European Journal of Clinical Nutrition (2003) 57, 299304

2003 Nature Publishing Group All rights reserved 09543007/03 $25.00

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ORIGINAL COMMUNICATION
Relationship of urinary sodium=potassium excretion
and calcium intake to blood pressure and prevalence
of hypertension among older Chinese vegetarians
TCY Kwok1*, TYK Chan1 and J Woo1
1
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New
Territories, Hong Kong

Objective: To examine the associations of dietary sodium and potassium, as reflected by the urinary sodium=potassium
excretion, and calcium intake with blood pressure and the prevalence of hypertension among older Chinese vegetarians in Hong
Kong.
Design: Cross-sectional study.
Setting: Research clinic in a teaching hospital in Hong Kong.
Subjects: A total of 111 ambulatory vegetarians over the age of 55 were recruited from members of religious organizations or
old age hostels.
Main outcome measures: Hypertension was defined as supine blood pressure > 140=90 mmHg or a history of hypertension.
Dietary sodium, potassium and calcium intakes were assessed by 24 h recall method or fasting urinary sodium or potassium=
creatinine ratios.
Results: Seventy-one subjects (64%) were found to have hypertension. Compared with normotensive subjects, hypertensive
subjects had lower calcium intake (411
s.d. 324 vs 589
428 mg, P 0.04), but higher urinary sodium=creatinine ratio
(32.6
19.3 vs 21.0
12.4, P 0.00) and sodium=potassium ratio (4.7
2.8 vs 3.4
2.3, P 0.02). Among 88 subjects not
taking diuretics or antihypertensive drugs, systolic blood pressure was related to calcium intake (r 7 0.40), urinary
sodium=creatinine ratio (r 0.39), urinary sodium=potassium ratio (r 0.30) and age (r 0.23). Diastolic blood pressure was
related to urinary sodium=creatinine (r 0.29). Twenty-three subjects with high urinary sodium=potassium and low calcium
intake and 16 subjects with low urinary sodium=potassium ratio and high calcium intake differed markedly with respect to
systolic blood pressure (159
26 vs 130
15 mmHg) and prevalence of hypertension (78% vs 25%).
Conclusions: Older Chinese vegetarians are predisposed to hypertension because of their sodium-rich but calcium-deficient
diets.
European Journal of Clinical Nutrition (2003) 57, 299 304. doi:10.1038=sj.ejcn.1601553
Keywords: hypertension; vegetarianism; calcium; sodium; diet; aged

Introduction
Vegetarians have lower blood pressure than non-vegetarians
after adjustments for the effects of age, sex and body weight

*Correspondence: TCY Kwok, Department of Medicine and Therapeutics,

The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin,
New Territories, Hong Kong.
E-mail: tkwok@cuhk.edu.hk
Guarantor: TCY Kwok.
Contributors: TCY Kwok, TYK Chan, J Woo.
Received 11 April 2002; revised 7 June 2002;
accepted 11 June 2002

(Sacks & Kass, 1988). Animal products, carbohydrate, different types of fats and isoflavonoids do not appear to be major
contributors to the blood pressure-lowering effects of vegetarian diets (Sack & Kass, 1988; Hodgson et al, 1999). In
contrast, we previously found that the blood pressures of
older Chinese vegetarians were not significantly different
when compared with that of local omnivorous older
women. The vegetarian diet was significantly lower in protein, but more abundant in calcium, potassium and ascorbic
acid (Woo et al, 1998a). Isoflavones and sodium intakes were
not directly measured, but would probably be higher due to
the common consumption of soya bean products and soya

