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Waiter, There's Potassium in My Soup!

      As renal dietitians, much of our time revolves around helping our patients to navigate the ever-changing nutrition market, whether it is new foods targeted to renal patients or upcoming food trends present in the media. Dialysis patients may be inclined to select low-sodium products as part of their nutrition education revolves around limiting dietary sodium intake. Low-sodium soups can act as an easy and quick meal for patients; however, they may be surprisingly high in potassium. This article will address potassium content of soup from two leading manufacturers of canned soup: Campbell's and Progresso.
      Salt reduction is not just a focus for renal patients; the majority of Americans eat too much salt.
      • Cogswell M.
      • Zhang Z.
      • Carriquiry A.
      • et al.
      Sodium and potassium intakes among US adults: NHANES 2003–2008.
      The average American consumes 3.6 to 4.8 g of sodium per day.
      • Cepanec K.
      • Vugrinec S.
      • Cvetković T.
      • Ranilović J.
      Potassium chloride-based salt substitutes: a critical review with a focus on the patent literature.
      According to the National Health and Nutrition Examination Survey 2003-2008, 99.4% of American's consume more than the American Heart Association's recommendation of 1,500 mg of sodium per day.
      • Cogswell M.
      • Zhang Z.
      • Carriquiry A.
      • et al.
      Sodium and potassium intakes among US adults: NHANES 2003–2008.
      The 2015-2020 Dietary Guidelines for Americans recommend less than 2,300 mg of sodium.
      Centers for Disease Control and Prevention
      CDC. Sodium reduction initiative.
      In the United States, cardiovascular disease (CVD) continues to be the number one killer of men and women, and hypertension is the leading cause of CVD.
      Centers for Disease Control and Prevention
      CDC. Million Hearts™: strategies to reduce the prevalence of leading cardiovascular disease risk factors. United States, 2011.
      Excess dietary sodium intake is associated with an increased risk of hypertension. This link between hypertension, heart disease, and increased mortality risk has driven the public health campaign to reduce sodium in food.
      Centers for Disease Control and Prevention
      CDC. Sodium reduction initiative.
      Centers for Disease Control and Prevention
      CDC. Million Hearts™: strategies to reduce the prevalence of leading cardiovascular disease risk factors. United States, 2011.
      To combat the high dietary sodium intake of Americans, food manufacturers are searching for salt substitutes to provide a salt-like flavor while limiting the overall sodium content. The most commonly used salt substitute is potassium chloride; potassium chloride has multiple benefits when replacing sodium chloride in foods. The World Health Organization has made a strong recommendation for the increase in dietary potassium intakes to reduce blood pressure, thereby reducing the risk of heart disease and stroke.
      WHO
      Effect of Increased Potassium Intake on Cardiovascular Disease, Coronary Heart Disease and Stroke.
      The National Health and Nutrition Examination Survey results reflected that less than 2% of the US adult population meets the 4,700 mg recommendation of daily potassium consumption.
      • Cogswell M.
      • Zhang Z.
      • Carriquiry A.
      • et al.
      Sodium and potassium intakes among US adults: NHANES 2003–2008.
      A study in 2006 showed a long-term beneficial effect on CVD secondary to a major increase in dietary potassium consumption with a moderate decrease in sodium consumption.
      • Chang H.Y.
      • Hu Y.W.
      • Yue C.S.
      • et al.
      Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men.
      Food Business News lauds potassium chloride as an additive of choice to meet the increasing demand to lower sodium in foods with the benefit of adding potassium.
      Dialysis patients are educated to limit their potassium intake, with most recommendations ranging from 2,000 to 3,000 mg.
      National Kidney Foundation
      K/DOQI clinical practice guidelines for nutrition in chronic renal failure.
      Potassium levels are monitored regularly in patients on dialysis, a normal potassium level is 3.5 to 5.0; a level greater than 6.0 can be life threatening.
      • Van Buren L.
