortality and morbidityglobally ( 1, 2), and interventions to reduce the burden o NCDs are valuable. Lowpotassium intake has been associated with a number o NCDs, including hypertension,cardiovascular disease, chronic kidney stone ormation and low bone-mineraldensity. An increased potassium intake may reduce blood pressure, decrease risk o cardiovascular disease, have bene cial e ects on bone-mineral density, and mitigatethe negative consequences o high sodium consumption ( 3-5).

The World Health Organization (WHO) currently does not have a recommendationor potassium intake. However, interest in potassium intake and its potential use

in public health is growing, due to the increasing burden o NCDs, and the need or

well-understood, cost-e ective and easible interventions to combat NCDs. There ore,Member States and the Codex Committee on Nutrition and Food or Special DietaryUses requested WHO to develop a guideline on potassium intake or adults and children,to in orm the development o public health nutrition programmes and policies aimedat reducing the risk o NCDs.

The objective o this guideline is to provide recommendations on the consumptiono potassium to reduce NCDs in adults and children. The recommendations givenhere can be used by those developing programmes and policies to assess currentpotassium intake levels relative to a benchmark. I necessary, the recommendationscan also be used to develop measures to increase potassium intake, through publichealth interventions such as ood and product labelling, consumer education, and theestablishment o ood-based dietary guidelines.

WHO developed the present evidence-in ormed guideline using the proceduresoutlined in the WHO Handbook or guideline development (6). The steps in this processincluded:

identi cation of priority questions and outcomes;

retrieval o the evidence;

assessment and synthesis of the evidence;

formulation of recommendations;

identi cation of research gaps;

planning for dissemination, implementation, impact evaluation and updatingo the guideline.

Background

Objective

Methods

Executive summary
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The evidence

Recommendations

The Grading o Recommendations Assessment, Development and Evaluation ( GRADE)methodology ( 7 ) was ollowed to prepare evidence pro les related to preselectedtopics, based on up-to-date systematic reviews o the scienti c literature. Aninternational, multidisciplinary group o experts participated in three WHO technicalconsultations. The rst was held in Geneva, Switzerland on 1418 March 2011; thesecond in Seoul, the Republic o Korea on 29 November to 2 December 2011; and thethird in Geneva, Switzerland on 2730 March 2012. At these meetings, the group o experts reviewed and discussed the evidence, dra ted recommendations, and reachedconsensus on the strength o each recommendation. In determining the strength o therecommendations, they took into consideration the desirable and undesirable e ectso the recommendation, the quality o the available evidence, values and pre erencesrelated to the recommendation in di erent settings, and the cost o options availableto public health ofcials and programme managers in di erent settings. All guidelinegroup members completed a declaration o interests orm be ore each meeting. AnExternal Expert and Stakeholder Panel was involved throughout the process.

Increased potassium intake reduced systolic and diastolic blood pressure in adults.Across a wide range o baseline intakes, increasing potassium intake was bene cial interms o blood pressure. The largest reduction in blood pressure was detected when thepotassium intake was increased to 90120 mmol/day, although potassium increasesreaching other levels o intake also reduced blood pressure. Increased potassium intakehad no signi cant adverse e ect on blood lipids, catecholamine levels or renal unction

in adults. In children, increased potassium intake reduced systolic blood pressureby a small, non-signi cant amount. Higher potassium intake was associated with areduced risk o incident stroke. There was no signi cant association between potassiumintake and incident cardiovascular disease or coronary heart disease. However, thestrong positive relationship between blood pressure and cardiovascular disease, andbetween blood pressure and coronary heart disease, provides indirect evidence thatincreasing potassium intake can improve these outcomes through a bene cial e ecton blood pressure. Based on the entire body o evidence, WHO generated the ollowingrecommendations or potassium intake in adults and children.

WHO recommends an increase in potassium intake from food to reduce bloodpressure and risk o cardiovascular disease, stroke and coronary heart disease inadults ( strong recommendation 1 ). WHO suggests a potassium intake o at least90 mmol/day (3510 mg/day) or adults ( conditional recommendation 2 ).

WHO suggests an increase in potassium intake from food to control3 bloodpressure in children ( conditional recommendation ). The recommendedpotassium intake o at least 90 mmol/day should be adjusted downward orchildren, based on the energy requirements o children relative to those o adults.

1 A strong recommendation is one or which the guideline development group is con dent that the desirable e ects o adherence outweigh the undesirable e ects.2 A conditional recommendation is one or which the guideline development group concludes that the desirablee ects o adherence probably outweigh the undesirable e ects, but the group is not con dent about the trade-o .3 Control or this recommendation re ers to the prevention o a deleterious rise in blood pressure with age.
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These recommendations complement the WHO guideline on sodium intake. They shouldbe used in conjunction with that and other nutrient guidelines and recommendations,to guide development o public health nutrition programmes and policies. Addressingthe optimal ratio o intake o sodium to potassium was outside the scope o thisguideline; however, i an individual consumes sodium at the levels recommended inthe WHO guideline on sodium intake, and potassium as recommended in the currentguideline, the ratio o sodium to potassium would be approximately one to one, whichis considered bene cial or health ( 8). However, most populations around the worldconsume less than the recommended levels o potassium ( 9, 10), and consume a ratio o sodium to potassium o two to one or more ( 11). The success ul implementation o theserecommendations would have an important public health impact through reductionsin morbidity and mortality, improvement in the quality o li e or millions o people, andsubstantial reductions in health-care costs ( 2, 12, 13).


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The objective o this guideline is to provide recommendations on the consumption o potassium or adults and children. It is important to establish nutrient guidelines so thatnutrition interventions can be developed in a logical, systematic, and scienti c mannertaking into account the best available evidence. The recommendations in this guidelinecan be used by programme and policy planners to assess current potassium intake levelsrelative to a benchmark and develop measures to increase potassium intake, wherenecessary, through public health interventions including, but not limited to, ood andproduct labelling, consumer education, and the establishment o Food-Based DietaryGuidelines (FBDG). This guideline does not provide guidance on speci c ood intakebecause such dietary guidelines should be based on the overall dietary goals, which

take into consideration all required nutrients. It should be used in conjunction withthe guideline on sodium intake and other nutrient guidelines to guide public healthnutrition programme and policy development.

This guideline provides a global, evidence-in ormed recommendation on potassiumintake or:

adults (16 years of age) for the reduction of blood pressure and risk ofcardiovascular disease, stroke and coronary heart disease;

children (215 years of age) for the control o blood pressure.

It does not provide recommendations or individuals with impaired urinary potassiumexcretion rom a medical condition or drug therapy.

The guideline will help Member States and their partners to make in ormed decisionson appropriate nutrition actions to reduce noncommunicable diseases (NCDs). It is intended

or a wide audience, including policy-makers and their expert advisers, and technical andprogramme sta in organizations involved in the design, implementation and scaling-up o nutrition actions or public health.

This document presents the key recommendations and a summary o the supportingevidence. Further details o the evidence base are provided in Annex 1 and other documentslisted in the re erences.

NCDs are the leading cause o death globally, killing more people each year than allother causes combined ( 14). The major NCDs currently account or approximately 60%o all deaths and 43% o disease burden globally, and these levels are expected tocontinue to rise ( 2, 15). In 2008, 29 million NCD-related deaths (almost 80%) occurred inlow and middle-income countries. In those countries, 29% o NCD-related deaths werein people under 60 years o age; in contrast, in high-income countries, only 13% o theNCD-related deaths were premature. In 2005, cardiovascular disease alone accounted

or 30% o all deaths; the equivalent o in ectious disease, nutritional de ciency, andmaternal and perinatal conditions combined ( 2).

