Choline Deficiency, Its Consequences and How You Fix It | Part 2 of the "Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them" Series

Don't you tell me there was no fancy cooking with the choline source #1, i.e. egg yolk! What about egg yolk on ricotta cauliflower ravioli filling, for example | get the recipe @ tastespotting.com

If you've read the last installment of this series, you can hardly be surprised that today, we are about to talk or rather I am about to write about choline. Choline is, as Wikipedia informs us, a water-soluble essential nutrient. Why choline is not officially called a "vitamin" is beyond me. "Experts" will still group it within the B-complex vitamins, anyway.

In my analyses in the series on nutrients other than cabohydrates that influence glucose control, you've read that the former, the "other", "real" B-vitamins are - in my humble opinion - totally overrated. Choline, which can come in various forms of quaternary ammonium salts all of which contain the caracteristic N,N,N-trimethylethanolammonium cation, on the other hand, it probably the most underrated micronutrient - not only for glucose control, by the way.

You can learn more about choline at the SuppVersity

Huge GH Spikes from GPC!?

Choline & Classic Bodybuilding

Improved Lipid Profile W/ Eggs

Caffeine, Choline, L-Car = Fat Loss

Choline Maximizes Carnitine Storage

Choline as a Nootropic?

One of the reasons choline has been depreciated is probably that it occurs in all the good foods of which scientists have been (falsely) telling you that you must not eat them for decades.

Figure 1: Eggs, or rather their fatty yolks, are a very good source of choline. One too few people appreciate for its nutritional density and too many people fear for its allegedly bad cholesterol content | learn why this is bullocks

Voilà, exhibit A (see Figure 1), an egg. The "bad" yolk of a single egg contains enough choline to "get you through the day" - whether that's also enough choline for optimal health is a question we are about to tackle later in today's installment of the Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them" Series (you can browse through past and previous issues, here, if you have an RSS compatible web-browser).

The fact that generations of bodybuilders have been throwing away the yolks only to supplement with even more choline than they'd have gotten from their eggs does yet certainly tell you something about the importance of this nutrient.

But I am digressing, here. What we actually wanted to talk about is after all "normal" people, not bodybuilders. Normal people like the participants of the 2005 National Health and Nutrition Examination Survey (NHANES) among which only 2% of postmenopausal women consumed the recommended amount of for choline, and in general "mean choline intakes for older children, men, women and pregnant women are far below the Adequate Intake established by the IOM" (Zeisel. 1991).

When people don't get enough choline in their diets, and the amount of choline in their system declines, will eventually lose their ability to methylate homocysteine to methionine. The result, their plasma levels of homocysteine increase and heart disease, dementia and even cancer are lurking right around the corner.

Why is high plasma homocysteine bad? In spite of the fact that it is still questionable, whether homocysteine is causally involved in the etiology of heart disease (Brattström. 2000), the present evidence leaves little doubt that high homocysteine levels are a marker of increased risks for several chronic diseases and conditions including cardiovascular disease, cancer, cognitive decline and bone fractures (HSC. 2002; Wu. 2002; Seshadri. 2002; van Meurs. 2004).

Even in the absence of vitamin B6, and B12, of which everybody is talking these days, choline and its cousin betaine have the ability to lower homocysteine levels (Chiuve. 2007). In this context you should also keep in mind that (a) homocysteine levels and the development of the triage we call "metabolic syndrom" (obesity, diabetes, high cholesterol) and that (b) choline is "lost" (oxidized) during the methylation process -- the choline requirements of the average, meanwhile at least chubby US citizen are thus naturally higher than the RDA scientists have determined in a day and age, when a BMI of >30 was still the exception.

Figure 2: The maintenance of healthy homocysteine levels is only one of choline's many important effects.

