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This section addresses three major questions related to the intake of fluid
and the electrolytes sodium and potassium.
What amount of fluid is recommended for health?
What are the effects of salt (sodium chloride) intake on health?
What are the effects of potassium intake on health?
The Committee placed a strong focus on sodium and potassium because of the substantial
body of research linking these electrolytes to levels of blood pressure. Part
B, "Introduction," provides background information on the problem of elevated
blood pressure and its control. That information can help the reader appreciate
the importance of blood pressure as a modifiable risk factor for cardiovascular
and kidney diseases and of dietary factors that can lower and possibly control
blood pressure.
The conclusions in this section are largely based on evidence from an extensive,
systematic, and very recent review of the scientific literature conducted by
an expert panel for the Institute of Medicine (IOM) (IOM, 2004). For topics not
covered in the IOM report, we conducted literature searches. The search strategies
used to find the scientific evidence related to each of these questions appears
in Section C.
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The combination of thirst and usual drinking behavior, especially the consumption
of fluids with meals, is sufficient to maintain normal hydration. Healthy individuals
who have routine access to fluids and who are not exposed to heat stress consume
adequate water to meet their needs. Purposeful drinking is warranted for individuals
who are exposed to heat stress or who perform sustained vigorous activity.
Recommendations for water are made to prevent the deleterious, primarily acute,
effects of dehydration. These effects include impaired cognitive function and
motor control. Although a low intake of water has been associated with some chronic
diseases, this evidence is insufficient to establish recommendations for water
The primary indicator of hydration status is plasma or serum osmolality. Appendix
G-1 from the recent IOM report (IOM, 2004) provides the serum osmolality by decile
of total water intake in the third National Health and Nutrition Examination
Survey (NHANES III). Serum osmolality concentrations were essentially identical
(the maximum range between the lowest and highest decile was only 3 mOsmol/kg).
These data indicate that persons in the lowest and highest deciles of total water
intake were neither systematically dehydrated nor hyperhydrated. Importantly,
this pattern of findings also was evident in men and women age 71 and older.
Thirst, which is the desire to drink by both physiological and behavioral cues,
may be triggered by a decrease in blood volume or severe dehydration. Over the
course of a few hours, body water deficits can occur. However, thirst mechanisms
come into play over the ensuing 24 hours to trigger replacement of fluids lost
(Johnson, 1964). Such replacement is enhanced by consuming beverages at meals
and in other social situations (Engell, 1995; Szlyk, 1990).
Total water intake includes drinking water, water in beverages, and water contained
in food. Because normal hydration can be maintained over a wide range of water
intakes, the Adequate Intake (AI) for total water was set based on the median
total water intake from U.S. survey data (IOM, 2004). The AI for total water
intake for young men and women (age 19 to 30 years) is 3.7 L and 2.7 L per day,
respectively. In NHANES III, fluids (drinking water and beverages) provided 3.0
L (101 fluid ounces; ~13 cups) and 2.2 L (74 fluid ounces; ~9 cups) per day for
men and women age 19 to 30, representing approximately 81 percent of total water
intake. Water contained in food provided about 19 percent of total water intake.
The AI should not be interpreted as a specific requirement or recommended intake.
Individual water requirements can vary greatly, even on a day-to-day basis, primarily
because of differences in physical activity and environmental conditions but
also because of differences in diet. A total water intake above the AI often
is required by those individuals who are physically active or who are exposed
to heat stress. In individuals who are neither physically active nor exposed
to heat stress, daily consumption below the AI can be sufficient to maintain
normal hydration. Dietary factors also influence water requirements because total
water consumption must be sufficient to excrete metabolites of protein and organic
compounds, as well as excess electrolytes.
Because healthy individuals have considerable ability to excrete excess water
and thereby maintain water balance, the IOM did not set a Tolerable Upper Intake
Level (UL) for water. However, acute water toxicity can occur following the rapid
consumption of large quantities of fluids that greatly exceed the kidney's maximal
excretion rate of approximately 0.7 to 1.0 L per hour.
The relationship between salt (sodium chloride) intake and blood pressure is
direct and progressive without an apparent threshold. Hence, individuals should
reduce their salt intake as much as possible. In view of the currently high levels
of salt intake, a daily sodium intake of less than 2,300 mg is recommended. Many
persons will benefit from further reductions in salt intake, including hypertensive
individuals, blacks, and middle- and older-aged adults. Individuals should concurrently
increase their consumption of potassium because a diet rich in potassium blunts
the effects of salt on blood pressure.
A recent report from the IOM (IOM, 2004) provides the basis for a recommended
daily sodium intake (an AI) of 1,500 mg and a UL of 2,300 mg for adults1,
2. These recommendations are based on an extensive examination
of the scientific literature by an expert IOM (IOM) panel. The primary basis
for setting the AI was to ensure overall nutrient adequacy, not to prevent chronic
disease. In contrast, the UL was set because of the direct relationship of salt
intake with blood pressure.
Studies of the Relationship of Sodium Intake and Blood Pressure.
The relationship between sodium intake and blood pressure is direct and progressive.
In addition to observational studies, supportive evidence comes from more than
50 clinical trials and meta-analyses (see IOM, 2004, Tables 6-12, 6-13, 6-15,
6-16, and Appendix I). The best available dose-response evidence comes from individual
trials that specifically examined this relationship (i.e., randomized trials
that tested the effects of three or more levels of sodium intake on blood pressure).
In these dose-response studies, the lowest level of sodium intake ranged from
approximately 230 to 1,500 mg of sodium per day, while the highest level ranged
from approximately 3,200 to over 34,000 mg of sodium per day. The largest and
most rigorous of these trials documented statistically significant, progressive
dose-response relationships (Johnson et al., 2001; MacGregor et al., 1989; Sacks
et al., 2001). Importantly, there was no evidence of a threshold; that is, the
direct relationships were evident throughout the range of salt intake.
The trial by Johnson et al. (2001) tested the effects of 5 levels of sodium
intake (lowest to highest: 920 mg per day to 7,800 mg per day) in 40 older-aged
persons (nonhypertensives, persons with isolated systolic hypertension, persons
with combined systolic-diastolic hypertension). The trial by MacGregor et al.