Background

Scope and purpose

Introduction


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Hypertension is considered a major risk actor or cardiovascular diseases, particularly

coronary heart disease and stroke. Suboptimal systolic blood pressure (>115 mmHg) isestimated to contribute to 49% o all coronary heart disease and 62% o all stroke ( 12). Thus,the burden o morbidity and mortality rom hypertension and related NCDs is currently oneo the most urgent public health problems globally. Although NCDs disproportionatelya ect adults, they and their risk actors are now being detected more requently in paediatricpopulations. Diet-related NCDs are chronic, and take years or decades to mani est; delayingthe onset o these diseases could improve lives and result in substantial cost savings ( 13).Blood pressure during childhood has a signi cant association with blood pressure duringadulthood, meaning that children with increased blood pressure are at high risk orhypertension and its related morbidities as adults ( 16). Additionally, elevated blood pressurein childhood contributes to cardiovascular disease pathology during childhood itsel ( 17 ).

Thus, addressing during childhood the problem o elevated blood pressure and other risk actors or NCDs that could mani est later in li e is crucial to combat NCDs.

Potassium is an essential nutrient needed or maintenance o total body uidvolume, acid and electrolyte balance, and normal cell unction ( 18). Normally, mostingested potassium is excreted via the urine. Under conditions o extreme heat andintense physical activity that result in a high sweat production, potassium lossesin sweat are increased and appreciable. However, acclimation occurs rapidly, andpotassium losses via sweat are reduced quickly. Thus, most individuals can replaceneeded potassium through ood consumption without the need or supplements orspecially ormulated products ( 19-21). Potassium is commonly ound in a variety o unre ned oods, especially ruits and vegetables. Food processing reduces the amount

o potassium in many ood products, and a diet high in processed oods and low inresh ruits and vegetables is o ten lacking in potassium ( 22). Data rom around the

world suggest that the population average potassium consumption in many countriesis below 7080mmol/day, the value recommended by the 2002 Joint World HealthOrganization/Food and Agriculture Organization o the United Nations (WHO/FAO)Expert Consultation ( 8). Few countries report an average consumption o 90 mmol/day, which is recommended in countries such as Belgium, Mexico, Spain and the UnitedKingdom o Great Britain and Northern Ireland ( 23-26). No countries report an averagepopulation consumption o 120 mmol/day, which is recommended in countries such asBulgaria, Canada, the Republic o Korea and the United States o America (USA) ( 9, 10,27-29). Women consistently have lower levels o potassium intake than men, but both

groups commonly consume a level that is below current recommendations.Reduced potassium consumption has been associated with hypertension and

cardiovascular diseases, and appropriate consumption levels could be protectiveagainst these conditions ( 8). A recent meta-analysis including 11 cohort studies reportedan inverse association between potassium intake and risk o stroke ( 30). Additionally,two meta-analyses o trials comparing increased potassium to lower potassium intake

ound that increased potassium intake lowers blood pressure ( 4, 31). These results wereurther supported by a systematic review without a meta-analysis, which concluded

that increased potassium intake results in decreased blood pressure in adults ( 3). Thus,a public health intervention aimed at increasing potassium intake rom ood could be acost-e ective strategy to reduce the burden o NCD morbidity and mortality. Moreover,

increasing potassium consumption rom ood in the population is sa e; in individualswithout renal impairment caused by medical conditions or drug therapy, the body isable to efciently adapt and excrete excess potassium via the urine when consumption


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exceeds needs ( 18, 32, 33). Intervention trials including potassium consumption as highas 400 mmol/day rom ood or several weeks and 115 mmol/day or up to a year havenot reported any adverse e ects ( 32, 33). There have been some isolated reports o acute toxicity rom extremely high potassium intake in supplement orm ( 34), but noreports o toxicity o potassium rom consumption in ood.

The unction o potassium in the body is closely related to that o sodium (18,35). As sodium consumption rises, increased consumption o potassium may beeven more bene icial because, in addition to other bene its, it can mitigate thenegative e ects o elevated sodium consumption on blood pressure (4). Somestudies have reported that the ratio o the two nutrients is an important actor incardiovascular disease and mortality (36, 37). Additionally, there is evidence romrandomized controlled trials (RCTs) that a combination o increased potassium anddecreased sodium intake can be e ective in reducing blood pressure, cardiovascularmortality and medical expenses (38, 39).

Much o the human and social impact caused each year by NCD-related morbidityand mortality could be averted through interventions that are well understood, coste ective and easible ( 14). As explained above, there is no evidence o adverse e ects

rom increased potassium intake rom oods in individuals with unimpaired potassiumexcretion, and increased potassium intake has been associated with reduced bloodpressure and cardiovascular disease outcomes in cohort and intervention trials.

Hence, intervening to increase dietary potassium consumption could make a positivechange to blood pressure and cardiovascular outcomes. Most populations aroundthe world consume sodium at levels ar exceeding physiological needs and currentrecommendations ( 40); there ore, public health interventions to combat NCDs and theirrisk actors should be in ormed by guidance on potassium consumption, combinedwith reduced sodium consumption. Although the evidence or the sa ety o potassiumintake rom ood is not disputed, there are some inconsistencies in the literatureabout the potential bene cial e ect o increased potassium on blood pressure andcardiovascular outcomes. One meta-analysis o studies o individuals with hypertensionreported no signi cant e ect o increased potassium intake on blood pressure ( 41). There ore, a systematic evaluation o all available epidemiological evidence to in ormthe generation o this guideline was warranted.

Considering this background, the 32nd Session o the Codex Committee onNutrition and Food or Special Dietary Uses (held in Santiago, the Republic o Chile on15 November 2010) made a special request to WHO to consider establishing a guideline

or daily potassium intake or adults and children. Member States also requestedWHO to develop a guideline on potassium intake to in orm public policy. There ore,the WHO Department o Nutrition or Health and Development, in collaboration withother departments o WHO Headquarters and regional ofces, developed the ollowingguideline on potassium consumption or adults and children.

Justi cation


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1

The Department o Research Policy and Cooperation has since been reorganized and the nutrition guidelinedevelopment work is being carried out in close collaboration with the Department o Knowledge Management andSharing.

Guideline development process

This guideline was developed in accordance with the WHO evidence-in ormed guidelinedevelopment procedures outlined in the WHO Handbook or guideline development (6).

Development o this guideline was undertaken by the WHO Department o Nutrition orHealth and Development, in partnership with the Department o Research Policy andCooperation 1, and members o the WHO Secretariat (Annex 3). The work was guided bythe WHO Steering Committee or Nutrition Guideline Development (Annex 4), which alsoprovided overall supervision o the guideline development process. The WHO Secretariatand the Steering Committee included representatives rom all departments o WHO

with an interest in the provision o scienti c advice on nutrition. Two additional groupswere ormed: an advisory guideline group and an external expert and stakeholderpanel, as outlined below.

Advisory guideline group

The WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Dietand Health was convened to support the development o this guideline (Annex 5). This group included experts who had previously participated in various WHO expertadvisory panels, and others identi ed through open calls or specialists. In orming thisgroup, WHO took into consideration the need or a balanced gender mix, expertise rommultiple disciplinary areas and representation rom all WHO regions. E orts were made

to include subject-matter experts; statistical, systematic review, programme evaluationand Grading o Recommendations Assessment, Development and Evaluation (GRADE)methodologists; and representatives o potential stakeholder groups (e.g. programmemanagers and other pro essionals involved in the health-care process). There were norepresentatives o commercial organizations, because such individuals are prohibited

rom being members o any WHO guideline group. External resource persons (includingsubject matter experts, and systematic review and GRADE methodologists) were invitedto the NUGAG meetings as observers to provide technical input. These individuals didnot participate in the decision-making processes. NUGAGs role was to advise WHO onthe choice o outcomes important or decision-making and on the interpretation o theevidence.

Panel

The External Expert and Stakeholder Panel was ormed during the planning stages o guideline development. The panel was consulted on the scope o the guideline, and onthe speci c research questions to be addressed and outcomes to be investigated in thesystematic reviews o the literature. The panel was later asked to review and provide

eedback on the completed dra t guideline (Annex 6). During the consultations on boththe scoping o the guideline and the dra t guideline documents, there was an open call

Advisory groups
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or all interested parties to join the External Expert and Stakeholder Panel. The panelcomprises individuals who responded to direct solicitation or contribution based ontheir known expertise and interest in the subject matter, or to the WHO open call orpublic comment executed through the electronic mailing lists o the WHO Departmento Nutrition or Health and Development and that o the Codex AlimentariusCommissioin, and through the posting o the call or public comment on the WHO andUnited Nations (UN) Standing Committee o Nutrition websites.