Aside from being involved in the clearance of homocysteine, choline is also, and maybe even more importantly, used in the synthesis of the constructional components of your body's cell membranes and much more (see Figure 2, as well):

• Choline figures in cell signaling, where the choline-containing phospholipids, phosphatidylcholine and sphingomyelin, are precursors for the intracellular messenger molecules, diacylglycerol and ceramide. And with the platelet activating factor (PAF, an activator and mediator of many leukocyte functions, including platelet aggregation and degranulation, inflammation, and anaphylaxis) and sphingophosphorylcholine (regulate trafficing around / across the cell membrane; Ramstedt. 2002), there are two additional choline metabolites with important systemic functions.
• The transmission of never impulses is another, certainly one of the most important functions of choline or rather acetylcholine, an important neurotransmitter involved in muscle control, memory, and many other functions. No wonder that low choline levels have been associated with the progression of Alzheimer's and non-Alzheimer's dementia (Babic. 1999; Seshadri. 2002)

Apropos beyond methylation - choline can make up for a lack of folate! The often decried lack of folate intake (just as a reminder the folate fortfication program in the US made no one healthier - with one exception, maybe: The recommendations to increase folate intake for pregnant women/women of childbearing age has been relatively successful for preventing neural tube defects in infants) would be much less of an issue in the diabesity problem, if the average American consumed 2,200mg of choline per day. The same amount of choline that is which preserved the markers of cellular methylation and attenuated folate deficiency related DNA damage in a genetic subgroup of folate-compromised men in a 2010 study by Shin et al.

• The effects on lipid (fat) transport and metabolism are probably still totally underrated by both the public and certain parts of the medical establishment. The fat and cholesterol that's consumed in the diet is after all transported to the liver by lipoproteins (chylomicrons) which are built from phosphatidylcholine. If there is not enough choline to build these 'cholesterol shuttles' the fat and cholesterol will begin to accumulate in you liver. No wonder scientists have long discovered an intricate relationship between choline intakes, on the one hand, and the development of non-alcoholic fatty liver disease, on the other hand - in fact, more recent evidence suggests that millions of US citizens have been able to escape a non-alcoholic fatty liver only due to "good genes" that allow them to budget their insufficient choline intake better than others (Spencer. 2011).

In spite of the fact that a full-blown choline deficiency will impair your exercise performance, the provision of supplemental choline has not been shown to consistently produce meaningful increases in exercise performance (Penry. 2008). As a physical culturist, you should still keep in mind that intense exercise will increase your basal choline requirements of which the wise USDA says based on data of which the researchers say that its quality "varies widely across studies", with the most significant sources of potential sources being over- or underreporting of portion sizes and frequency of intake, omission of foods, and inaccuracies related to the use of food composition tables. Accordingly Yates et al. add for consideration:

Table 1: High choline foods for omnivores and vegetarians; choline content in milligrams / 100g | data adapted from nutritiondata.com

"Therefore, the values reported by nationwide surveys or studies that rely on self-report may be somewhat inaccurate and possibly biased. Food composition databases that are used to calculate nutrient intake from self-reported and observed intake data introduce errors due to random variability, genetic variation in the nutrient content, analytical errors, and missing or imputed data.

In general, when nutrient intakes for groups are estimated, the effect of errors in the composition data is probably considerably smaller than the effect of errors in the self-reported intake data (NRC, 1986). However, it is not known to what extent this is true for folate, biotin, pantothenic acid, or choline." (Yates. 1998)

That's bad, because the first signs of liver damage in humans (beginning NAFLD if you will) occur after only 3 weeks on a choline deficient diet (Zeisel. 1991). In view of the fact that doses of safe therapeutic doses go into the 8-10 gram range and considering the fact that the total amount of choline in foods is not exactly exorbitantly high, it would appear prudent to follow the "more is better principle", when it comes to choline-rich foods (see Table 1 and bottom line for suggestions | Didn't find the food you were looking for? Try the official USDA Overview).

Don't go overboard on supplements! When it comes to supplementation, on the other hand, you better be careful not do overdo it. While choline is generally relatively benign, it can produce side effects that range from increased potassium and magnesium requirements over depressive like symptoms (a general sluggishness) to vomiting and, in some people, acne-like skin rashes. Dosages in the below 3g per day range do yet generally appear to be tolerated very well. In the long term the phospholipid bound forms of choline can yet produce quite nasty depressive-like side-effects - another reason to prefer the cheap and effective citrates and tartrates if you are just "supplementing" your diet or looking for the metabolic effects, primarily.