(1989) tested the effects of 3 levels of sodium intake (1,100; 2,300; and 4,600
mg of sodium per day) in 20 hypertensive adults. The largest of the dose-response
trials, the Dietary Approaches To Stop Hypertension (DASH) -Sodium
trial, tested the effects of three different sodium intakes separately in two
distinct diets—the DASH diet and a control diet. The DASH diet is described in
detail in Section D1 and in Table D1-18. In brief, the DASH diet is rich in fruits,
vegetables, and low-fat dairy products and reduced in total fat, saturated fat
and cholesterol. The control diet is typical of what many Americans eat, that
is, relatively high in total and saturated fats and low in fruits, vegetables,
and low-fat milk products. Mean achieved levels of sodium intake, as reflected
by 24-hour urinary sodium excretion, corresponded to approximate intakes of 1,500;
2,500; and 3,300 mg in the lower, intermediate, and higher doses, respectively.
Of the 3 dose-response trials, the DASH-Sodium trial enrolled the largest and
most diverse population; 41 percent were hypertensive, 40 percent were white,
and 57 percent were black. However, the DASH-Sodium trial had the narrowest range
of sodium intake; approximately half of the U.S. population consumes sodium in
excess of the highest level tested in this trial (Rose et al., 1988).
The main results of the DASH-Sodium trial are displayed in Figure D6-1. The
blood pressure response to sodium reduction was nonlinear. Specifically, reducing
sodium intake by approximately 920 mg per day caused a greater lowering of blood
pressure when the initial sodium intake was at the intermediate level than when
it was at the higher intake; this pattern of results was especially evident on
the control diet. Results from the INTERSALT observational study (Rose et al,
1988) and from the Johnson trial likewise suggest that the blood pressure response
to changes in sodium intake is steeper below 2,300 mg per day than above 2,300
mg per day.
In protocol-specified subgroup analyses of the DASH-Sodium trial (Vollmer et
al., 2001), a reduced-sodium intake significantly lowered blood pressure in each
of the major subgroups on the control diet. On the control diet, reduced-sodium
intake led to greater systolic blood pressure reduction among hypertensive individuals,
blacks, and persons age 45 years and older compared to their counterparts. Net
systolic/diastolic blood pressure reductions associated with reducing salt from
the higher to the lower level in hypertensives and nonhypertensives were 8.3/4.4
and 5.6/2.8 mmHg, respectively. On the DASH diet, a qualitatively similar pattern
was evident, but the extent of blood pressure reduction was less; net systolic/diastolic
blood pressure reductions associated with reducing salt from the higher to the
lower level in hypertensives and nonhypertensives were 4.9/2.5 and 1.7/1.1 mmHg,
respectively. In each subgroup, the lowest blood pressure was observed on the
DASH diet with the lower sodium level.
In subsequent pos-hoc analyses, Bray et al. (2004) presented results in joint
subgroups (age and hypertension status, race/ethnicity and hypertension status,
and sex and race/ethnicity). In the control diet, sodium reduction significantly
lowered systolic blood pressure in each subgroup. In the DASH diet, many but
not all blood pressure changes associated with sodium reduction were statistically
significant in the subgroups. In all subgroups, the DASH diet significantly lowered
blood pressure at the higher sodium level; however, at the lower sodium level,
several blood pressure reductions did not achieve statistical significance. Overall,
the general pattern of results in subgroup analyses was similar to that of the
main results. Deviations between main results and subgroup analyses, especially
post-hoc analyses, should be interpreted cautiously because of reduced sample
size and hence the potential for false negative associations.
The control diet, in which the blood pressure effect of sodium reduction was
the largest, is closer to what most Americans currently eat than is the DASH
diet. For instance, in the United States less than 10 percent of adult men and
1 percent of women consume 4.7 g per day of potassium (the potassium goal of
the DASH diet), and less than 25 percent of adult men and less than 5 percent
of adult women have a daily calcium intake from foods of 1,240 mg per day (the
calcium goal of the DASH diet) (IOM, 2004). The low-saturated fat and total-fat
contents of the DASH diet (goals of 6 percent and 27 percent kcal, respectively)
are likewise uncommon in the U.S. population. These observations, coupled with
the consistency of the findings across subgroups, support recommendations to
concurrently reduce sodium intake and consume the DASH diet. Although the duration
of each feeding period lasted only one month, it is reasonable to speculate that
adherence to the combination of the DASH diet and reduced sodium intake might
help blunt the well-documented rise in blood pressure that occurs with age, especially
because reductions in systolic blood pressure were greater in the older than
younger participants.
As documented above (also, see IOM, 2004 Tables 6-13 and 6-15) the effects of
sodium on blood pressure are large and clinically relevant in hypertensive individuals
not on medication. Sodium reduction also lowers blood pressure in the presence
of antihypertensive drug therapy (Appel et al., 2001). Although the effects of
sodium intake on blood pressure are smaller in nonhypertensive individuals, the
potential benefits of sodium reduction on blood pressure have substantial public
health relevance. Stamler et al. (1989) estimated that a 3 mmHg reduction in
systolic BP could lead to an 8 percent reduction in stroke mortality and a 5
percent reduction in mortality from coronary heart disease. In observational
studies, a reduced salt intake (as manifest by 24-hour urinary sodium excretion)
is also associated with a blunted ate-related rise in blood pressure (Rose et
al., 1988).
Sodium reduction can also prevent incident hypertension. To date, three trials
have explored the effects of a reduced sodium intake as a means to prevent hypertension
(Hypertension Prevention Trial [HPT], Trial of Hypertension Prevention
Phase I [TOHP1], and Phase II [TOHP2 Collaborative Research Group,
1997]). HPT and TOHP1 were pilot studies that were conducted to inform the design
of TOHP2. Each study was a controlled trial in which a behavioral intervention
focused exclusively on reducing sodium intake. HPT and TOHP2, also included groups
that simultaneously implemented other interventions: increased potassium intake
in HPT and weight loss in TOHP2 (1997). Net reductions in urinary sodium excretion
on the sodium reduction arm were modest in the three studies, ranging from the
equivalent of 300 mg to ~1,300 mg of sodium per day, at the end of followup.