WHO developed an initial set o questions to be addressed in the guideline. Thesedra t questions were based on the needs o Member States and international partners

or policy and programme guidance. They were also in uenced by the request o theCodex Committee o Nutrition and Foods or Special Dietary Uses. The population,intervention, control and outcomes (PICO) ormat was used in generating the questions(Annex 7). The PICO questions were rst discussed and reviewed by the WHO Secretariatand the WHO Steering Committee or Nutrition Guideline Development, and were thenmade available or public comment rom 1 to 28 February 2011. Feedback was received

rom 16 individuals or organizational stakeholders, and the questions were adaptedaccordingly.

The dra t set o PICO questions was presented to the NUGAG Subgroup on Diet andHealth during its meeting on 1418 March 2011. During that meeting, the guidelinetopic was introduced and the scope o the guideline to be generated was nalized.

The PICO questions were discussed, and outcomes and populations were ranked inimportance by NUGAG members. The prioritization o the PICO questions de ned thescope o the evidence to be used in in orming the guideline development. Subsequentto the meeting, WHO reviewed the scienti c literature and conducted new systematicreviews and meta-analyses to address the PICO questions. WHO was supported in theexecution o these reviews by external experts with subject-matter expertise, andexpertise in systematic reviews and the GRADE methodology.

A ollow-up meeting o the NUGAG Subgroup on Diet and Health was held rom29 November to 2 December 2011. WHO presented the systematic reviews o evidence,and a dra t recommendation that had been prepared be ore the meeting. This dra trecommendation included:

a summary of the evidence from the systematic reviews;

draft GRADE evidence pro les assessing the quality of the body ofevidence;

potential research gaps, concerns and opportunities for feasibleimplementation o the recommendations in diverse cultural contexts;

appropriate references.

The NUGAG Subgroup on Diet and Health discussed the evidence and the GRADEassessment o the quality o evidence, and advised WHO on the interpretation o

Scoping o theguideline, evidence

appraisal anddecision-making


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Management o con icts o interest

the results. The subgroup also discussed the dra t recommendation and, throughconsensus, reached an agreement on that recommendation.

The systematic reviews and the GRADE evidence pro les or each o the criticaloutcomes were used as the evidence base or dra ting the guideline. Classi cation o the strength o each recommendation included consideration o the desirable andundesirable e ects o the recommendation, the overall quality o the evidence, valuesand pre erences related to the recommendation in di erent settings, and the cost o options available to public health authorities in implementing the recommendationin di erent settings (Annex 8). The classi cation was discussed among the NUGAGmembers, invited external resource persons and the members o the WHO Secretariatpresent at the meeting. The nal wording o the recommendations and determinationo their strength were based on the consensus o members o the WHO Secretariatpresent and the NUGAG members only. There were no strong disagreements amongthe NUGAG members.

From 1 to 29 February 2012, a dra t o this guideline was made available or publiccomment. Participants in the External Expert and Stakeholder Panel were consulted,and other interested parties were invited to comment, as outlined above. More than165 comments were received rom 30 individuals and representatives o stakeholdergroups. WHO reviewed the comments and made appropriate updates to the guideline. The guideline was then presented or nalization to the NUGAG Subgroup on Diet andHealth at their meeting on 2730 March 2012. The nalized guideline was submitted orclearance by WHO be ore publication.

According to the rules in the WHO Basic documents (42), all experts participating inWHO meetings must declare any interest relevant to the meeting be ore participating. The declaration o interest orms or all guideline group members were reviewed byWHO when nalizing the composition o the NUGAG Subgroup on Diet and Health.All NUGAG members, external experts and other special invitees participating ineach o the NUGAG meetings submitted a declaration o interests orm, togetherwith their curriculum vitae. In addition, each participant verbally declared interests atthe beginning o each meeting. The procedures or management o interests strictly

ollowed the WHO Guidelines or declaration o interests or WHO experts (43). Thepotential interests declared by members o the NUGAG Subgroup on Diet and Healthand external expert and resource persons are summarized in Annex 9.
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The lower potassium intake level varied among studies and ranged rom 45 to 100 mmol/day, with a median value o 73 mmol/day. The increased potassium intake ranged rom 70to 247 mmol/day, with a median value o 127 mmol/day. There was a median di erence inincreased potassium relative to lower potassium o 57 mmol/day (74%).

The meta-analysis o 21 studies with 21 comparisons ound that increasedpotassium resulted in a decrease in resting systolic blood pressure o 3.49 mmHg(95% con dence interval [CI]: 1.82, 5.15) (quality o evidence high 1) and a decrease inresting diastolic blood pressure o 3.02 mmHg (95%CI: 1.17, 4.86) (quality o evidencehigh). The meta-analysis o our studies with our comparisons reporting ambulatoryblood pressure ound that increased potassium intake decreased ambulatory systolicblood pressure by 3.04 mmHg (95%CI: 0.66, 5.42) (quality o evidence moderate), andambulatory diastolic blood pressure by 1.24 mmHg (95%CI: 0.66, 3.13) (quality o evidence moderate). The ndings demonstrate that across a wide range o baselineintakes, increasing potassium intake is bene cial in terms o blood pressure and theyconcur with three earlier systematic reviews and meta-analyses ( 3, 4, 31), but not with a

ourth (41).

The results suggest that the greatest impact on blood pressure was achieved when theincreased potassium intake was approximately 90120mmol/day (44). The meta-analysis o vestudies (with ve comparisons) that achieved an increased potassium intake o 90120mmol/day demonstrated a reduction in systolic blood pressure o 7.16 mmHg (95%CI: 1.91, 12.41)(quality o evidence high), and a reduction in diastolic blood pressure o 4.01 mmHg (95%CI:0.42, 8.44) (quality o evidence moderate). Only one study with one comparison, in which theincreased potassium intake was 90120 mmol/day, reported ambulatory systolic and diastolicblood pressure; increased potassium intake resulted in a non-signi cant decrease o 1.80 mmHg(95%CI: -2.42, 7.02) in ambulatory systolic blood pressure and 1.40mmHg (95%CI: -2.34, 5.14) inambulatory diastolic blood pressure (quality o evidence moderate).

All-cause mortality, cardiovascular disease, stroke, and coronary heart disease in adults

WHO conducted a systematic review on the relationship between potassium consumptionand cardiovascular disease, stroke, coronary heart disease and all-cause mortality ( 45). The review updated and reanalysed data rom the recent systematic review o DElia andcolleagues ( 30). Only one study that met the inclusion criteria reported all-cause mortality. The results o this study were inconclusive (risk ratio [RR] 1.08 2 ; 95%CI: 0.91, 1.29) (quality o evidence very low). Twelve prospective cohort studies with more than 127,000 participantsmeasured potassium intake through urinary potassium excretion, dietary records or somecombination o these methods, and compared the incidence o cardiovascular disease, strokeor coronary heart disease between the lowest and highest potassium-consuming groups.Populations had wide ranges o potassium intake: some consumed approximately 35 mmol/day in the lowest group and 65 mmol/day in the highest group, whereas others consumedapproximately 65 mmol/day or more in the lowest group and 110150 mmol/day in the

1 Based on the grades o evidence set by the GRADE Working Group: high quality , we are very con dent that thetrue e ect lies close to that o the estimate o the e ect; moderate quality , we have moderate con dence in the e ectestimate; the true e ect is likely to be close to the estimate o the e ect, but there is a possibility that it is substantially

di erent; low quality , our con dence in the e ect estimate is limited; the true e ect may be substantially di erent romthe estimate o the e ect; very low qualit y, we have very little con dence in the e ect estimate; the true e ect is likelyto be substantially di erent rom the estimate o the e ect.2 In the analysis o data rom cohort studies, RR


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highest group. The ollow-up period ranged rom 2 to 19 years. Studies were conducted inAsia, Europe and the USA, and one study used data rom individuals in 40 di erent countries. Two studies were conducted exclusively in individuals without hypertension, two werespeci cally in a heterogeneous group o individuals both with and without hypertension,and the remaining studies did not speci y the blood pressure status o the study population.