Urinary sodium=potassium excretion and calcium intake

TCY Kwok et al

300
sauce. It would be interesting to explore the relative importance of these dietary factors on their blood pressures and
prevalence of hypertension.
Epidemiological studies have shown a positive association
between dietary salt intake, level of blood pressure and
prevalence of hypertension (Law, 1997). Dietary salt reduction lowers blood pressure, especially in hypertensive subjects (Graudal et al, 1998). Observational studies have
demonstrated an inverse relationship between dietary potassium intake and blood pressure (Intersalt Cooperative
Research Group, 1988). Oral potassium supplementation
lowers blood pressure (Whelton et al, 1997), and this effect
is more pronounced in subjects with a high sodium intake. It
has been suggested that the very high sodium diet combined
with low potassium intake that most Western communities
now eat may be in part, responsible for the prevalence of
high blood pressure (MacGregor, 1983). Low dietary calcium
intake, which is often seen in Asian communities (Woo et al,
1998b; Iso et al, 1991), is associated with a higher blood
pressure (Cappuccio et al, 1995). Calcium supplementation
leads to a reduction in blood pressure (Allender et al, 1986).
In this cross-sectional study, we examined the importance
of dietary sodium, potassium intake as reflected by the
urinary sodium=potassium excretion, and calcium intake as
the determinants of blood pressure and the prevalence of
hypertension among older Chinese vegetarians in Hong
Kong.

Subjects and method

Study population
Vegetarians over the age of 55 were recruited from members
of religious organizations or old age hostels in Hong Kong
(Woo et al, 1998a). They had been vegetarians for at least 10 y
because of religions Taoism and Buddhism. The Taoist
subjects were vegans, while the Buddhist subjects consumed
some milk, and occasionally eggs. These subjects were independently mobile and self-caring. As there were very few
men, only women were studied. After the nature and purpose of the study were explained, 111 women volunteered to
participate. They attended Prince of Wales Hospital a
regional teaching hospital and were assessed by a trained
nurse. Mental status was assessed by the information=orientation part of the Clifton assessment procedure
of the elderly (Pattie & Gilleard, 1976). In order to ensure
reliability of the dietary intake data recalled, subjects with a
mental score of less than 8 out of 12 were excluded from 24 h
dietary recall (Woo et al, 1994).

Measurement of blood pressure and body mass index

After lying supine for several minutes, blood pressure was
measured by one of the two trained nurses, using a standard
mercury sphygmomanometer. Height and weight were measured in light clothing without shoes, using a standard scale
European Journal of Clinical Nutrition

with height measurement. Body mass index (BMI) was calculated as weight (kg) divided by height (m)2.
Using a definition of hypertension as systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg
(Chalmers et al, 1999), or a history of hypertension requiring
drug treatment, the prevalence of hypertension was determined.

Assessment of dietary intakes and urine collection

Dietary intakes of sodium, potassium, calcium, protein and
dietary fibres were assessed by 24 h recall method. All food
items consumed and the portion size over a typical 24 h
period were recorded by a research nurse. The use of calcium
and vitamin supplements was noted. The quantity of nutrients and energy intake were calculated, using food composition tables for this region (US Department of Health,
Education and Welfare, 1972).
Sodium intake in these subjects could not be assessed
accurately by the 24 h recall method alone because of the
frequent use of soya sauce. A fasting 20 ml urine specimen
was also collected in a plain container for the measurement
of sodium, potassium and creatinine. Hence, urinary
sodium/creatinine, potassium/creatinine and sodium/potassium ratios were also used to reflect the dietary intakes of
these cations (Woo, 1988; Woo et al, 1992).

Other data collection

During the interview by a research nurse, subjects were also
asked about their past medical history, concurrent drug
treatment and alcohol intake. A fasting blood specimen
was taken for measurement of blood glucose, serum albumin, creatinine, vitamin B12 and folate levels. All laboratory
analysis was performed in the Chemical Pathology Department of Prince of Wales Hospital. Subjects with a history of
diabetes mellitus or fasting blood glucose > 7.8 mmol=l were
classified as diabetic.
A resting electrocardiograph (ECG) was performed by the
research nurse and read by a physician (TK). The Minnesota
Coding (Rose & Blackburn, 1968) was used to classify ECG.
The Whitehall criteria (Rose et al, 1977) were used to classify
the ECG into probable (codes 1.1, 1.2) or possible (codes 1.3,
4.1 4.4, 5.1 5.3, 7.1) ischaemic heart disease. For data
analysis both categories were combined. Left ventricular
hypertrophy was also noted (codes 3.1 3.3).