Unless you are following a no fat diet, the use of dietary supplements to cover your baseline requirements of 500-600mg (I am deliberaterly not using the ostensibly "accurate" RDA, here) shouldn't  be necessary - at least if you eat your healthy eggs every day ;-)

Choline as a "metabolic activator" and diet aid!?

If you mimic the old-school body- builders and have your choline supps with meat, this will increase the retention & effects of carnitine.

If you remember my previous article on the relatively unknown "CCC-Stack" which consists of caffeine, carnitine, and... you guessed it, choline you will yet remember that doubling your intake with 500mg of choline tartrate or citrate had quite remarkable effects on the metabolism (learn more | for metabolic purposes I would prefer the citrate and tartrate forms over the expensive phospholipid bound version of choline, which may have its advantages, though, when it comes to brain-related effects).

Moroever, a recent study from the Zagazig and the Mansura University in Egypt suggests that choline alone, will produce quite impressive weight loss effects - even in the absence of the "fat liberator" caffeine and the "fat transporter" carnitine, i.e. the other "C"s in the CCC stack.

The study, Elsawy, Abdelrahman and Hamza conduted investigated the effects of choline supplementation on body mass reduction and leptin levels among female taekwondo and judo athletes in the pre-competition phase (Elsawy. 2014).

Figure 3: Relative changes in lipid oxidation, body fat (%), body mass and strength parameters in female athletes during contest prep with (choline) and without (control) 2x2g of supplemental choline in their meals (Elsawy. 2014)

Twenty-two female athletes (15 taekwondo and 7 judo athletes) were selected from different weight
categories and divided into two groups, according to weight. The players in the experimental group consumed their choline supplements (2x2.0g of choline bitartrate) daily with meals for one week.

I guess the results actually speak for themselves. As expected, the experiment revealed significant differences between pre- and post-competition measurements of free plasma choline, and urine choline levels. The significantly higher fat loss, on the other hand, is something even the researchers did not necessary expect to see. In view of the reduction in malondyaldehyde (MDA = lipid oxidation) and the increase in carnitine retention and effects you've read about in a previous SuppVersity article ("Choline Maximizes Carnitine Retention + Effects" | read more) it is yet eventually not surprising that the choline group lost more body fat without suffering significant reductions in strength and lean mass.

Eat three of these or combine two of them: One whole eggs, 4oz of shrimp, or 5oz scallop, 5oz chicken, 5oz turkey

Eat four of these or combine four of them: 4oz cod, 1.5 cups of collard greens, 1.75 cups of Brussel sprouts, 1.75cups of broccoli, 5oz tuna, 5oz salmon, 6oz beef, 6 oz saridines

Eat five of these or combine one of each 2cups of swiss chard, 2cups of cauliflower, 2cups of asparagus, 2.25cups of spinach, 2cups green peas, 2.5 cups cabbage, 2 cups of Shiitake mushrooms

Other foods with choline, of which you'd yet probably have to eat too much to get to your SRI (SuppVersity recommended intake for adults) of 500-600mg are green beans and bok choy (5% of SRI per cup), summer squash, miso and tomatoes (1-2% of SRI per cup)

Bottom line: I am well aware that the fat loss effects, I deliberately mentioned last are probably the "sexiest" benefits choline has to offer. Compared to the conservation of liver, brain and heart hearth for which you "just" have to make sure that you consume enough of the foods in the list to the left, the ability of supplemental choline to promote fat loss and conserve lean mass and strength in "average Janes" (read more) and competitive athletes (Figure 3) is actually quite pathetic.