      • Dötsch-Klerk M.
      • Seewi G.
      • Newson R.S.
      Dietary impact of adding potassium chloride to foods as a sodium reduction technique.
      Hyperkalemia can be asymptomatic and cause ventricular arrhythmias; these alterations in the rhythm of the heart can be fatal.
      • Kamel K.S.
      • Wei C.
      Controversial issues in the treatment of hyperkalaemia.
      Although potassium is an essential electrolyte and may be considered an important nutrient for blood pressure control for the general population, it is a nutrient of concern that needs to be regularly monitored for hemodialysis patients.
      The presence of potassium in soups marketed to be of reduced sodium or “heart healthy” can be seen in Table 1. Potassium chloride is the salt substitute of choice for these products. A concern for dialysis patients is the use of potassium products in soups that are not labeled as reduced sodium and do not advertise the increased potassium content. Progresso's Light Soup products use potassium chloride; however, the main selling point of the soup is a reduction in calories. The reduced-sodium Progresso soups contained 1,000 to 1,700 mg of potassium per container, whereas their light soups contained 500 to 1,200 mg of potassium. These soups can provide as much as 50% or greater of total recommended intake of potassium for dialysis patients.
      Table 1Sodium and Potassium
      Potassium chloride present in all soups listed.
      Content in Leading Canned Soup Brands (Single Serving vs. Total Container)
      Soup ProductTotal Potassium, mg/ContainerPotassium, mg/1 Cup ServingTotal Sodium, mg/ContainerSodium, mg/1 Cup Serving
      “Reduced” Sodium
       Campbell's Healthy Request Minestrone (10.75 oz.)2,5751,0301,020410
       Campbell's Chunky Healthy Request Savory Vegetable (18.6 oz.)2,1001,050820410
       Campbell's Healthy Request Tuscan-Style Lentil (11 oz.)2,0508201,025410
       Campbell's Healthy Request Tomato (10.5 oz.)1,750700820410
       Campbell's Healthy Request Chicken Noodle (18.6 oz.)1,700850820410
       Campbell's Health Request Savory Chicken with Brown Rice (18.6 oz.)1,480740820410
       Campbell's Healthy Request Chicken Noodle (10.5 oz.)9503801,025410
       Progresso Reduced Sodium Garden Vegetable (18.5 oz.)1,360680960480
       Progresso Reduced Sodium Hearty Minestrone (18.5 oz.)1,340670960480
       Progresso Reduced Sodium Black Bean & Vegetable (18.5 oz.)1,240620900450
       Progresso Light New England Clam Chowder (18.5 oz.)1,2006001,380690
       Progresso Reduced Sodium Italian Style Wedding (18.5 oz.)1,060530960480
       Progresso Light Beef Pot Roast (18.5 oz.)1,040520960480
       Progresso Light Chicken & Dumpling (18.5 oz.)5202601,360680
       Progresso Light Chicken Noodle (18.5 oz.)5002501,380690
      The potassium and sodium levels are listed as per 1 cup serving and per container.
      Potassium chloride present in all soups listed.
      The soups listed in Table 2 show “original” chicken noodle soup products versus chicken noodle soup products listed as reduced sodium or heart healthy. The products offer a wide range of sodium and potassium content; however, 5 of the 7 products contain over 1,000 mg of sodium per can. It is important to reiterate to patients the use of the nutrition food label. A low-potassium diet is approximately 2,000 mg; of the soups compared, 3 of the 4 reduced-sodium soups contain greater than 900 mg of potassium per container. These high-potassium foods can be considered dangerous for patients on dialysis and may lead to hyperkalemia.