Statistical analysis
The bivariate correlations between blood pressures, dietary
intake variables (protein, energy, calcium, potassium, fibre,
vitamin C, thiamine and urinary sodium/creatinine, potassium/creatinine and sodium/potassium ratios) and other
predictors (age, diabetes mellitus, serum creatinine, albumin
and vitamin B12, old age residence, years of vegetarian diet
and BMI) were examined for statistical significance. Those

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TCY Kwok et al

301
variables with P-values of less than 0.05 were entered into a
stepwise regression analysis model for systolic and diastolic
blood pressures respectively.

Result
One hundred and eleven vegetarians participated in the
study. Twenty-nine subjects (26%) had a history of hypertension, but only 22 (76%) were on drug treatment. Other
common diagnoses were previous fractures (16), heart disease (16), arthritis (16), gastrointestinal problem (14), diabetes mellitus (11), cerebrovascular disease (6) and chronic
obstructive airway disease (5). There were three subjects with
significant renal impairment (creatinine > 150 (mol=l), the
highest creatinine level being 290 (mol=l. All three were
hypertensive, two of whom were on antihypertensive
treatment.
Forty-two other subjects (38%) were found to have a
blood pressure > 140=90 mmHg. The overall prevalence of
hypertension was therefore 64%. Eleven subjects gave a
history of diabetes mellitus. Four other subjects were found
to have a raised fasting blood glucose level. Eight subjects
had missing blood glucose data. The prevalence of diabetes
mellitus in this vegetarian population was therefore 15=103
(15%).
The demographic and clinical characteristics of the 71
hypertensive subjects and 40 normotensive subjects are
compared in Table 1. Hypertensive subjects had been vegetarian for a longer period than normotensives (41.8
s.d.
18.2 y vs 33.9
18.2 y, P 0.03). The hypertensive subjects
were more likely to have ischaemic ECG changes, but the
difference was not quite significant. There were only two
subjects who had evidence of left ventricular hypertrophy on
ECG. Both of them were hypertensive.

Table 1 Comparison of the demographic and clinical characteristics of

hypertensive and normotensive vegetarian subjects

Number of subjects
Age (y)
Vegan : lacto vegetarian ratio
Duration fo vegetarianism (y)
Old age home residents
2
Body mass index (kg=m )
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Ever alcohol use
Mental score (max 12)
Diabetes mellitus
Serum creatinine (mmol=l)
Cholesterol (mmol=l)
Triglyceride (g=)
b
Ischaemic ECG
a

Hypertensive

Normotensive

P-value

71
78.7
6.9
46 : 25
41.8
18.2
42 (59%)
22.9
3.7
165
23
81
10
2 (3%)c
9.3
2.3c
11 (17%)
81.3
42.9e
e
4.9
1.2
e
1.7
1.5
d
31 (45%)

40
76.7
7.9
20 : 20
33.9
18.2
25 (63%)
23
3.8
125
11
68
10
1 (3%)
9.7
2.0
4 (11 %)
76.5
20.4e
d
4.6
0.8
d
1.4
0.8
a
10 (26%)

NS
NS
0.03
NS
NS
0.00
0.00
NS
NS
NS
NS
NS
NS
0.06

Data presented as mean
standard deviation, Student t-test for continuous

data, chi-square test for nominal data.
b
Defined by Minnesota coding and Whitehall criteria (see Method section).
ce
Refer to 1, 2, 3 subjects with missing data, respectively.

