Potassium labeling of foods: Potential benefit for blood pressure

More than 100 years ago, a connection between excess sodium consumption and blood pressure was identified.1 Exactly 50 years ago, the White House Conference on Food, Nutrition, and Health urged food manufacturers to “minimize the amount of salt” in their products.2 And almost a decade ago, because of continued high sodium consumption, the Institute of Medicine recommended that the US Food and Drug Administration (FDA) set gradually declining mandatory limits on sodium levels in various categories of foods.3 In 2016, the FDA proposed voluntary limits, which have not yet been finalized. Reducing sodium in processed foods is challenging, partly because few salt substitutes have been discovered. However, at least two non-mutually exclusive means of lowering sodium are readily available. The first option is for companies simply to use less salt. For instance, Nabisco decreased sodium in Wheat Thins from 360 (1972) to 200 mg per ounce today, and General Mills reduced sodium in Wheaties from 370 (1984) to 190 mg per ounce today, apparently without consumer objections. Undoubtedly, many other companies could achieve similar reductions without affecting consumer acceptance or endangering food safety. A second option is to take advantage of the salty taste of potassium chloride (KCl) to replace some of the salt. That option is also attractive because in controlled studies increased potassium intake (from supplements) decreases blood pressure, at least among people with high blood pressure, who now comprise nearly half (46%) of all US adults.4, 5 It has been estimated that consuming optimal levels of potassium could reduce the prevalence of hypertension by as much as 17%.6 While high levels of KCl substitution can taste bitter or metallic, KCl can replace 20 to 50% of salt in many processed foods without negatively affecting taste. A marketer of KCl, NuTek, informed the FDA that added KCl lowered sodium by an average of 34% in 19 different foods, from American cheese to hot dogs to white bread, and by up to 50% in pepperoni, while maintaining equivalent taste.7 A barrier to this beneficial substitution, however, is that a priority for many companies is to have “clean labels”—that is, ingredient lists without chemical-sounding names. Some manufacturers fear that adding “potassium chloride” to ingredient lists would scare off some consumers who might associate the word “chloride” with “chemicals,” chlorine bleach, or other undesirable ingredients.8 Hence, the FDA has been petitioned to allow the term “potassium salt” as a non-objectionable synonym for KCl. Several trade associations and major companies, health organizations, hypertension experts, and a US consumer group (MFJ's organization, the Center for Science in the Public Interest) have supported the term “potassium salt.” The FDA recognizes the need to lower sodium intakes. However, in a proposed Guidance, the agency said that “potassium salt” has not been used as a “common or usual name” for potassium chloride and that some consumers might confuse “potassium salt” with sodium chloride or other potassium-containing salts.9 For that reason, the FDA has proposed “potassium chloride salt” as a synonym. Unfortunately, “potassium chloride salt” retains the offending word “chloride” and is wordier. Also, that term also has rarely been used and is no more a “common or usual name” than “potassium salt.” We believe that companies wanting “clean” labels are likelier to replace some of the regular salt with an ingredient named “potassium salt” than “potassium chloride salt.” The FDA has the authority to designate “potassium salt” as a synonym for KCl based either on common usage or by its own determination. If the FDA used that authority, consumers would be educated by news articles, blogs, and other means and quickly would understand that potassium salt is just a different name for potassium chloride. The labeling change would encourage companies to take advantage of KCl to reduce sodium, in addition to just using less salt. That could lower sodium consumption and increase potassium consumption at the population level. We would expect the result to be lower prevalences of both hypertension and cardiovascular disease. While much greater use of KCl could increase the risk of hyperkalemia in patients with advanced kidney disease and those taking certain pharmaceuticals, those patients will be better able to monitor their potassium intake when the new Nutrition Facts label, including the amount of potassium per serving, becomes mandatory in 2020. None for MFJ. NRCC was a paid consultant to the Novartis Foundation (2016-2017) to support their program to improve hypertension control in low- to middle-income countries, which included travel support for site visits and a contract to develop a survey. NRCC has provided paid consultative advice on accurate blood pressure assessment to Midway Corporation (2017) and is an unpaid member of World Action on Salt and Health (WASH).

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