In this setting, a reduced sodium intervention that did not include any other
lifestyle change led to a decreased relative risk of incident hypertension (range
0.69 to 0.82).
Results from TOHP2 are especially relevant because this trial was designed and
adequately powered to test the effects of a reduced dietary sodium intervention
as a means to prevent hypertension. TOHP2 was a randomized, controlled 2 x 2
factorial trial that tested the effects of 3 lifestyle interventions (sodium
reduction, weight loss, or combined weight loss and sodium reduction) on blood
pressure and incident hypertension over 3 to 4 years of followup in overweight
individuals aged 30 to 54 years with an initial diastolic blood pressure of 83
to 89 mm Hg and a systolic blood pressure < 140 mm Hg. At 6 months, the height
of intervention adherence, the incidence of hypertension was lowest in the combined
group (2.7 percent), intermediate in the weight loss only (4.2 percent) and sodium
reduction only (4.5 percent) groups, and highest in the control group (7.3 percent).
At 18 months, the pattern persisted. By the end of follow-up, the incidence of
hypertension was 18 to 22 percent less in each lifestyle group (p< 0.05 compared
to control) but not different from each other. Results of this trial indicate
that lifestyle interventions can prevent hypertension over the long-term. Also,
the pattern of incident hypertension at 6 and 18 months suggests that the effects
of weight loss and reduced sodium intake, under optimal conditions of adherence,
may be additive.
Relying on behavioral interventions to reduce dietary intake of sodium presents
a major barrier to the achievement of greater reductions in blood pressure and
to a reduction in the associated CVD complications. In contrast to the short-term
(3-day) feeding trials that could achieve contrasts in sodium intake of nearly
34,300 mg per day (Luft et al., 1979), the maximum contrast in the primary prevention
trials was 1,300 mg per day in TOHP1. The average contrast in long-term trials
lasting 6 months was only 800 mg per day (Hooper et al., 2002). The limited contrast
in sodium intake in these trials reflects the difficulties of sustaining behavior
change when the most common source of sodium, namely processed foods, accounts
for > 75 percent of total sodium intake and when discretionary salt intake
accounts for only 11 percent (5 percent added during cooking and 6 percent added
at the table) (Mattes, 1997). The sodium that occurs naturally in foods accounts
for the remainder (approximately 10 percent).
Salt Sensitivity. Evidence from a variety of studies,
including observational studies and clinical trials, has demonstrated heterogeneity
in the blood pressure responses to sodium intake. Those individuals with the
greatest reductions in blood pressure in response to decreased sodium intake
are termed salt sensitive. Despite the use of the terms
salt sensitive and salt resistant
to classify individuals in research studies, the change in blood pressure in
response to a change in salt intake is not binary. Rather, the reduction in blood
pressure from a reduced sodium intake has a continuous distribution across individuals.
Also, there are no standardized diagnostic criteria and tests. Despite these
limitations, it is possible to make some general observations.
Salt sensitivity is modifiable. The rise in blood pressure
from increased salt intake is blunted in the setting of
a high potassium intake (4.7 g of supplemental
potassium per day in one trial, (Morris et al., 1999); 6.7
g per day in another trial, (Schmidlin et al., 1999)). The
rise in blood pressure from increased salt
intake was also blunted in the setting of the DASH diet,
which is rich in potassium (4.6 g of potassium per day)
as well as other minerals (Table 6-1) (Bray et al.,
2004; Karanja et al., 1999; Sacks et al., 2001; Vollmer et
al., 2001); nonetheless, a dose-response relationship between
sodium intake and blood pressure persisted.
Individuals with hypertension, diabetes, and chronic kidney disease, as well
as middle- and older-aged persons and blacks tend to be more salt sensitive than
their counterparts. Genetic factors also influence the blood pressure response
to salt. Each of the 14 identified genes that affect blood pressure affects renal
salt handing. Such evidence provides indirect support of an etiologic role of
sodium in blood pressure homeostasis (Lifton, 2002).
Relationships Between Salt Intake and Health Outcomes Other Than
Blood Pressure. As documented by the IOM (IOM, 2004), an increased
sodium intake might have adverse effects on additional health outcomes. These
include clinical cardiovascular outcomes (i.e., stroke and coronary heart disease),
subclinical cardiovascular outcomes (i.e., left ventricular mass), and noncardiovascular
outcomes (e.g., urinary calcium excretion, osteoporosis, and gastric cancer).
Cross-sectional studies consistently document an association between urinary
sodium excretion and left ventricular mass, but only one small controlled trial
assessed the effects of sodium reduction on this endpoint. Numerous trials document
that a reduced sodium intake lowers urinary calcium excretion (Table 6-19; IOM,
2004), but urinary calcium excretion, by itself, is not a well-accepted surrogate
marker for bone mineral density or dietary induced osteoporosis. Evidence that
links sodium intake with gastric cancer is reasonably strong but still insufficient
to establish a UL for sodium. No trial has tested the effects of sodium reduction
as a means to prevent cardiovascular disease (CVD). However, the most rigorous
observational studies (He and MacGregor, 1999; Tuomilehto et al., 2001; see Table
6-17 IOM, 2004) have documented a direct relationship of sodium intake with CVD.
Salt Taste Preferences. At birth, there is no indication
that salty substances are distinguishable or preferred (Beauchamp et al., 1986).
Preference for the salty taste appears at about four months postnatal (Beauchamp
et al., 1994; Beauchamp et al., 1986; Harris and Booth, 1987). Limited evidence
suggest that infants' and children's salt preference is shaped by their experience
with salt in foods (Beauchamp, 1990; Stein et al., 1996)
Adult salt preferences can be influenced by dietary exposure. Studies have demonstrated
that reducing one's dietary sodium intake can decrease one's preference for salty
foods and increase acceptance of foods with reduced sodium content (Bertino et
al., 1982). Several studies document a temporary increased preference for salt
over the initial few weeks when sodium intake is reduced (Bertino et al., 1981;
McCance, 1936, Teow et al., 1985–1986; Yensen, 1959). Subsequently, a shift in
preference occurs such that by 8 to 12 weeks individuals prefer less salty foods
(Bertino et al., 1982; Mattes et al., 1991; Mattes, 1997). This phenomenon also
has been demonstrated in long-term studies lasting one year or more (Blais et
al., 1986).