The meta-analysis o our studies with our comparisons with cardiovasculardisease as an outcome was inconclusive regarding the association between potassiumand cardiovascular disease (RR 0.88; 95%CI: 0.70, 1.11) (quality o evidence very low). Themeta-analysis o nine studies with 10 comparisons with stroke as an outcome was supportiveo a reduction in risk o stroke with increased potassium (RR 0.79; 95%CI: 0.68, 0.93) (qualityo evidence low). The meta-analysis o our studies with our comparisons between apotassium intake o 90 mmol/day and


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increased potassium consumption (HDL 0.01 mmol/L; 95%CI: 0.1, 0.13; triglyceride 0.11mmol/L; 95%CI: 0.26, 0.48) (quality o evidence high). The meta-analysis o three trialsshowed that increased potassium intake relative to lower potassium intake resulted in anon-signi cant decrease o 4.32 pg/mL (95%CI: 15.13, 23.78)in plasma noradrenaline (and3.94 pg/mL (95%CI: 1.34, 9.22) plasma adrenaline ( (quality o evidence high). No studiesthat met the inclusion criteria reported urinary catecholamine levels. As an indicator o renal

unction, three studies quanti ed serum creatinine concentration. The meta-analysis o thesestudies suggested that increased potassium intake had no e ect on renal unction with anon-signi cant increase o 4.86 mol/L (95%CI: 3.87, 13.59) in these samples o individualswith apparently normal renal unction (quality o evidence high). Although the evidencewas limited, the data rom RCTs were conclusive o no adverse e ect o increased potassiumintake in terms o blood lipids, catecholamine levels or renal unction.

No minor side-e ects as a result o increased potassium intake were reported in anyo the RCTs. Though these studies were all o relatively short duration, the absence o anycomplaints o adverse e ects with increased potassium intake is consistent with the literature(32, 33). The body is able to efciently adapt and excrete excess potassium via the urinewhen consumption exceeds needs ( 18, 32, 33), and there have been no reports o toxicity o potassium rom consumption in ood ( 34).

Blood pressure in children

WHO conducted a systematic review o the e ect o increased potassium intake onblood pressure, blood lipids, catecholamine levels and other potential adverse e ects inchildren ( 46). Only our studies in children reporting on blood pressure met the inclusioncriteria or the review, and none o these reported on blood lipids, catecholamine levelsor other adverse e ects. Three o the our studies were controlled trials conducted inthe USA. They included a total o 326 boys and girls averaging 13 years o age. Thepotassium intake values in the lower groups averaged 57 mmol/day, compared with 95mmol/day in the increased potassium groups. The ourth study was an observationalcohort study conducted in the Netherlands; it included children aged 517 years o age at baseline and ollowed them or 7 years. The meta-analysis o the three controlledtrials with ve comparisons showed that increased potassium intake a ected a non-signi cant decrease o 0.25 mmHg (95%CI: 0.49, 1.05) in systolic blood pressure and0.92 mmHg (95%CI: 0.16, 2.00) in diastolic blood pressure(quality o evidence low). The

results o the observational cohort study in children were consistent with a bene ciale ect o increased potassium on blood pressure over time. In that study, potassiumintake was inversely related to the rate o increase in blood pressure over a 7-yearperiod ( 52).

There were ew high-quality RCTs testing the e ect o increased potassium intakeon blood pressure and potential adverse e ects in children. Hence, in generating theguideline or children, the data rom the systematic review conducted in adults ( 44)were used as part o the evidence base or estimating the e ect o increased potassiumon health outcomes in children. Renal unction is ully developed in early childhood;thus, it was considered acceptable to use in ormation rom adults to in er the e ect o potassium intake on blood pressure in children. The evidence rom studies conductedin adults was downgraded rom high to moderate in quality because o indirectness (i.e.the use o a proxy population or the target population).

Children


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WHO attempted to discern di erences in the e ect o increased potassium on outcomesaccording to type o intervention (i.e. supplements, orti cation or ood), type o potassium supplement (i.e. potassium citrate, potassium chloride or other) and gender.In the systematic review and meta-analysis o RCTs in adults reporting blood pressureas an outcome ( 44), the subgroup analysis o 19 studies using potassium supplementsshowed a decrease in systolic blood pressure o 3.31 mmHg (95%CI: 1.55, 5.07) (qualityo evidence high), and the subgroup analysis o three studies using dietary changesshowed a decrease in systolic blood pressure o 4.19 mmHg (95%CI: 1.92, 6.46) (qualityo evidence high). The results suggest that an increase in potassium intake rom eithersupplement or ood has a bene cial e ect on blood pressure.

In assessing the results o supplementation studies, it was possible to isolate thee ect o potassium because it was the only variable manipulated between increasedpotassium and usual or lower potassium groups. The consistency in results romstudies with increased potassium through dietary change supports the health bene to potassium speci cally, and not the conjugate anion ound in the supplements usedin the supplementation studies. Additionally, all cohort studies compared groupsconsuming di erent levels o potassium rom oods ( 44). The cohort studies suggesteda positive e ect o increased potassium on stroke, urther strengthening the conclusionthat speci cally increasing potassium has bene cial e ects on health. No studies thatmet the inclusion criteria looked speci cally at potassium orti cation o ood, mainlybecause such studies also manipulated sodium levels. One study used potassium citrate,one used potassium bicarbonate and one used a combination o potassium citrate and

bicarbonate, whereas all other supplementation studies used potassium chloride; thus,it was not possible to compare di erent supplement types. Twenty o the 22 RCTs andnine o the 12 cohort studies were in mixed populations o men and women. Althoughdi erences by gender could not be compared, the overall positive e ect o increasedpotassium ound in these studies supports a bene cial e ect in both men and women.

Addressing the optimal ratio o sodium to potassium was outside the scope o thisguideline; however, we undertook subgroup analysis o the RCTs to explore whetherdi erent levels o sodium intake in uence the e ect o potassium on blood pressure.Only one study had a mean sodium intake level o 4 g/day, increased potassium intake decreased systolic blood pressure by 6.91 mmHg(95%CI: 2.29, 11.53) (quality o evidence high). Although the di erence in the e ectestimates was not statistically signi cant, the results suggest that potassium may bemore e ective in reducing blood pressure at higher sodium consumption levels, whichis consistent with previous ndings (4). There was still a signi cant bene t o increasedpotassium intake on blood pressure when populations consumed 24 g/day o sodium;hence, with most populations around the world consuming more than 24 g/day o sodium ( 40), increased potassium intake should bene t most countries.

Finalconsiderationso the evidence


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The RCTs were also grouped by baseline potassium intake. In the two studiesin which baseline intake was 80mmol/day, increased potassium intake decreased systolic blood pressure by 4.11mmHg (95%CI: 1.97, 6.26) and diastolic blood pressure by 3.38 mmHg (95%CI: 2.02, 4.74). Thus, increased potassium intake had a bene cial e ect on blood pressure regardless o baseline potassium intake.