Speaking of "pathetic" the notion that eggs would be bad for you, because they contain cholesterol is probably even more pathetic than the notion that being ripped was more attractive than being healthy. In view of the fact that the amount of highly bioavailable choline in a single egg can cover 20%-35% (depending on its size) of your daily choline demands, having an egg for breakfast is nothing you should consider, but rather something you should simply do! The increase in choline intake, the beneficial effects on your cholesterol particle and phospholipid profile and the increase in HDL-driven lipid reverse-transport are after all something you don't want to sacrifice on the altar or unwarranted prejudices and in blind obedience to dietary guidelines of which more and more researchers say that they "are not benefiting the public as a whole and may actually have negative nutritional implications." (Herron. 2004)

References:

• Babic, T. "The cholinergic hypothesis of Alzheimer’s disease: a review of progress." Journal of Neurology, Neurosurgery & Psychiatry 67.4 (1999): 558-558.
• Brattström, Lars, and David EL Wilcken. "Homocysteine and cardiovascular disease: cause or effect?." The American journal of clinical nutrition 72.2 (2000): 315-323.
• Elsawy, Gehan, Osama Abdelrahman, and Amr Hamza. "Effect of Choline Supplementation on Rapid Weight Loss and Biochemical Variables Among Female Taekwondo and Judo Athletes." Journal of Human Kinetics 40.1 (2014): 77-82.
• Herron, Kristin L., and Maria Luz Fernandez. "Are the current dietary guidelines regarding egg consumption appropriate?." The Journal of nutrition 134.1 (2004): 187-190.
• HSC: Homocysteine Studies Collaboration. "Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis." Jama 288.16 (2002): 2015-2022. 
• Penry, Jason T., and Melinda M. Manore. "Choline: an important micronutrient for maximal endurance-exercise performance?." International journal of sport nutrition and exercise metabolism 18.2 (2008): 191.
• Ramstedt, Bodil, and J. Peter Slotte. "Membrane properties of sphingomyelins." FEBS letters 531.1 (2002): 33-37.
• Seshadri, Sudha, et al. "Plasma homocysteine as a risk factor for dementia and Alzheimer's disease." New England Journal of Medicine 346.7 (2002): 476-483. 
• Shin, William, et al. "Choline intake exceeding current dietary recommendations preserves markers of cellular methylation in a genetic subgroup of folate-compromised men." The Journal of nutrition 140.5 (2010): 975-980.
• Spencer, Melanie D., et al. "Association between composition of the human gastrointestinal microbiome and development of fatty liver with choline deficiency." Gastroenterology 140.3 (2011): 976-986.
• van Meurs, Joyce BJ, et al. "Homocysteine levels and the risk of osteoporotic fracture." New England Journal of Medicine 350.20 (2004): 2033-2041.
• Wu, Lily L., and James T. Wu. "Hyperhomocysteinemia is a risk factor for cancer and a new potential tumor marker." Clinica Chimica Acta 322.1 (2002): 21-28.
• Yates, Allison A., Sandra A. Schlicker, and Carol W. Suitor. "Dietary reference intakes: the new basis for recommendations for calcium and related nutrients, B vitamins, and choline." Journal of the American Dietetic Association 98.6 (1998): 699-706. 
• Zeisel, STEVEN H., et al. "Choline, an essential nutrient for humans." The FASEB journal 5.7 (1991): 2093-2098.

Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them - Part 1: Potassium Deficiency, Bone & Protein Loss, Stroke, Heart Disease & High Mortality

The fact that many Americans don't get enough of the "non-salt" electrolytes (calcium, magnesium, potassium) is also due to the fact that mineral water is still an exotic beverage in the US.

A recent paper by scientists from the Council for Responsible Nutrition in Washington (Wallace. 2014) says: Large portions of the population had total usual intakes below the estimated average requirement for vitamin A (35%), vitamin C (31%), vitamin D (74%), vitamin E (67%), choline (92%) and vitamin K (67%), as well as potassium (100%), calcium (39%) and, of course, magnesium (46%) - and that despite the fact that more than 50% of the US citizens consume a multivitamin and -mineral supplement of which probably 90% believe that it would balance their dietary shortcomings.

Reason enough to take another look at the possible health consequences and ways to fix these deficiencies by increasing the intake of certain foods or supplements.

There are more articles to come in this series, but you can use these to sugar the wait:

Pasta "Al Dente" = Anti-Diabetic

Vinegar & Gums for Weight Loss

Teflon Pans Will Kill You!