On average, the natural salt content of food accounts for only 10 percent of
total intake, while discretionary salt use (i.e., table and cooking salt) provides
another 5 to 10 percent of total intake. The remaining 75 percent is derived
from salt added by manufacturers (James, 2000; Mattes 1991, 1997). When total
intake of salt is decreased, discretionary salt use is fairly stable, even when
available ad libitum (Mattes, 1997). Therefore, any program for reducing
the salt consumption of a population should concentrate primarily on a reduction
in the salt used during food processing (James, 2000) and on changes in food
selection (e.g., more fresh, less-processed items, less sodium-dense foods) and
preparation (Mattes, 1997). Previous guidelines have focused on decreasing the
intake of foods and beverages high in salt (HHS 1985, 1990, 1995, 2000) because
of their large contribution of salt intake in the diet.
The IOM set the AI for sodium for adults at 1,500 mg per day to ensure that
the overall diet provides sufficient amounts of other nutrients and to cover
sodium sweat losses in unacclimatized individuals who are exposed to high temperatures
or who are moderately physically active (IOM, 2004). This amount of sodium does
not apply to highly active individuals, such as endurance athletes and certain
workers (e.g., foundry workers) who lose large amounts of sweat on a daily basis
and thus require a higher sodium intake.
The IOM set the UL at 2,300 mg of sodium per day (IOM, 2004). In dose-response
trials, this level of sodium intake commonly was the next tested level above
the AI. The UL of 2,300 mg of sodium daily is not a recommended intake. There
is no benefit to consuming sodium in an amount that exceeds the AI. For members
of groups that are most sensitive to the blood pressure effects of increased
salt intake (that is, middle- and older-aged persons, blacks, and individuals
with hypertension, diabetes, or chronic kidney disease), it is advisable to consume
an amount of sodium that is less than the UL. These groups also have higher levels
of blood pressure
Positions Taken by Other Policymaking Groups. Numerous
policymaking organizations have recommended a reduced salt intake as a means
to lower blood pressure in the general population. In the United States, the
National High Blood Pressure Education Program set a sodium intake goal of 100
mmol (2,300 mg) per day as a means to prevent hypertension in nonhypertensive
individuals (Whelton et al., 2002) and as first line and adjuvant therapy in
hypertensive individuals (Chobanian et al., 2003). The American Heart Association
set an intake of 6 g of salt (2,400 mg of sodium) per day as a recommended upper
limit for healthy Americans. In Great Britain, the Scientific Advisory Committee
on Nutrition in 2003 conducted an independent review of available evidence and
also set an upper limit of 6 g of salt (2,400 mg of sodium) per day. Recently
published Canadian recommendations for the prevention and treatment of hypertension
are to restrict salt intake to 65 mmol to 100 mmol (1,500 mg to 2,300 mg) per
day in hypertensive individuals and to 100 mmol (2,300 mg) per day in normotensive
individuals at risk for becoming hypertensive (Touyz et al., 2004). Note that
in the United States, 90 percent of adults will develop hypertension (Vasan et
al., 2002). In its report, Diet, Nutrition and the Prevention
of Chronic Diseases (2003), the World Health Organization set an upper limit of 70 mmol (1,600 mg)
of sodium per day as a means to lower blood pressure.
According to data from NHANES III (IOM, 2004), the median intakes of sodium
among adult men and women age 31 to 50 are 4,300 mg and 2,900 mg of sodium per
day, respectively. One quarter of adult men exceed 5,200 mg of sodium per day,
and one quarter of women exceed 3,500 mg per day. Approximately 95 percent of
adult men and 75 percent of adult women exceed the UL of 2,300 mg of sodium per
day, and 100 percent exceed the AI of 1,500 mg of sodium per day. On average,
blacks and non-blacks consume similar amounts of sodium. The reported sodium
intakes probably are underestimates of total sodium intake because the NHANES
III did not ask about discretionary salt intake.
Diets rich in potassium can lower blood pressure and lessen the adverse effects
of salt on blood pressure, may reduce the risk of developing kidney stones, and
possibly decrease bone loss. In view of the health benefits of potassium and
its relatively low intake by the general population, a daily potassium intake
of at least 4,700 mg is recommended. Blacks are especially likely to benefit
from an increased intake of potassium.
Effect of Potassium on Blood Pressure and Salt Sensitivity.
Supportive evidence for the conclusion that an increased potassium intake lowers
blood pressure appears in the IOM report (IOM, 2004), as follows:
Table 5-2 covering 17 observational studies
Tables 5-3 through 5-5 covering 36 clinical trials
Most trials tested pill supplements, typically in the form of potassium chloride
(Tables 5-4 and 5-5, IOM, 2004). Three meta-analyses of these trials document
that, on average, increased potassium intake lowers blood pressure in nonhypertensive
and hypertensive individuals (Cappuccio and MacGregor, 1991; Geleijnse et al.,
2003; Whelton et al., 1997). In the meta-analysis by Whelton et al. (1997), average
net systolic/diastolic blood pressure reductions from a net increase in urinary
potassium excretion of 2 g per day (50 mmol per day) were 4.4/2.5 mmHg among
hypertensive individuals and 1.8/1.0 mmHg among nonhypertensive individuals.
No dose-response trial tested the effects of more than two levels of potassium
intake on blood pressure.
Relatively few trials tested the effects of potassium as provided in foods (Table
5-3, IOM, 2004). The potassium in fruits and vegetables is accompanied by bicarbonate
precursors rather than chloride. In the initial DASH trial, a diet rich in fruit
and vegetables (and therefore rich in potassium) lowered blood pressure (Appel
et al., 1997). Another trial documented that increased fruit and vegetable consumption
can significantly lower blood pressure (John et al., 2002), but that trial did
not report the potassium intake of participants on the fruit and vegetable intervention.