The RCTs were grouped by blood pressure status at baseline. In the three studiesconducted exclusively in individuals with normal blood pressure, increased potassiumintake resulted in a non-signi cant increase in systolic blood pressure o 0.09 mmHg(95%CI: 0.95,0.77) (quality o evidence moderate). In the 16 studies conducted inindividuals with hypertension, increased potassium intake decreased systolic bloodpressure by 5.32 mmHg (95%CI: 3.43, 7.20 (quality o evidence high). Although it appearsthat potassium may only reduce blood pressure in individuals with hypertension, thestudies in individuals without hypertension were o relatively short duration, and thee ect over time on the prevention o elevated blood pressure is not known. Given thehigh prevalence o hypertension in adult populations globally ( 2), the relatively lowpotassium intake in most populations ( 9, 10, 53), and the clear bene t o increasedpotassium intake in individuals with high blood pressure, increasing potassium intake

is likely to be broadly bene cial to populations around the world.Finally, the modest reduction in systolic blood pressure (3.49 mmHg) and in diastolic

blood pressure (3.02 mmHg) would have important public health bene ts. Elevatedblood pressure is the leading risk actor or mortality, accounting or almost 13% o death globally ( 2). In the USA, a relatively small decrease o 2 mmHg in diastolic bloodpressure in the population could result in an estimated 17% decrease in the prevalenceo hypertension, 6% decrease in risk o coronary heart disease, and 15% decrease inrisk o stroke; it could also prevent an estimated 67,000 coronary heart disease eventsand 34,000 stroke events every year ( 54). In the United Kingdom, researchers estimatethat a 5 mmHg reduction in systolic blood pressure could reduce the prevalence o hypertension by 50% ( 55). Additionally, the relationship between blood pressure andrisk o vascular mortality is positive, strong and linear down to a systolic blood pressureo 115 mmHg, below which there is no evidence ( 49). Thus, almost all reduction in bloodpressure is bene cial or health, and modest population-wide reductions in bloodpressure result in important reductions in mortality, substantial health bene ts andmeaning ul savings in health-care costs ( 2, 12, 13).


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For this recommendation, adults includes all individuals 16 years of age.

For this recommendation, children includes all individuals 215 years of age.

The recommendation for children does not address the recommended period ofexclusive breast eeding (06 months) or the period o complementary eeding withcontinued breast eeding (624 months).

These recommendations apply to all individuals, with or without hypertension(including pregnant and lactating women) except or those with impaired urinarypotassium excretion.

These recommendations do not address the optimal ratio of sodium to potassium;however, i this guideline and the WHO guideline on sodium consumption areachieved, the molar ratio o sodium to potassium would be approximately oneto one. To maintain this molar ratio at higher levels o sodium consumption, therecommended level o intake o 90 mmol/day potassium should be increased.

These recommendations complement the WHO guideline on sodium consumptionand should not be interpreted to replace or supersede that guideline. Public healthinterventions should aim to increase potassium intake through oods (Annex 2), andto simultaneously reduce sodium intake.

Remarks

Recommendations and remarks

1 A strong recommendation is one or which the guideline development group is con dent that the desirable e ects o adherence outweigh the undesirable e ects. The recommendation can be either in avour o or against an intervention.Implications o a strong recommendation are as ollows: or patients, most people in their situation would desire therecommended course o action, only a small proportion would not; or clinicians, most patients should receive therecommended course o action, and adherence to this recommendation is a reasonable measure o good-quality care;

or policy-makers, the recommendation can be adopted as a policy in most situations.2 A conditional recommendation is one or which the guideline development group concludes that the desirable e ectso adherence probably outweigh the undesirable e ects, but the group is not con dent about the trade-o . The reason

or not being con dent could be the absence o high-quality evidence; the presence o imprecise estimates o bene tor harm; uncertainty or variation on how certain individuals will value the outcome; small bene ts; and bene ts thatare not worth the costs (including the costs o implementing the recommendation). Implications o a conditionalrecommendation are as ollows: or patients, most people in their situation would want the recommended course o

action, but many would not; or clinicians, patients may need help to make a decision in relation to the recommendationthat is consistent with their own values; or policy-makers, there is a need or debate and involvement o stakeholders indeciding whether to adopt the recommendation as policy.3 Control or this recommendation re ers to the prevention o a deleterious rise in blood pressure with age.

Recommendations WHO recommends an increase in potassium intake from food for reduction ofblood pressure and risk o cardiovascular disease, stroke and coronary heartdisease in adults ( strong recommendation 1 ). WHO suggests a potassium intake o at least 90 mmol/day (3510 mg/day) or adults ( conditional recommendation 2).

WHO suggests an increase in potassium intake from food to control3 bloodpressure in children ( conditional recommendation ). The recommended potassiumintake o at least 90 mmol/day should be adjusted downward or children, basedon the energy requirements o children relative to those o adults.


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This nutrient guideline on potassium can aid the logical, systematic, and scienti c developmento nutrition interventions taking into account the best available scienti c evidence. Thisguideline should be used in conjunction with sodium and other nutrient guidelines to guidepublic health nutrition programmes and policies.

The recommendations in this guideline can be used by programme and policy plannersto assess current potassium intake relative to a benchmark and develop measures to increasepotassium intake, where necessary, through public health interventions including, but notlimited to, ood and product labelling and consumer education. Additionally, this guidelinecan be translated at the country-level into culturally and contextually speci c FBDGs thattake into account locally available ood and dietary customs.

Though providing overall dietary guidance is outside the scope o this guideline becausesuch dietary guidance should be based on overall dietary goals, which consider all requirednutrients, it is recommended that potassium be consumed through ood. It is also recognizedthat it is easible to achieve this recommendation while respecting national dietary customsbecause potassium is ound in a wide variety o oods (Annex 2). Additionally, because resh

ruits, vegetables and beans are high in potassium, an increased intake o potassium can beachieved without increasing caloric intake i these oods replace oods lower in potassiumlevels in the diet.

High-quality RCTs in children are needed that address the e ects of increasedpotassium intake compared with lower potassium intake on blood pressure,and adverse e ects such as changes in blood lipids and catecholamine levels.

Further high-quality RCTs in adults are needed that assess the e ects of increasedpotassium intake compared with lower potassium intake on cardiovasculardisease, stroke and coronary heart disease.

High-quality RCTs with multiple intervention arms designed to directly test thee ect o multiple levels o potassium intake on health outcomes are warranted,to strengthen the evidence base or the precise target potassium intake value.

High-quality trials with multiple intervention arms designed to test various formso potassium compounds (i.e. potassium citrate, potassium bicarbonate andpotassium chloride), in either supplement or orti cation orm, are warranted.

The current guideline will be disseminated through:

electronic media such as slide presentations;

mailing lists of the WHO Department of Nutrition for Health and Development

and the UN Standing Committee on Nutrition; the web site of the WHO Department of Nutrition for Health and Development.

Translation and implementation

Research gaps and uture initiatives

Implications oruture research

Dissemination


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A summary o this guideline will also be available in all six UN languages through theWHO Department o Nutrition or Health and Developments electronic Library o Evidence or Nutrition Actions. The library displays WHO guidelines related to nutrition,and complementary documents such as systematic reviews and other evidencein orming the guidelines, biological and behavioural rationales or the e ectivenesso a guideline, and other relevant resources produced by Member States and globalpartners.

The recommendations in this guideline will be reviewed by the end o 2017. I newin ormation is available by that date, a guideline review group will be convened toevaluate the new evidence and revise the recommendation. However, i a large amounto new evidence becomes available be ore that date, a guideline review group maybe convened earlier. The Department o Nutrition or Health and Development at theWHO Headquarters in Geneva, together with partners in other departments within theWHO Secretariat, will be responsible or coordinating the updating o the guideline,

ollowing the ormal WHO Handbook or guideline development (6) procedures. Whenthe guideline is due or review, WHO will welcome suggestions or additional questionsthat could be addressed in the guideline.

Updating theguideline


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Examples o oods that contain potassium, and their approximatepotassium content

The table below provides examples o oods rom around the world that containpotassium, and gives the approximate average potassium content o thoseexamples rom various ood composition databases.

Annex 2

Food group Approximate Examplespotassium content,(mg/100g resh weight)

Beans and peas 1300 Cowpeas, pigeon peas, lima beans,

A rican yam beans

Nuts 600 Hazelnuts, walnuts, cashew nuts,

brazil nuts

Green vegetables 550 Spinach, cabbage, parsley

Root vegetables 200 Carrots, onions, beetroot

Other vegetables 300 Tomatoes, cucumbers, pumpkins

Fruits 300 Bananas, papayas, dates

Note: The in ormation in this table is based on approximate calculations o the averagepotassium content rom an example o oods within each ood group rom ood compositiondatabases rom around the globe. The potassium content varies within the ood groups. Thus,the in ormation provided can be used only or approximate comparisons o various ood groups,and should not be used to estimate daily intake.