Yohimbine Burns Stubborn Fat

You Can Wash Pesticides Away

Milk = Poisonous Hormone Cocktail

Instead of tackling them in an alphabetical order, I would like to start with the two in my humble opinion most critical deficiencies - "critical", not necessarily because they entail the worst health consequences, but "critical", because no one appears to care about them:

You will probably think I am exaggerating (and in fact, I am), but if we are talking about America's Heart Disease Burden (CDC), i.e.

US "Heart Disease Map" (CDC)

• about 600,000 deaths due to heart disease in the United States every year – that’s 1 in every 4 deaths,
• heart disease being the leading cause of death for both men and women in the US,
• 720,000 heart attacks with 515,000 "first timers" and 205,000 people who had at least one heart attack before, and 
• a financial burden of $108.9 billion each year for heart disease and its consequences, alone, 

we cannot do so without talking about the insufficient potassium and choline intakes of the average American. Why? Well, because these constantly overlooked nutrients are at least as important for your heart as any of the overrated vitamins and the publicly transfigured alleged "supermineral" magnesium.

Today's episode will be about potassium - potassium and nothing but potassium! But don't worry we will deal with choline in the next episode and tackle all the non-significant rest in later episodes. Obviously I am exaggerating, but as mentioned before: I truly believe that choline and potassium are the most overlooked, yet crucially important nutrient deficiencies the average Westerner will have.

Table 1: Paleolithic nutriton according to Eaton (2000) - /1/ based on 3000 kcal/d, 35 % animal: 65 % plant subsistence; /2/ average of US men and women according to the Food and Nutrition Board (1989)

If you look at the Mediterranean diet, the DASH diet and, of course, the Paleo diet, you will find that there is more to it than olive oil, higher protein intakes and no grains. Let's take the Paleo diet, I mean, the half-science based version and not the strange amalgam of all sorts of dietary trends you will find in the blogosphere, as an example (see Table 1).

It is of course higher in calcium, in magnesium folate, B1, B2, vitamin A and vitamin E than the current US diet, but those are nutrients everyone thinks about. Copper (10x higher!) and not even in the list Wallace et al. present in their recent paper in the Journal of the American College of Nutrition (Wallace. 2014), potassium (4.2x higher) and manganese (3.8x higher) are micronutrients no one ever talks about.

Urinary potassium excretion vs. food logs: In subjects who are not on diuretics or other medications that would influence the urinary potassium excretion, the urinary potassium excretion is not necessarily a more accurate, but certainly a more reliable and objective measure of an individual's total potassium intake.

The FDA in their infinite wisdom even limits the maximal amount of potassium in dietary supplements to 99mg - i.e. ~2% of their own recommended daily allowance and the prescribed potassium intake on the DASH diet (4,700mg/day for adults (18y+, breastfeeding women "may" consume an extra 500mg/day). If we take the potassium intake of the average Cretan iteration of the Mediterranean (according to Kafatos. 2000) diet or the Paleo diet (according to Eaton. 2000) as a reference it would be as a reference that's 1.8% and 0.8%, respectively. That's unquestionably much less than you would need to double the pathetic 2500mg/day of potassium the average American gobbles down with a 3,000kcal/day diet (Eaton. 2000) - bad news, in view of the fact that insufficient potassium intakes are associated with...

• 29% higher all-cause mortality risk in the 1,448 randomly selected healthy subjects in the Rotterdam Study (Geleijnse. 2007)
• 20% increased higher all-cause-mortality risk in the 12,267 participants of the Third National Health and Nutrition Examination Survey Linked Mortality File (1988-2006), a prospective cohort study of a nationally representative sample (Yang. 2011) 
• 36% increased CVD risk (stroke, myocardial infarction, coronary revascularization, or CVD mortality) for the subjects with the lowest (vs. highest) urinary potassium excretion in 2,275 adults with prehypertension aged 30 to 54 year (Cook. 2009)

Table 2:  Estimated Usual Intakes of Sodium, Potassium, and Calories and Sodium-Potassium Ratio at Baseline by Sex, NHANES IIII Linked Mortality Filea (Yang. 2011)

Even exercise won't save your ass, if you don't get enough potassium! That's at least what the results of Yang's analysis of the data from the shows. The increased mortality risk did after all not differ significantly by sex, race/ethnicity, body mass index, hypertension status, education levels, or physical activity (Yang. 2011).