Because virtually all trials used potassium chloride supplements while observational
studies assessed dietary potassium intake from foods (paired with nonchloride
anions), the effect of potassium on blood pressure appears to result from potassium
rather than its conjugate anion. No single trial tested the effects of three
or more levels of potassium intake on blood pressure; hence, the dose-response
relationship is unclear. Still, blood pressure reductions from supplemental potassium
occurred when baseline intake was low (e.g., 1.3 to 1.4 g of potassium per day
in Brancati et al., 1996) and when baseline intake was much higher (> 3.1
g of potassium per day in Naismith and Braschi (2003)).
Evidence from the observational studies and clinical trials
has demonstrated heterogeneity in the blood pressure responses
to potassium intake. Blacks and
hypertensive individuals are more sensitive to the effects
of potassium than their nonblack and normotensive counterparts,
respectively. Dietary salt intake
also modifies the effects of potassium on blood pressure.
Specifically, the effects of potassium on blood pressure
are greater when salt intake is high than when
salt intake is low (see Table D7-1).
Some trials have assessed the effects of increased potassium intake on salt
sensitivity, that is, the pressor response to increased salt intake. Study populations
included nonhypertensive predominantly black individuals (Morris et al., 1999;
Schmidlin et al., 1999) and hypertensive individuals (Morgan et al., 1984). These
trials are consistent in documenting that potassium blunts the pressor (blood-pressure
raising) effects of salt. One dose-response trial documented that increasing
potassium intake to 4.7 g per day reduced salt sensitivity in nonhypertensive
blacks (Morris et al., 1999). In aggregate, these trials highlight the potential
benefits of increasing potassium intake in blacks, a group of individuals with
a high prevalence of hypertension and of blood pressure-related cardiovascular-renal
To date, no trial has tested the effects of increased potassium intake on blood
pressure-related clinical outcomes. However, observational studies suggest that
increased potassium intake may prevent stroke and perhaps coronary artery disease
(see Table 5-6, IOM, 2004).
Effect of Potassium in Preventing Bone Loss and Kidney Stones.
A diet rich in potassium from fruits and vegetables favorably affects acid-base
metabolism because these foods also are rich in precursors of bicarbonate (Sebastian,
et al., 1994, 2002). Acting as a buffer, the bicarbonate-yielding organic anions
found in fruits and vegetables neutralize acids generated from meats and other
high-protein foods. In the setting of an inadequate intake of bicarbonate precursors,
excess acid in the blood titrates bone buffer. This results in demineralization
of the bone. Increased bone breakdown and calcium-containing kidney stones are
adverse consequences of excess acid derived from the diet. Therefore, diets rich
in potassium with its bicarbonate precursors might help prevent kidney stones
and bone loss.
To date, two observational studies have documented that high intakes of potassium
(median of 4.0 g per day in men and 4.7 g per day in women) are associated with
a reduced risk of incident kidney stones (Curhan et al., 1993, 1997). In a third
observational study conducted in Finland, the relationship was statistically
nonsignificant, perhaps because of the much higher usual levels of potassium
consumed in this population (Hirvonen et al., 1999). In addition, one trial (Barcelo
et al., 1993) documented that approximately 3.6 to 4.7 g of supplemental potassium
citrate reduced the risk of recurrent kidney stones. The potassium added to processed
foods and the potassium in supplements typically has chloride as the conjugate
anion. Since chloride cannot neutralize excess acid in the body, this form of
potassium is not expected to help prevent kidney stones or bone loss.
Observational studies, including both cross-sectional studies and longitudinal
studies, suggest that increased potassium intake is associated with increased
bone mineral density (See IOM, 2004, Table 5-7). Trials also have documented
that supplemental potassium bicarbonate can reduce bone breakdown and increase
bone formation (Sebastian et al., 1994). However, no trial has tested the effect
of increased potassium or diets rich in potassium on bone mineral density or
on clinical outcomes related to osteoporosis.
The IOM set the AI for potassium for adults at 4,700 mg per day. This level
of intake should maintain lower blood pressure levels, mitigate the adverse effects
of salt on blood pressure, reduce the risk of developing kidney stones, and possibly
decrease bone loss. At present, dietary intake of potassium by all groups in
the United States is considerably lower than 4,700 mg per day. In recent surveys,
the median intake of potassium by adults in the United States was approximately
2,900 to 3,200 mg per day in men and 2,100 to 2,300 mg per day in women. On average,
blacks consume less potassium than non-blacks. Among men, age 31 to 50 years,
median potassium intake was approximately 2,600 mg in blacks and 3,300 mg in
non-blacks. Corresponding figures in women were 1,900 mg and 2,400 mg, respectively
(see Table D1-7). Because blacks have a relatively low intake of potassium and
a high prevalence of elevated blood pressure and salt sensitivity, this subgroup
of the population would especially benefit from an increased intake of potassium.
In the generally healthy population with normal kidney function, a potassium
intake from foods that exceeds 4.7 g per day poses no potential for increased
risk because excess potassium is readily excreted in the urine. Hence, the IOM
did not set a UL for potassium (IOM, 2004). However, a potassium intake below
4.7 g per day is indicated for individuals whose urinary potassium excretion
is impaired. Adverse cardiac effects (arrhythmias) can result from hyperkalemia,
which is a markedly elevated serum level of potassium. Common drugs that can
substantially impair potassium excretion are angiotensin converting enzyme (ACE)
inhibitors, angiotensin receptor blockers (ARB), and potassium-sparing diuretics.
Medical conditions associated with impaired potassium excretion include diabetes,
chronic kidney disease, end stage renal disease, severe heart failure, and adrenal
insufficiency. As a group, elderly individuals are at increased risk of hyperkalemia
because they often have one or more of these conditions or take one or more of
the above medications.