      Table 2Sodium and Potassium Content in Chicken Noodle Soup (Single Serving vs. Total Container)
      Soup ProductPotassium, mg/1 Cup ServingSodium, mg/1 Cup ServingTotal Potassium, mg/ContainerTotal Sodium, mg/Container
      Reduced sodium
       Campbell's Chunky Healthy Request (18.6 oz.)8504101,700820
       Progresso Reduced Sodium (18.5 oz.)470480940960
       Campbell's Healthy Request (10.5 oz.)3804109501,025
       Campbell's 25% Less Sodium (10.5 oz.)906602251,650
      Original
       Campbell's Chunky (18.6 oz.)4307908601,580
       Progresso (18.5 oz.)3506907001,380
       Campbell's (10.5 oz.; condensed)508901252,225
      The table compares reduced sodium chicken noodle soup with original chicken noodle soup. The potassium and sodium levels listed are per 1 cup serving and per container amounts.
      The nutrition label on soup products can help steer patients to make informed choices, allowing them to be advocates for their own health. Dual-column labeling indicates the amount of calories and nutrients, representing both the amounts per serving versus entire container. A common canned soup serving is one cup, but people are likely to consume the full container, which is 2 to 2½ cups depending upon the brand. Potassium is not yet a required component of the nutrition facts label; however, when potassium chloride is added to a product, manufacturers are required to list it on the ingredient panel. The mandatory use of the updated nutrition facts label (that includes potassium/serving and dual-column labeling) has been delayed until January 1, 2020.
      U.S. Food & Drug Administration
      Changes to the Nutrition Facts Label.
      The dietitian can provide education on deciphering the nutrition facts label and recognizing potassium additives on soup and other processed foods. Education on portion control can be an important tool for dialysis patients to help provide greater liberalization to the diet, as determined on an individualized basis. In addition, the dietitian can suggest homemade soup seasoned with spices and vegetables to limit sodium and potassium content among other suggestions. Although not discussed, it is important for patients to be reminded that fluid from soup is included within fluid recommendations. As the momentum and demand for sodium-reduced food increases, issues with potassium additives will demand the attention of nutrition care professionals.
      U.S. Food & Drug Administration
      Remarks by Scott Gottlieb, M.D. Commissioner of food and Drugs. Natl Food Policy Conference.Washington, DC Reducing Burden Chronic Dis, March 29, 2018.

      References

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        • Zhang Z.
        • Carriquiry A.
        • et al.
        Sodium and potassium intakes among US adults: NHANES 2003–2008.
        Am J Clin Nutr. 2012; 96: 647-657
        • Cepanec K.
        • Vugrinec S.
        • Cvetković T.
        • Ranilović J.
        Potassium chloride-based salt substitutes: a critical review with a focus on the patent literature.
        Compr Rev Food Sci Food Saf. 2017; 16: 881-894
        • Centers for Disease Control and Prevention
        CDC. Sodium reduction initiative.
        2018 (Available at:)
        • Centers for Disease Control and Prevention
        CDC. Million Hearts™: strategies to reduce the prevalence of leading cardiovascular disease risk factors. United States, 2011.
        MMWR. 2011; 60: 1248-1251
        • WHO
        Effect of Increased Potassium Intake on Cardiovascular Disease, Coronary Heart Disease and Stroke.
        World Health Organization (WHO), Geneva2012
        • Chang H.Y.
        • Hu Y.W.
        • Yue C.S.
        • et al.
        Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men.
        Am J Clin Nutr. 2006; 83: 1289-1296
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        • National Kidney Foundation
        K/DOQI clinical practice guidelines for nutrition in chronic renal failure.
        Am J Kidney Dis. 2000; 35: S1-S140
        • Van Buren L.
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        Nutrients. 2016; 8: 235
        • Kamel K.S.
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        Controversial issues in the treatment of hyperkalaemia.
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        • U.S. Food & Drug Administration
        Changes to the Nutrition Facts Label.
        (Available at:)
        • U.S. Food & Drug Administration
        Remarks by Scott Gottlieb, M.D. Commissioner of food and Drugs. Natl Food Policy Conference.Washington, DC Reducing Burden Chronic Dis, March 29, 2018.
        (Available at:)