Sources: (56-61)


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WHO Secretariat

WHO Headquarters

Dr Francesco BrancaDirectorDepartment o Nutrition or Health andDevelopment

Dr Chizuru NishidaCoordinatorNutrition Policy and Scienti c Advice Unit

Department o Nutrition or Health andDevelopment

Dr Nancy AburtoScientistNutrition Policy and Scienti c Advice UnitDepartment o Nutrition or Health andDevelopment

Dr John BeardDirector, Ageing and Li e CourseFamily and Community Health

Dr Shanthi MendisCoordinatorChronic Diseases Prevention andManagementDepartment o Chronic Diseases andHealth Promotion

Dr Poul Erik PetersenDental OfcerHealth PromotionDepartment o Chronic Diseases andHealth Promotion

Ms Mariana Widmer Technical OfcerImproving Maternal and Perinatal HealthReproductive Health and Research

Dr God rey Xuereb Technical OfcerSurveillance and Population-basedPreventionDepartment o Chronic Diseases andHealth Promotion

Dr Cynthia SouzaGuidelines Review Committee Secretariat

Dr Regina KulierGuidelines Review Committee Secretariat

Dr Margaret HarrisGuidelines Review Committee Secretariat

WHO regional ofces

Dr Abel DushimimanaMedical OfcerWHO Regional Ofce or A ricaBrazzaville, the Congo

Dr Chessa LutterRegional AdviserUnit on Child and Adolescent HealthWHO Regional Ofce or the Americas/Pan American Health OrganizationWashington, USA

Dr Kunal BagchiRegional AdviserNutrition and Food Sa etyWHO Regional Ofce or South-East AsiaNew Delhi, India

Dr Joao BredaScientistWHO Regional Ofce or EuropeCopenhagen, Denmark

Dr Ayoub Al-JawaldehRegional AdviserNutritionWHO Regional Ofce or the Easter nMediterraneanCairo, Egypt

Dr Tommaso Cavalli-S orzaRegional AdviserNutritionWHO Regional Ofce or the Western Paci cManila, the Philippines

Annex 3


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Members o the WHO Steering Committee or Nutrition GuidelineDevelopment 2010 - 2011

Annex 4

WHO Headquarters

Dr Francesco BrancaDirector, Nutrition or Health andDevelopment Department

Dr Tikki Pang (Pangestu)Director, Research Policy and Cooperation

Dr Elizabeth MasonDirector, Child and Adolescent Health andDevelopment Alternate:Dr Nigel RollinsScientist, Newborn and Child Health andDevelopment

Dr Ala AlwanActing Director, Chronic Diseases and HealthPromotion Alternate:

Dr God rey Xuereb Technical OfcerChronic Disease and Health Promotion

Dr Ruediger KrechDirector, Ethics, Equity, Trade and HumanRights Alternate:Ms Nicole Valentine Technical Ofcer, Ethics, Equity, Trade andHuman Rights

Dr Maged YounesDirector, Food Sa ety, Zoonoses andFoodborne Diseases

Dr Robert D. NewmanDirector, Global Malaria Programme Alternate:Dr Sergio SpinaciAssociate Director, Global Malaria Programme

Dr Aa e RietveldMedical Ofcer, Global Malaria Programme

Dr Willem Van LerbergheDirector, Health Policy, Development andServices

Dr Gott ried Otto HirnschallDirector, HIV/AIDS Alternate:Mr Craig Michael McClureSenior Technical Ofcer, HTM/HIV

Dr Jean-Marie Okwo-BeleDirector, Immunization, Vaccines andBiologicals

Dr Michael MbizvoDirector, Reproductive Health and

Research

Dr Mario RaviglioneDirector, Stop Tuberculosis Alternate:Dr Knut LonnrothMedical Ofcer, Stop Tuberculosis

Dr Daniel Eduardo Lopez AcunaDirector, Strategy, Policy and ResourceManagement

Dr Nevio ZagariaActing Director, Emergency Response &Recovery Operations

International Agency orResearch on Cancer

Dr Isabelle RomieuDirector, Nutrition Department


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Members o the NUGAG Subgroup on Diet and Health and external resourcepersons 2010 - 2011

Annex 5

Pro essor Pascal BovetUniversity Institute o Social and PreventiveMedicine,Lausanne University HospitalSwitzerlandand Ministry o HealthSeychellesProgramme manager, noncommunicablediseases

Pro essor Michael ClarkeSchool o Nursing and Midwi ery Trinity College, Irelandand United Kingdom Cochrane CentreUnited KingdomMethods, systematic review

Pro essor John H CummingsCentre or Oncology and Molecular MedicineDivision o Medical SciencesUniversity o DundeeUnited KingdomCarbohydrates, dietary bre

Pro essor Ibrahim Elmad aInstitution o Nutritional SciencesUniversity o ViennaAustriaHuman nutrition, nutrient requirements, atsand atty acids, dietary diversity

Pro essor Nahla HwallaFaculty o Agricultural and Food SciencesAmerican University o BeirutLebanonDietetics, nutrition, ood-based dietary guidelines, diet and health

Associate Pro essor Rachel HuxleyDivision o Epidemiology & CommunityHealthUniversity o MinnesotaUSAEpidemiology, physiology, biostatistics,meta-analysis, obesity

Pro essor Shiriki KumanyikaCenter or Clinical Epidemiology &BiostatisticsUniversity o Pennsylvania School o MedicineUSAHuman nutrition, epidemiology, obesity,salt/sodium

Pro essor Mary LAbbeDepartment o Nutritional SciencesFaculty o MedicineUniversity o TorontoCanadaNutrition science, trans- atty acids, risk assessment and risk management,diet and health

Pro essor Duo LiDepartment o Food Science and NutritionZhejiang UniversityChinaNutritional epidemiology, ats and atty acids

Pro essor Jim MannDepartment o Medical and SurgicalSciencesUniversity o OtagoNew ZealandCarbohydrates, sugars, diabetes, ats

and atty acids

Pro essor Carlos MonteiroDepartment o Nutrition, School o PublicHealthUniversity o Sao PauloBrazilHuman nutrition, epidemiology,double-burden o malnutrition

Pro essor Dariush Moza arianHarvard School o Public HealthHarvard UniversityUSACardiology, epidemiology, diet and health

Members o the NUGAG Subgroup on Diet and Health(Note: the areas o expertise o each guideline group member are given in italics)


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Pro essor Srinath ReddyPublic Health Foundation o IndiaIndiaCardiovascular diseases, obesity,noncommunicable diseases

Pro essor Murray Skea University o OtagoNew ZealandFats and atty acids, biomarkers, diet and health, human nutrition

Dr Cho-il KimDepartment o Food and Nutrition IndustryKorea Health Industry Development Institute The Republic o Korea

Dr Joerg MeerpohlGerman Cochrane CentreInstitute o Medical Biometry and Medical

In ormaticsUniversity Medical Center FreiburgGermany

Pro essor Paula MoynihanInstitute or Ageing and HealthSchool o Dental SciencesUniversity o NewcastleUnited Kingdom

Pro essor H.H. (Est) VorsterFaculty o Health SciencesNorth-West UniversitySouth A ricaNutrition physiology, public health nutrition,

ood-based dietary guidelines

External resource persons

Pro essor Francesco CappuccioUniversity o Warwick Warwick Medical SchoolUnited Kingdom

Pro essor Paul ElliottMRC-HPA Centre or Environment and Healthand Department o Epidemiology

and BiostatisticsSchool o Public HealthImperial College LondonUnited Kingdom

Dr Caroline Lee HooperSchool o Medicine, Health Policy andPracticeUniversity o East AngliaUnited Kingdom

Dr Sarah KellyInstitute or Ageing and HealthSchool o Dental SciencesUniversity o NewcastleUnited Kingdom


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External Expert and Stakeholder PanelAnnex 6

Members commenting on priority questions (February 2011)