Data on dietary intake was available in 86 subjects. The

remaining 25 subjects were excluded because of subnormal
Clifton mental test scores (n 18), reluctance to participate
(n 3) or loss of the original data (n 4). Twelve of the
included subjects were routinely given oral calcium tablets,
amounting to an additional intake of 600 mg of calcium per
day, in their old age home. This was therefore included in
the calculation of their daily calcium intakes.
The nutritional profile of normotensive and hypertensive
subjects was compared in Table 2. Compared with the
normotensive subjects, hypertensive subjects had significantly lower daily calcium intake (441
324 mg vs
589
428 mg, P 0.04) and higher urinary sodium=creatinine ratio (32.6
19.3 vs 21.0
12.4, P 0.00) and urinary
sodium=potassium ratio (4.7
2.8 vs 3.4
2.3, P 0.02).
Among the 88 subjects who were not taking diuretics or
other antihypertensive drugs, the only correlation between
subjects demographic and clinical characteristics and blood
pressure was between age and systolic blood pressure
(r 0.24, P 0.04). The dietary variables which correlated
significantly with systolic blood pressure were calcium intake
(r 7 0.40), urinary sodium=creatinine ratio (r 0.39), and
urinary sodium=potassium ratio (r 0.30). The only variable
which correlated significantly with diastolic blood pressures
was urinary sodium=creatinine (r 0.29). Urinary potassium=creatinine ratio did not significantly correlate with
either systolic or diastolic blood pressure (P 0.82, 0.36
respectively).
In the linear regression model for systolic blood pressure,
urinary sodium=creatinine ratio alone accounted for 16% of
the variance. The addition of urinary potassium/creatinine
or urinary sodium/potassium ratio did not change the r2
Table 2 Comparison of dietary
normotensive vegetarian subjectsa
Hypertensive

profile

of

hypertensive

Normotensive

and

P-value

Urinary electrolytes
Number of subjects
Na=creatinine ratio
K=creatinine ratio
Na=K ratio

71
32.6
19.3
7.7
3.8
4.7
2.8

39
21
12.4
6.9
3.1
3.4
2.3

0
NS
0.02

Daily dietary intake

Number of subjects
Energy (kcal)
Protein (g)
Calcium gb
Potassium (mg)
Vitamin C (mg)
Thiamine (mg)
Fibre (g)

56
1181
348
33.1
14.0
411
324
1160
606
128
81
0.48
0.30
9.2
6.8

30
1225
397
38.4
20.9
589
428
1131
661
136
65
0.50
0.31
9.2
5.9

NS
NS
0.04
NS
NS
NS
NS

Blood levels
Number of subjects
Vitamin B12 (pmol=l)
Folate (mmol=l)
Albumin (g=l)

70
205 (196)
47.5 (9.83)
37.5
2.9b

37
244 (323)
45.6 (11.1)
37
2.4c

NS
NS
NS

Data presented as mean
standard deviation; b68 subjects, c38 subjects.

Contribution of calcium supplement included.

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302

significantly. The addition of age increased the r2 to 0.19.

When dietary calcium intake was further added into the
model, the r2 increased to 0.29. On linear regression for
diastolic blood pressure, urinary sodium accounted for 9%
of the variance (r2 0.09).
In order to further examine the importance of dietary
sodium, potassium and calcium intakes, we compared the
blood pressure and prevalence of hypertension among subjects with high or low calcium intake and urinary sodium/
potassium ratio. The median urinary sodium: potassium
ratio and daily calcium intake of all the available subjects
were 3.9 and 346 g respectively. Among the 88 subjects who
were not on antihypertensive or diuretics, 66 had dietary
data. These subjects were divided into four groups, depending on whether their urinary sodium=potassium ratio and
calcium intake were greater or smaller than the respective
median values. As can be seen in Table 3, there was a
significant group difference in age in that the group with
high urinary sodium/potassium ratio and low calcium intake
was significantly older than the other groups. There was a
group difference in systolic blood pressure which was significant on univariate analysis after adjustment for age. The
main difference in systolic blood pressure lay between the
high urinary sodium/potassium ratio-low calcium intake and
low urinary sodium=potassium ratio-high calcium intake
groups (159
26 vs 130
15 mmHg). The blood pressure of
two other dietary groups was intermediate between these. In
contrast, there was no significant group difference in diastolic blood pressure. There was also a significant group difference in the prevalence of hypertension (P 0.01, chi-squared
test). Again, the main difference was between the high
urinary sodium=potassium ratio-low calcium intake and
low urinary sodium=potassium ratio-high calcium intake
groups (78% vs 25%).

Discussion
The dietary sodium, potassium and calcium intakes varied
considerably among the vegetarians in this study. Some
subjects might have had increased sodium intake by liberal
use of soya sauce to augment the flavour of vegetarian foods.