Healthy persons who have routine access to fluids and who are not exposed to
heat stress consume adequate water to meet their needs. Thus, the Committee makes
no special recommendations concerning water intake. To help lower blood pressure,
the Committee recommends that individuals reduce their salt intake as much as
possible, aiming for less than 2,300 mg of sodium daily. The Committee recommends
a concurrent increase in potassium intake to 4,700 mg daily. In addition to helping
lower blood pressure and blunting the effects of salt on blood pressure, this
amount of potassium intake may reduce the risk of developing kidney stones and
possibly reduce bone loss. Blacks are especially likely to benefit from reductions
in sodium intake and increases in potassium intake.
Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA,
Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the
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Figure D7-1. Dose-Response Relationship Between Systolic Blood Pressure
and Sodium Intake in Two Diets: Main Results From the DASH Sodium Trial (Sacks
FM et al., 2001)
Control Diet represents the typical American diet. DASH diet emphasizes fruits,
vegetables, and low-fat dairy foods, includes whole grains, poultry, fish, and
nuts, and is reduced in fats, red meat, sweets, and sugar-containing beverages.
The 3 sodium levels are defined as higher (3,450 mg/d), intermediate (2,300 mg/d)
and lower (1,150 mg/d).
Table D7-1. Trials That Assess the Main and Interactive
Effects of Salt and Potassium on Blood Pressure
Select icon to view table
1Previous recommendations
from authoritative sources have recommended consuming less than 2,400 mg of sodium
rather than 2,300 mg. The limit of 2,400 mg is equivalent to 6 g of sodium chloride,
whereas the limit of 2,300 mg corresponds to 100 mmol of sodium. Previous standards
had been based on milligrams of sodium chloride rather than millimoles of sodium.
2In view of the form of published
data and nutrition labeling, which typically provide milligrams of sodium rather
than milligrams of salt, this section will present recommendations in milligrams
of sodium.
of Contents
A. Executive Summary
B. Introduction
C. Methodology
D. Science Base
Read Public Comments


text:
'North Korea Has Launched a Missile' tweet sent by mistake
Red faces at Yokahama city government after slip of the mouse
City officials in Yokohama were left feeling rather embarrassed earlier this week after jumping the gun on possible nuclear armageddon by mistakenly tweeting that North Korea had launched a missile.
The over-enthusiastic managers of the @yokohama_saigai Twitter account were to blame for the incident, which happened just before midday on Wednesday, according to AFP.
Alongside the message "North Korea has launched a missile" was apparently a space where the time should have been inserted. "We had the Tweet ready and waiting, but for an unknown reason it was dispatched erroneously," a red-faced official told the news wire.
The city deleted the message some 20 minutes after it went live, but then drew attention to the mistake by apologising for the error in a subsequent tweet.
Japan is on high alert after NORKS' repeated threats to target the US and its allies and this week deployed Patriot PAC-3 anti-missile batteries to Tokyo.
Despite Yokohama jumping the gun on Wednesday, there is a widespread anticipation that Pyongyang is planning a missile test or some kind of military display of strength to coincide with the anniversary of founder Kim Il-Sung's birth.
Increasing tensions on the peninsula have not been eased by panicky media reports that the totalitarian state has nuclear capabilities, an allegation politicians like UK Prime Minister David Cameron have been keen to point out.
As El Reg reported this week, however, it's more likely to be North Korean bluster than a real and present threat.
If nothing else, the incident should serve as yet another warning to social media managers to keep their eyes on the ball. ®

subset: commoncrawl


text:
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Neal Abid1 Sunday, December 2, 2012 Marks Street Community Ce nter in Orlando, Florida Esam Alhadi, Interviewer and Translator for University of Florida George A. Smathers Libraries Edited by Jardee Transcription Also present, Richard Saltzburg Alhadi: Hello, Mr. Neal. Abid: Hello. Alhadi: My name is Esam Alhadi. I am a lecturer at the University of Florida in Gainesville. We are happy to have you with us toda y. It is now 1:50 PM. Today is Sunday, December 2, 2012. We are here in Marks St reet Convention Center in the city of Orlando, Florida. Thank you for giving us this opportunity to have this interview with you. Abid: You are very welcome. Alhadi: First, we would like to get to know you and to know a littl e bit about the early phase of your life before coming to America, includi ng your place of bi rth and education. Abid: I was born here in America in Engl ewood, New Jersey, in 1958. My father came to America in 1920, and lived here for thirty ye ars before returning to Palestine to get married and come back with his wife. We we nt back to Palestine in 1966, and lived there in a small village called Deir Debwan, in the Ramallah area, where I finished my elementary and middle school education. In 1980, I came back to America and joined college. I didnt continue beyond my first year of college education. I decided to move on and find work. Alhadi: What college did you go to? 1 Alternate English spelling: Nile Abiid.