Spanish Association o Dietitians &Nutritonists, Spain

Unilever, the Netherlands

International Li e Sciences Institute, USA

(with ofces around the world)

Northwestern University Feinberg School o Medicine, USA

Health Service Executive, Ireland

Heart and Stroke Foundation, South A rica

Ministry o Health, Uzbekistan

Pan American Health Organization ExpertGroup on Salt Reduction, Americas

Consensus Action on Salt and Health,United Kingdom

The George Institute or Global Health,Australia

Metropolitan University CollegeCopenhagen, Denmar k

U.S. Food and Drug Administration; U.S.Delegate to the Codex Committee onNutrition and Foods or Special DietaryUses and the Codex Committee on FoodLabelling, USA

National Institute or Public Health and theEnvironment (RIVM), the Netherlands


Comments received rom Afliation

Eduard Baladia (on behal o Maria Manera,Julio Basulto and Eduard Baladia)

Gerda Feunekes

Suzanne Harris

Mark Hu man

Siobhan Jennings

Erika Ketterer

Anatoliy Khudaiberganov

Branka Legetic (on behal o the PanAmerican Health Organization ExpertGroup on Salt Reduction)

Graham MacGregor

Bruce Neal

Aileen Robertson

Barbara Schneeman

Hans Verhagen

Jacqueline Webster


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Members commenting on the dra t guidelines (February 2012)

National Nutrition Institute, Egypt

The Albert Einstein College o Medicine, USA

National Institute o Nutrition and Food Technology, Tunisia

Shiraz University o Medical Sciences, Iran(Islamic Republic o )

Health Promotion Board, Singapore

National Food Agency, Sweden

Network or Sustained Elimination o IodineDe ciency, Canada

University o Calgary, Canada

National Institute o Nutrition and Food Technology, Tunisia

Institute o Food Technologists, USA


German Federation or Food Law and FoodScience, Germany

Northwestern University Department o Preventive Medicine, USA

National Institute or Health and Wel are,Finland

ILSI North America, USA

WHO Collaborating Center or Maternal andChild Health, IRCCS Burlo Trieste, Italy

EuSalt (European Salt Producers Association),Belgium

Wol son Institute, Queen Mary University o London, United Kingdom


Nebal Aboul Ella

Michael Alderman

Leila Alouane

Salmeh Bahmanpour

Amber Bastian

Wul Becker

Lucie Bohac

Norm Campbell

Jalila el Ati

Sheila Fleischhacker

Gihan Fouad

Isabel Gaertner

Mark Hu man

Antti Jula

Chor San Khoo

Marzia Lazzerini

Sandrine Lauret

Graham MacGregor


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National Heart, Lung, and Blood Institute,United States o America

Non Communicable Disease Section, DiseaseControl Division, Ministry O Health, Malaysia


Nutrition Division, Ministry o Health,Malaysia


Department o Clinical and ExperimentalMedicine, University o Naples Medical School,Italy


Department o Health, England,United Kingdom

Institute o Public Health o Vojvodina / Schoolo Medicine University o Novi Sad, Republico Serbia




Kathryn McMurry

Viola Michael

Gulsen Saleh

Rusidah Selamat BT

Letty Shiu

Pasquale Strazzullo

Eman Sultan

Alison Tedstone

Ljiljana Trajkovic Pavlovic

Jacqueline Webster

Clare Whitton

Sahar Zaghloul


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Priority questions in the ormat o population, intervention, control andoutcomes (PICO)

Population

Intervention(or exposure)

Control

Speci ccomparisons

Outcomes

Settings

Adults (16 years o age) with or without hypertension, or a populationo adults (some with and some without hypertension) not acutely ill andnot requiring potassium management (with or without type 2 diabetes,previous cardiovascular disease, previous cancer, etc)

Intervention: increased potassium via advice, speci c oods, supplementsor whole diet provided and uncon ounded by other dietary, weight,li estyle or pharmaceutical interventions.

Exposure: single baseline or repeated potassium intake measurement bydietary intake assessment or urinary potassium excretion

Diet with a potassium level lower than in the intervention (may be usualintake or speci c potassium intake) via advice or no advice or speci c

oods or supplements or whole diet provided.

Increased potassium intake (any level) versus lower potassium(usual potassium intake)Increased potassium intake to at least 90mmol/day versus lower intake.Increased potassium intake to at least 120mmol/day versus lower intake.Increased potassium intake to at least 155mmol/day versus lower intake.

Blood pressure (systolic and/or diastolic), all-cause mortality,cardiovascular disease, stroke, coronary heart disease, renal unction,adverse e ects (blood lipids, catecholamine levels and any other adverseevents reported by study authors)

All countries

Annex 7

Adults

What is the efect o increased potassium compared with lower intake on health outcomes? What is the optimal level o potassium intake or maximum bene t?
http://whqlibdoc.who.int/publications/2009/9789243596662_spa.pdf


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Children

What is the efect o increased potassium intake compared with lower intake on blood pressure and potential adverse efects?

Population

Intervention(or exposure)

Control

Speci ccomparisons

Outcomes

Settings

Children or adolescents (215 years inclusive), not acutely ill and notrequiring potassium management (with or without type 2 diabetes,previous cardiovascular disease, previous cancer, etc.)

Intervention: increased potassium via advice, speci c oods, supplementsor whole diet provided and uncon ounded by other dietary, weight,li estyle or pharmaceutical interventions.

Exposure: single baseline or repeated potassium intake measurement bydietary intake assessment or urinary potassium excretion

Diet with a potassium level lower than in the intervention (may be usualintake or speci c potassium intake) via advice or no advice or speci c

oods or supplements or whole diet provided.

Increased potassium intake (any level) versus lower potassium(usual potassium intake)

Increased potassium intake to at least 90mmol/day versus lower intake.Increased potassium intake to at least 120mmol/day versus lower intake.Increased potassium intake to at least 155mmol/day versus lower intake.

Blood pressure (systolic and/or diastolic), adverse e ects (blood lipids,catecholamine levels and any other adverse events reported by studyauthors)

All countries
http://whqlibdoc.who.int/publications/2009/9789243596662_spa.pdf


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Summary o considerations or determining the strength o therecommendations

Quality o evidence:

Values andpre erences:

Trade-o between bene tsand harm:

High-quality evidence that increasing potassium is bene cial forblood pressure with no indication o adverse e ects in adults.

Because of the well-established relationship between bloodpressure and cardiovascular disease outcomes, the evidence o an e ect o potassium on blood pressure was also consideredmoderate-quality indirect evidence or cardiovascular disease,stroke and coronary heart disease.

The limited amount of direct evidence regarding cardiovascular

disease and coronary heart disease shows no harm or bene trom increased potassium intake.

Low-quality direct evidence suggests a bene t of increasedpotassium intake on reducing risk o stroke.

Moderate-quality evidence for blood pressure with no indication ofadverse e ects in children.

High and moderate-quality evidence that increasing potassiumintake to at least 90 mmol potassium/day in adults is bene cial;however, high quality RCTs testing varying levels o potassiumintake to maximize health bene ts are lacking, and additionalresearch may clari y the precise optimal target level o intake.

NCDs are the main contributor to mortality globally, andinterventions to reduce the burden o NCDs are valuable.

NCDs a ect countries in all regions and all income levels, meaningthat interventions to reduce the burden o NCDs are valuablein all contexts.

High-quality evidence of bene t of increasing potassium intake todecrease blood pressure in adults.

Blood pressure is a good proxy indicator for risk of cardiovasculardisease, stroke and coronary heart disease outcomes. Althoughinconclusive, there was evidence rom the meta-analyseso cohort studies measuring cardiovascular disease or coronaryheart disease that a bene t o increased potassium was possible. The cohort data supported the bene cial e ect o increasedpotassium on stroke.

Moderate-quality (indirect) evidence of bene t of increasingpotassium intake in children on blood pressure.

High-quality evidence of no harm on blood lipids, catecholamine

levels, or renal unction with increased potassium intake in adults. No evidence of harm in children. No risk of toxicity with consumption through food.