Table 3

Subjects with dental problems might have avoided vegetables and fruit, thereby having a lower potassium intake. In
Asian countries, calcium intakes in the general population
are frequently low, largely because of the decreased consumption of dairy products (Woo et al, 1998b). Many vegetarian dishes were based on soya beans. The greater
consumption of soya bean products and dark green vegetables might account for the higher calcium intake in vegetarians compared with the general population. Absorption of
calcium from some Chinese vegetables appears to be as
good as from dairy products (Weaver et al, 1997). Subjects
living in a vegetarian old age home were also routinely given
calcium supplements which increased their calcium intake
significantly.
To assess urinary sodium and potassium excretion, 24 h
urine collection is generally recommended. In older people,
however, reliable 24 h urine collections are difficult to
achieve. In our previous studies of the local population,
urinary sodium and potassium outputs estimated by analyzing the first voided morning urine were found to be useful
indices of the dietary intakes of these cations (Woo, 1988;
Woo et al, 1992).
Longer duration of vegetarianism was associated with
hypertension. This implies that a certain aspects of the Chinese vegetarian diet may have predisposed the vegetarians to
hypertension. Three observations from this study suggested
that blood pressure and the prevalence of hypertension were
related to dietary intakes of sodium and calcium. Firstly,
hypertensive subjects had a higher urinary sodium/potassium
or sodium=creatinine ratio and a lower calcium intake than
normotensive subjects (Table 2). Secondly, in the total study
population, urinary sodium=creatinine ratio and calcium
intake were important determinants of supine blood pressure.
These two factors together with a small contribution from age
accounted for 29% of the variance in supine blood pressure.
Thirdly, subjects with a higher urinary sodium=potassium
ratio but a lower calcium intake had the highest supine
blood pressure and prevalence of hypertension (Table 3). In
contrast, subjects with a lower urinary sodium=potassium
ratio but a higher calcium intake had the lowest supine
blood pressure and prevalence of hypertension. Our observa-

Comparison of blood pressures and prevalence of hypertension in subjects with different urinary sodium=potassium ratios and calcium intakes

Number of subjects
Age
Urine Na=K
Ca intake (g=day)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Hypertension (%)
a

High urine Na=K,

low Ca intake

High urine Na=K,

high Ca intake

Low urine Na=K,

low Ca intake

Low urine Na=K,

high Ca intake

P-valuea

23
80.5
5.5
6.7
1.8
254
62
159
26
78
12
18 (78%)

14
76.9
6.7
6.6
3.0
553
285
145
21
78
13
8 (57%)

12
75.8
8.6
2.2
0.7
199
85
143
28
73
15
6 (50%)

16
74
7.5
2.4
0.9
736
376
130
15
73
10.8
4 (25%)

0.03
0.00
0.00
0.01
0.54
0.01

Comparison of blood pressures by univariate analysis, using age as covariate; comparison of prevalence of hypertension by chi-square test; comparison of age by
ANOVA.