Abid: I went to City College in San Francisco. Alhadi: Your trip has been from New Jersey to Palestine to San Fran cisco. Why did you make this move from the East Coast to the West Coast? Abid: My father and mother decided to stay in Palestine. I decided to join some of my uncles and other relatives who were living in Califor nia. This is the main reason behind my decision of going to California. Alhadi: Tell us about your relatives in California. Abid: I have relatives in San Francisco and other parts of California. I also have relatives in New Jersey and New York. Alhadi: What did you study when you went to college? Abid: My intention was to study political sc ience. I started by ta king general courses. Alhadi: When did you move fr om California to Florida? Abid: I came here in 1997. Alhadi: Why did you choose Orlando to be your home town in Florida? Abid: Before coming to Orlando, I used to work for John Hancock Mutual Life. It is a life insurance and investment company. I was also the president of Deir Debwan Society. I came to Florida to meet with many members of this society who live in the main cities such as Tampa and also in the South Florid a area. Our society has members all over the States. This society does charity work to support our village back home. I came to Orlando because a friend of mine used to live he re. Four years later after that trip, I made the decision to move to Orlando. Alhadi: Before examining the details about your professional and life experiences in America, I would like to ask you tell us a little bit about your experi ences in Palestine. You
mentioned that you had all your pre-college educ ation there. Can you tell us more about your memories and friends from this period? Abid: I finished my education at Deir Debwan. It was very hard at the beginning because I was only eight years old when I went there in 1966. I had no knowledge of Arabic at that time. My family thought I would be able to pick up the Arabic language very quickly because I was still young. My older sister di dnt have the same problem because she had the opportunity to travel to Pa lestine before. My other sist er joined an Arabic/English school. The shift from an English-speaking se tting to an Arabic-s peaking one made my childhood days in Palestine very hard at the beginning. The result was that I lost my English and had no good luck with Arabic. Th e first two years were very hard, and I continued to suffer until I reached middle schoo l. Participating in many activities in middle school such as volleyball and basketball helped me to restore my self-confidence and to live a normal life. During my chil dhood, I loved to question everything. I asked my parents about nature, customs and traditio ns in our country that I was unable to understand. I also had many questions about customs and traditions in America. Alhadi: I hope you didnt have a problem with English when you came back to America? Abid: I had. That created a second language cr isis for me. However, I managed to get through it safely. Alhadi: What did your father used to do wh en he was here, and what was his field of experience? Abid: He used to work in an American factory for a long period of time in New Jersey and New York. He also served in the American Army and fought during WW II. He was stationed in Alaska. My fath er lived here for thirty year s beginning in the 1920s. There
werent that many Arab immigr ants at the time. This led him to integrate himself completely into the American social fabric a nd to become part of it. He spoke English with no accent. My accent is more pronounced th an his. His nature and behaviors were more American than mine. Alhadi: I find it puzzling for a person who was so Americanized to leave a nd to spend the rest of his life back home. Abid: When he started to get older, he figured that it would be better for him to go back and spend his retirement days there. He also wanted his children to be brought up the Palestinian way. He prepared himself for this move. He built a house there. My mother also played a part in this decision because she wanted to be with her relatives and brothers who were living back in Palestine. Also, the small number of Arabs here in America during the 1960s was another reason fo r him to leave. The biggest waves of Arab immigration and particularly those from Palestine began late in the 1960s and the 1970s. Alhadi: Anyone might think that it would be much be tter to retire in this country to benefit from the medical and other health services that are available here for elders. Abid: When my father decided to retire, he wa s in good health and had no problems at all. This might be because of his service in the militar y. He also received a monthly pension from the military in addition to the Social Securi ty benefit. His monthly payment was about $3500. This is a lot of money for the 1960s peri od. We were living almost a royal life. He estimated that the decision he took was in his best interest. He also knew that all members of his family are American citizens a nd have the right to come back to America whenever they want.
Alhadi: Would you tell me a little bit about your siblings? Abid: I have three brothers. One of them di ed in San Francisco in 1993. I also have three sisters. One of my brothers and one of my sisters live in Ne w Jersey. Two of my sisters live in California. Alhadi: Do you have any of your immediat e family still living in Palestine? Abid: My mother lives here in Orlando. The only people we still have there are my uncles and cousins. There are too many of them. Alhadi: Are you still maintaining your re lationship with Ramallah and Deir Debwan? Abid: Yes, I went back in 1982, 1984, 1988, 1992, 1994, 1998 and the last time was in 2006. Alhadi: How long do you stay when you go there? Abid: It depends. I usually stay for a period of two to four weeks. Alhadi: I assume you have no problem going back and forth since you are an American citizen? Abid: Apart from the few troubles that the Israe lis gave me the last time I was there, I didnt have any problem. Alhadi: Thank you for the very good informa tion that you have given us about your early upbringing, education and family. Let us now move on to the business arena. Would you please tell us a little bit about the kind of business you ar e doing here in Florida, and how long have you been doing it? Abid: I do credit card processing. I help stores by providing cr edit card processing machines, the set-up, and making sure they function properly. Alhadi: May I ask for more elaboration about this kind of business? I personally dont understand too much about it. What is your ro le after this machine is installed and set up?
Abid: Our company provides 24-hour-a-day cust omer service in case any problems come up. Seventy percent [70%] of my customers ar e of Arab descent. They feel more comfortable dealing with me. They always love to talk to me rather than calling customer service. This goes back to th e good treatment I give my customers and my good relationship with them. Wh en any of the Arab immigrants start a new business, they manage to reach me and ask for help. We also offer other services such as gift cards and wireless services. It is now possible to use this service through the phone. Our company provides such a service. Alhadi: What company do you work for? Abid: It is called First Data. Alhadi: I believe working in this field would not succeed without a solid background and experience. How did you start working in this field? Abid: I have been in sales my entire life. I was in the wholesale busin ess when I was with John Hancock Mutual life. I always have had the ability and capacity to build wide relationships, particularly with Arab immigran ts. I am very activ e in Arab immigrant communities. We are the or ganizers of todays health, immigration, and employment fair. I was the president of th is society in 2007. I am currently the vice president. I am currently working to open new branches for this society in South Florida and in Tampa. I have been in touch with the Arab community my entire life and always look for things to do for them. My business depends on whats called residual income which works by getting a fixed percent of the income from bills that are paid every month. The bigger the number of customers I get, the bigger my m onthly income grows. If the number of
customers fluctuates, then my income will no t be stable. It also depends on how well businesses do. These are the reasons why I involve myself in many things. Alhadi: Would you please give us more deta ils about the company? When did you start working in it and who helps you? Abid: I started working for First Data three years ago. It is one of the bigg est companies in this field. It dominates over 53% of the market in this field of business. Many of the big banks and companies use this service. Before getting into this fiel d, I learned about the company. When I made the decision to join the [company], I was s ubjected to intensive training and attended meetings and conference calls with them I also had to keep up with the regular and routine updates concer ning their various areas of work. This company is considered one of the top and olde st companies in the credit card processing business in America. Alhadi: What is your exact role in the company? Abid: I have my own company that works under the First Data umbrella. I am an independent sales agent and decide my own work hours and when and how to work. I set my own appointments. I am known as a company representative who operates independently. Alhadi: Does this mean you get your own customers? Abid: True. Alhadi: Does anyone help you with your business, or do you do it all by yourself? Abid: My son helps me with office work. He is also the one who doe s the pricing, processes applications, and faxes them. He does prici ng on the computer and the follow-up work. He is the only one who is helping me. Alhadi: Does your son rega rd this as his career?