Annex 8


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Costs andeasibility: Individuals can feasibly reach these intake goals through theconsumption o a reasonable amount o resh ruits andvegetables, beans, dairy and other potassium-containing oods.

Implementation of this intervention requires consumer education,public health communications and nutrition communication.

Reduction of NCDs is highly cost bene cial. These recommendations can be incorporated into existing public

health nutrition education campaigns and other existingnutrition programs at the global, regional, national andsubnational level.


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Management o con ict o interestAnnex 9

NUGAG members

Pro essor John Cummings, Pro essor Shiriki Kumanyika and Pro essor Este Vorster declared thatthey received support rom the local organizers o the third meeting o the Subgroup on Dietand Health; that is, the Korean Food and Drug Administration (KFDA)/Korea Health IndustryDevelopment Institute (KHIDI).

It was considered that the declared interests did not constitute any con ict o interest or their roles as members o the NUGAG Subgroup on Diet and Health, nor did they represent any con ict o interest or the work being undertaken by the NUGAG Subgroup on Diet and Health.

Pro essor Ibrahim Elmad a declared that he has received research grants rom the Ministryo Health, Austria; the European Commission; the European Food Standard Agency; andNutrisciencia, Switzerland. The grants were received by his university, and unds were mainlyused or sta costs or those working in the research projects and eldwork.

Further in ormation obtained rom Pro essor Elmad a regarding Nutrisciencia indicated that it is a Liechtenstein or-pro t oundation, registered with the Public Registry o the Principality o Liechtenstein under number FL-0002.251.294-8. The purpose o the oundation is to support research, education and science to universities in Germany. It also contributes to charitable and humanitarian organizations. No commercially operating companies are involved in the operation o

the oundation, either directly or indirectly. The declared interests were not considered to constituteany con ict o interest or Pro essor Elmad as role as a member o the NUGAG Subgroup on Diet and Health, nor did they represent any con ict o interest or the work being undertaken by the NUGAGSubgroup on Diet and Health.

Pro essor Nahla Hwalla declared that she has received research support including grants,collaborations, sponsorships and other unding rom WHO, the International Atomic EnergyAgency (IAEA), the Lebanese National Council or Scienti c Research, the UN University (UNU)and Nestle Middle East.

Further in ormation obtained rom Pro essor Hwalla regarding the declared grant received

rom Nestle Middle East indicated that the grant supports two types o projects at the AmericanUniversity o Beirut (AUB): intervention activities to promote healthy eating in schools, and researchactivities o three aculty members in the Faculty o Agriculture and Food Sciences, where Pro essor Hwalla, as the Dean o the Faculty, oversees the implementation o these activities. Pro essor Hwallaalso indicated that there is an agreement between AUB and Nestle Middle East that all intellectual property (including technology, method, know-how or data rights) produced during the course o the projects will belong to AUB. Pro essor Hwallas declared interests do not present any con ict o interest or the work o the NUGAG because the unds she received or her own research were romUN agencies (i.e. WHO, IAEA and UNU) and a governmental institution (i.e. the Lebanese National Council or Scienti c Research). It was agreed that Pro essor Hwalla could participate in the March2011 meeting as a member o the NUGAG Subgroup on Diet and Health, especially since:


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the interest is not personal; the amount received is not signi cant in view of the total budget of the faculty;

f unding is going to a programme that was already established be ore the Nestle contributionand that has governmental support. It was suggested that an appropriate disclosurestatement be prepared to indicate her declared interest. Pro essor Hwalla participated inthe March 2011 NUGAG meeting but was not able to attend the November 2011 meetingwhen the current guideline was developed.

Pro essor Mary LAbbe declared that she received research grants rom the CanadianInstitutes o Health Research, to evaluate the impact o Canadas sodium reduction policy;the Public Health Agency o Canada, to prepare a report on public ood procurement policiesrelated to sodium; and the Bee In ormation Centre (a non-pro t research oundation unded,but administered at arms length, by the Canadian bee industry), to examine the ironbioavailability o the diets o Canadians. Pro essor LAbbe also receives other unding or researchin NCD prevention and health promotion. She also declared that she has spoken at the annualmeeting o the Canadian Meat Council to explain Canadas Sodium Working Group reportrecommendations, and the process being used to develop Canadas sodium targets or oods.Her travel expenses were paid by the Canadian Meat Council, but no honorarium was received.Pro essor LAbbe appeared as a witness to the Canadian Parliaments Standing Committee onHealth, as Chair o Canadas Sodium Working Group, to advocate or action to reduce sodium inCanadian oods and to increase consumer awareness o sodium, and to support research in thesodium eld.

The research grant received rom the Bee In ormation Centre was or a study to examine theiron availability of the diets among the Canadian populations; this activity was not related to thearea o recommendations being reviewed and updated by the NUGAG Subgroup on Diet and Health.Hence, it was suggested that the declared interest be reported in the process and the meeting report with details, but that no action be taken and Pro essor LAbbe be accepted as a member o the NUGAGSubgroup on Diet and Health.

Pro essor Jim Mann declared that he is employed by a university that has an interest in nutritionas it relates to human health, and receives research grants rom New Zealand governmentalagencies. He also declared that, as an individual and as advisory committee member, he has

provided expert advice relating to nutrition and human health to innumerable national andinternational bodies including WHO, FAO, the World Cancer Research Fund and the media.

The declared interests were not considered to constitute any con ict o interest or Pro essor Manns role as a member o the NUGAG Subgroup on Diet and Health, nor did they represent any con ict o interest or the work being undertaken by that subgroup.

Pro essor Dariush Moza arian declared that he has received a signi cant number o research grants to study the e ects o dietary actors on chronic diseases rom the US NationalInstitutes o Health; the Searle Scholar Award rom the Searle Funds at the Chicago Community Trust; the Genes and Environment Initiative at the Harvard School o Public Health; the GatesFoundation/WHO Global Burden o Diseases, Injuries and Risk Factors Study; and GlaxoSmithKline, Sigma-Tau and Pronova or an investigator-initiated, not- or-pro t trial o sh oil to preventpost-surgical arrhythmia. He has also received modest honoraria and travel reimbursement or


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speaking at scienti c con erences and reviewing on topics related to diet and cardiovasculardisease, including rom the US Food and Drug Administration, International Li e SciencesInstitute, Aramark, Unilever, SPRIM, Nutrition Impact, WHO, UpToDate, and several universitiesand scienti c organizations. He has no ownership, patents, stocks, advisory board membershipor speaking board membership.

The trial o sh oil, or which Pro essor Mozafarian received grants rom GlaxoSmith Kline,Sigma-Tau and Pronova, is not related to the work o the NUGAG Subgroup on Diet and Health. GivenPro essor Mozafarians honoraria, travel reimbursement and speaking and reviewing engagements,it was agreed that the declared interest in the process be documented in the meeting report and that no action be taken. It was decided he could participate as member o the NUGAG and his participationin the guideline development meetings would be reviewed or each meeting topic in the uture.

Pro essor Murray Skea declared various memberships as ollows:

Serving as a member of the Public Health Scienti c Advisory Group and the chair ofthe Food and Nutrition Working Group o the New Zealand National Heart Foundation. These groups advise the Heart Foundation, a nongovernmental organization, about thescienti c basis o its public health e orts to reduce the burden o heart disease in NewZealand. He is not an employee o the Heart Foundation and receives no remuneration

or work related to the Advisory Group.

Appointed in 2008 as a Scienti c Fellow o Food Standards Australia New Zealand

(FSANZ). The FSANZ Fellows Program aims to establish a network o distinguishedscientists and experts rom key disciplines in areas relevant to ood regulation. Thenetwork is intended to promote close collaborative relations between FSANZ sta , theFellows, and their afliated institutions to the bene t o all parties. No remuneration isgiven to Fellows.

Serving as a member o the New Zealand Food Sa ety Academy (NZFSA). The NZFSA is agovernmental department within the Ministry o Agriculture and Fisheries. From time totime,

ingesta de potasio en niños y adultos

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