Furthermore, the difference in all-cause mortality risk between participants with low (Q1) intakes and those who approached "paleo" or at least "Mediterranean" potassium intakes was even large: 39% even after full adjustment!

• 38% increased total stroke and ischemic stroke in among 43,738 US men, 40 to 75 years old, without diagnosed cardiovascular diseases or diabetes, who completed a semi-quantitative food frequency questionnaire in 1986 (Ascherio. 1998) 

• 

  Figure 1: Potassium intake and adjusted risk of stroke among 43,738 US men aged 40 to 75 years followed for eight years. Risk was adjusted for age, total energy intake, smoking, alcohol consumption, history of hypertension, history of hypercholesterolaemia, parental history of myocardial infarction before age 65 years, profession, and quintiles of body mass index and physical activity (He. 2001)

  28% increased ischemic stroke risk in the 85,764 women in the Nurses’ Health Study cohort, aged 34 to 59 years and free of diagnosed cardiovascular disease and cancer who completed the dietary questionnaires of scientists from the Brigham and Women’s Hospital and Harvard Medical School in 1980 (Iso. 1999)
• 50% increased total stroke risk in the 5,600 men and women older than 65 years and free of stroke at enrollment in The Cardiovascular Health Study (Green. 2002)
• 28% increased total stroke risk according to a 2001 (re-)analysis of data from 9805 US men and women who participated in the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-Up Study (Bazzano. 2001) 
• significantly lower bone mineral density (BMD) in elderly men and women with per unit differences that were significantly higher than for magnesium (~30%) and total fruit and vegetable intake alone (+400%; cf. Tucker. 1999)
• higher protein loss due to low-grade acidity; just like the bone loss (Dawson-Hughes. 2000) the loss of nitrogen can be countered by potassium bicarbonate supplements (~4-6g per day lead to a 86.4% reduction in urinary nitrogen excretion in postmenopausal women; cf. Frassetto. 1997 | learn more)

Sociodemographic and -economic studies show that older men and women and people from lower socioeconomic groups are at particularly  high risk of low potassium (and high sodium) intakes (Loftfield. 2013).

Figure 2: Graphs showing age-adjusted death rates in the US from cerebrovascular accidents, 1968 through 1988, by socioeconomic quintiles, i.e. median income and high school completeion (Modan. 1992)

No wonder that their risk of hypertension-related diseases is significantly higher than that of their better-off peers. Needless to say, as well, that a low potassium and high sodium intake are inevitable consequences of the standard American convenience diet with lot's of high salt, low potassium processed foods and few minimally / unprocessed low salt, high potassium foods.

Figure 3: Low carb, low fat, vegetarian, vegan, low glycemic, Mediterranean, balanced and palolithic diets, they may be based on different premises, but the food recommendations are the same (Katz. 2014).

A pattern of which the diet overview in Katz' and Meller's recent paper "Can We Say What Diet Is Best for Health?" indicates that it one of the few criteria all the en-vogue diets from low-carb to paleo have in common.

Being based on a limited amount of refined starches, added sugars, processed foods; limited intake of certain fats and emphasizing whole plant foods, with or without lean meats, fish, poultry, seafood. They are all well capable of providing the RDA 4,700mg/day of potassium so few of the modern convenient food buyers are consuming on a daily basis.

Potassium: Why and from where?

• Increasing potassium intake lowers blood pressure in both hypertensive and normotensive people. 
• Increasing potassium intake and reducing sodium intake are additive in lowering blood pressure High potassium intake reduces the risk of stroke and prevents renal vascular, glomerular, and tubular damage. 
• Increasing potassium intake reduces urinary calcium excretion, which reduces the risk of kidney stones and helps prevent bone demineralisation.
• Increasing serum potassium concentrations reduces the risk of ventricular arrhythmias in patients with ischaemic heart disease, heart failure, and left ventricular hypertrophy.