Abid: He is doing this work besides his job at th e Hilton Hotel. He graduated a year ago with a degree in business. Alhadi: As I mentioned before, I dont know mu ch about this kind of business. What can you do to develop this work further? Is it only a matter of getting more customers? Abid: There are many ways to develop this work. It is possible to recruit agents to work for you. It is also possible to recruit more custom ers. It is also possible to create more connections with merchants. It is also possible to use the Inte rnet to market your business and bring more customers to your company. Alhadi: Are all your customers from Florida? Or do you recruit customers from all over the country? Abid: Most of them are from Florida such as Orlando, Tampa, and South Florida. I have some customers from Louisiana. It is possibl e to have customers from other states. Alhadi: Currently, do you have customer s from outside Florida and Louisiana? Abid: Currently, I dont. Alhadi: Does that mean the possibility is there? Abid: Correct. However, my mother is sick a nd I have to spend most of my time taking care of her. This is what is limiting me at this time. Alhadi: Is there an opportunity to expand this work outside America? Abid: It is possible since the entire world is now moving towards using credit cards, thanks to todays technological advances th at made the world very well connected. This makes the possibility of running such a business at the international le vel very possible. Alhadi: This sounds like a very interesting busin ess experience. As I told you earlier, I havent come across any similar experience.
Abid: The Arabs who are doi ng this are very limited. Alhadi: Do you know any others who are doing it? Abid: I dont know more than th ree or four Arabs in the entire state of Florida who may be working in this business. Alhadi: Could the reason for your focus on the Arab business owners be that it is easy to deal with them? Abid: The main reason is that I have always be en actively involved in all matters related to the Arab immigrant community. I have always been active since I came to America in the political, cultural, and social arenas. This activism gave me the opportunity to be well connected with most of the Arab immigrants. Alhadi: It is useful to learn more about these endeavors. What are the various things you do and how do you facilitate the needs of the Arab immigrant community? I also want to know more about todays event that is taking pl ace in this center which is organized by your association. Can you tell us more about these? Abid: The Arab American Community Center AACCstarted in 1990. It was founded by Dr. Khalid Diryab, may God rest hi s soul in peace. He was a Palestinian. The aim behind this community was to bring the growing Arab community under one umbrella. This society has become quite notable and remarkable in America. We have taken very serious steps during the last ten years. This is in spite of the fact that all those who serve on the society board are volunteers. We dont have even one single full-time employee. When I was the president in 2007, we promoted the goals of our society through offering social services to our Arab commun ity in the Orlando area. These services included immigration services. These were offered through our immigration director and
lawyer who were there to help by answering any question, if neede d, or to direct our members to the right lawyers office or any other official offices that may offer their service free of charge. We deal with many lawyers of Arab descent. Our immigration director is Mr.Nayef Mubarak. This is part of our regular services that we offer. We also organize an annual convention for health and immigration services like this one we are having today. People come and meet with specialists who will be here to offer any services and answer questions free of charge. They will be referred to a specialist if needed and we will help them get services at a reduced price. We work to offer health services to our community me mbers. These will be in areas such as prevention services or by referring our members to the free clinics that are here in town. Such service is of great help to those w ho may have low income or have no medical insurance. We also get help from a number of doctors of Arab descent who volunteer to give free visits. We also offer an annual event for free health services. We also offer services in the employm ent area. We help our members to get work. We work with Workforce of Central Florida which tries to match everyones skills with the jobs that are available. They dire ct people to the places that they know are hiring and help with resume-bu ilding and training. We direct our members to go to these offices. This is part of the work that we do in this society. We have also organized cultural festival s during the last two years. The last one we had was in downtown Orlando on March 25 of this year and attracted about 20,000 viewers; 25% of them were not of Arab descent. That day is now officially designated by the Orlando Mayor as Arab Day in Orlando. In addition to the mayor, that day was also attended by the sheriff and the district at torney. The idea behind this festival is to
make people aware of our culture, civilization, an d culinary traditions. It is also intended to quell any doubts and suspicions which arose and which have been repeatedly directed at the Arab communities since 9/11 and to show our culture and society in an honest and open way. We succeeded in spreading our good work and message to the Tampa and South Florida areas. In addition to social and cultural activ ities, our society is also involved in a number of charity projects. One example of our work in this area is a food drive that we organized together with an Arab church in the downtown area. We distributed food to 300 individuals and gave away more than 300 blankets to the needy. We are also active in the political area We persuade and help our members to register and participate in all election campaigns. We i nvited about twenty candidates from both parties who were running for pub lic offices to come and talk to our membership about their programs and why they think we should vote for them. We are registered as a bipartisan 501(c) (3) tax-exempt organization. Among those who came to talk to our membership were a number of congressional hopefuls, sheriff candidates and senate and county candidates. Some of thes e meetings were attended by no less than 175 of our members, compared to many other similar public events where you dont find more than fifteen or twenty attendees. They were very impressed by these events. Alhadi: These are very impressive activities. Le t me ask one more question before we conclude this interview. Do you keep an accurate list and do you tr ack Arab community members here in Orlando? And if yes, how many members do you have? Abid: Statistics and estimates of the Arab comm unity in the entire stat e of Florida point to around 225, 000. We dont have accurate statistics on them in Orlando, but the number
may vary between 50, 000 to 60,000. Thirty th ousand [30,000] to 35, 000 of them are of Moroccan descent. This is the largest gr oup of those with Arab nationality, and the largest group in Orlando. The reason for this is that the Moroccan Pavilion at the Epcot theme park at Disney has been known sin ce the 1970s. Many Moroccans came here with a work visa to work on this pavilion and continued to live here since that time. This is what makes the Moroccan community the la rgest group of Arab nationals in Orlando. Alhadi: Does this Moroccan Pavilion still exist at Disney? Abid: It does, and is owned by our very good friend Rashid Choufani. Alhadi: We are very happy to listen to your inte resting, rich, and great experiences. I wish you the best of luck. You are doing a great and honorable work. Abid: Thank you. [END OF INTERVIEW]