The best way to increase potassium intake is to eat more fresh fruit and vegetables and the list on the left gives you an idea which of them contain particularly high amounts of this essential electrolyte. On a whole foods diet supplements shouldn't be necessary.

In the end, things could be so easy: Whether you are consuming high carb, low carb, no carb, high protein, low protein, or even vegetarian diet - there is no reason any of you would have to be taking potassium supplements.

So don't fret about the FDAs unquestionably inexplicable conclusion to prohibit the inclusion of more than 99mg of potassium in dietary supplements, but make sure that you get add at least one of the fruit and vegetable items from the following list of high potassium foods in each of your meals

Fruits ★★★ Apricots Avocados Bananas Dates Figs Kiwi Mangos Melons Nectarines Oranges Papayas Peaches, fresh Pears, fresh Prunes

Vegetables ★★★ Artichokes Beans: kidney, lima, pinto, red, white, etc. Greens: beet, chard, collard, kale, mustard, spinach, turnip Parsnips Potatoes: sweet, white French fries, chips, etc. Pumpkins Tomatoes: fresh, canned, paste, etc. Winter squash Yams Zucchini

Other ☆★★ Chocolate Cocoa Custard Lentils Milk Milk drinks Milkshakes Nut butters Nuts Peanut butter Peanuts Pudding Salt Substitutes Yogurt

And what about hyperkalemia? Potassium balance is normally maintained by precise physiological mechanisms that match potassium excretion to intake, mainly through the kidney but also through the gastrointestinal tract. Large loads of potassium are excreted rapidly with only a minimal increase in plasma potassium concentration (He. 2001). A high food and even oral suppplement intake is thus not an issue for people with healthy kidneys who don't have to take potassium sparing diuretics or similar meds.

References:

• Ascherio, A., et al. "Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men." Circulation 98.12 (1998): 1198-1204.
• Bazzano, Lydia A., et al. "Dietary potassium intake and risk of stroke in US men and women National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study." Stroke 32.7 (2001): 1473-1480.
• CDC. Heart Disease Fact Sheet. < www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm > visited on March 20, 2014.
• Cook, Nancy R., et al. "Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up study." Archives of internal medicine 169.1 (2009): 32-40. 
• Dawson-Hughes, Bess, et al. "Treatment with potassium bicarbonate lowers calcium excretion and bone resorption in older men and women." Journal of Clinical Endocrinology & Metabolism 94.1 (2009): 96-102.
• Geleijnse, Johanna M., et al. "Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam Study." European journal of epidemiology 22.11 (2007): 763-770.
• Green, D. M., et al. "Serum potassium level and dietary potassium intake as risk factors for stroke." Neurology 59.3 (2002): 314-320.
• He, Feng J., and Graham A. MacGregor. "Fortnightly review: beneficial effects of potassium." BMJ: British Medical Journal 323.7311 (2001): 497.
• Iso, Hiroyasu, et al. "Prospective study of calcium, potassium, and magnesium intake and risk of stroke in women." Stroke 30.9 (1999): 1772-1779.
• Kafatos, Anthony, et al. "Mediterranean diet of Crete: foods and nutrient content." Journal of the American Dietetic Association 100.12 (2000): 1487-1493. 
• Katz, D. L., and S. Meller. "Can We Say What Diet Is Best for Health?." Annual Review of Public Health 35.1 (2014).
• Loftfield, Erikka, et al. "Potassium and fruit and vegetable intakes in relation to social determinants and access to produce in New York City." The American journal of clinical nutrition 98.5 (2013): 1282-1288. 
• Modan, Baruch, and Diane K. Wagener. "Some epidemiological aspects of stroke: mortality/morbidity trends, age, sex, race, socioeconomic status." Stroke 23.9 (1992): 1230-1236. 
• Wallace, Taylor C., Michael McBurney, and Victor L. Fulgoni III. "Multivitamin/Mineral Supplement Contribution to Micronutrient Intakes in the United States, 2007–2010." Journal of the American College of Nutrition 33.2 (2014): 94-102.
• Yang, Quanhe, et al. "Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey." Archives of internal medicine 171.13 (2011): 1183-1191.