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tions are consistent with the suggestion that dietary saltinduced increases of blood pressure can be augmented by
diets deficient in calcium or potassium (Kotchen & Kotchen,
1997). However, potassium intake as estimated by urinary
excretion and 24 h dietary recall did not appear to influence
blood pressure in this population.
Hypertension becomes more common with advancing
age (Whelton, 1994), yet there have been relatively few
studies of the association between dietary cation intakes
and blood pressure among older individuals. The role of
sodium intake in hypertension is well recognized (MacGregor, 1983). The mechanisms whereby dietary potassium and
calcium intakes can influence blood pressure have been
reviewed (Kotchen & Kotchen, 1997; Ely, 1997; McCarron,
1997). A proposed mechanism for the blood pressure lowering effects of potassium and calcium is their natriuretic
properties (Kotchen & Kotchen, 1997).
In Rotterdam, the dietary intakes of 3239 subjects aged
 55 y were assessed by a semi-quantitative food frequency
questionnaire (Geleijnse et al, 1996). After adjustment for
age, sex, BMI and alcohol intake, an increase in potassium
intake of 1 g=day was associated with a 0.9 mmHg lower
systolic and a 0.8 mmHg lower diastolic blood pressure.
Calcium intake was not independently related to blood
pressure, except for a subgroup of 1360 hypertensive subjects
in whom a significant inverse association with diastolic
blood pressure was seen. Also in Rotterdam, urinary
sodium and potassium excretions of 1006 subjects aged
 55 y were assessed in a time nocturnal urine sample and
standardized to 24 h values (Geleijnse et al, 1997). In the
multivariate model, a 100 mmol increase in daily urinary
potassium excretion was associated with a 9.4 mmHg
decrease in systolic and a 4.9 mmHg decrease in diastolic
blood pressure.
Controlled trials generally confirmed the importance of
dietary factors in the prevention and management of hypertension in individuals. In the Dietary Approaches to Stop
Hypertension (DASH) trial, salt restriction together with the
DASH diet, a diet that is rich in vegetables, fruits and low-fat
dairy products, lowered blood pressure in 412 adults with or
without hypertension (Sacks et al, 2001). The influence of a
mineral salt on 24 h ambulatory blood pressure was studied
in 20 elderly hypertensive subjects (Katz et al, 1999). Ordinary table and cooking salt was substituted with a special
sodium-reduced, potassium-, magnesium- and l-lysine
hydrochloride-enriched salt for 6 months. Antihypertensive
drugs were unaltered. Nine subjects showed significant
reductions in their systolic and diastolic blood pressure in
the daytime (11.5 and 15.0 mmHg) and the night-time (2
and 9.3 mmHg). Blood pressure in the other 11 subjects
showed no improvement. Clinical trials of calcium supplementation have not been consistent, probably because of
high baseline calcium intake (McCarron et al, 1994). Recent
meta analysis did confirm the association between calcium
intake and blood pressure (Cappuccio et al, 1995), but the
reduction in blood pressure with calcium supplementation

was estimated to be no more than 2 mmHg on average

(Allender et al, 1996).
In this study, potassium intake did not appear to correlate
with blood pressure, probably because of small sample size.
For the same reason, it was somewhat surprising to observe a
significant association between low calcium intake and elevated systolic blood pressure. This contrasts with another
local study of older Chinese people which showed a slight
positive correlation between calcium intake and systolic
blood pressure (Woo et al, 1988). When compared with
these subjects, our vegetarian subjects were older, and had
greater urinary excretion of sodium and potassium. Whether
any of these factors are relevant to the apparent hypotensive
effect of higher dietary calcium require further investigation.
There were other potential confounders which have not
been considered in this study. It is known that dietary
magnesium, saturated and unsaturated fatty acids (Grimsgaard et al, 1999; Miyajima et al, 2001) influence the development and progression of hypertension and consequently
coronary heart disease.
Another important parameter to consider is plasma concentrations of asymmetrical dimethylarginine, one of the
methylated arginine residues. Asymmetrical dimethylarginine is increasingly recognized as an important cardiovascular risk factor (Vallance, 2001). It has been shown to
inhibit the production of nitric oxide, the endotheliumderived relaxing factor essential for regulating vascular
tone and haemodynamics (Puddu et al, 2000). Plasma concentrations of asymmetrical dimethylarginine have been
reported to be increased in patients with end stage renal
disease (Kielstein et al, 2001). More importantly, they are
elevated in hyperhomocysteinaemia (Stuhlinger et al, 2001)
and in hypertensive patients on a high salt diet (Fujiwara
et al, 2000). Therefore our older vegetarian subjects might
have elevated plasma concentrations of asymmetrical
dimethylarginine as they had high salt intakes as reflected
by urinary sodium:creatinine ratios, and they were at risk of
hyperhomocysteinemia because of vitamin B12 deficiency
(Mezzano et al, 2000). We have previously reported that as
many as 42% of them were vitamin B12 deficient (Kwok et al,
2002).
It is interesting that there was a trend of ischaemic ECG
changes in hypertensive subjects without much evidence of
left ventricular hypertrophy. This suggested that hypertension is an important risk factor of ischaemic heart disease in
this population, even though their prevalence of ischaemic
heart disease was lower than that of women of similar age in
Hong Kong (Kwok et al, 2000).
We concluded that in contrast to the Western vegetarian
diets, features of the Chinese vegetarian diet high sodium
and low calcium intakes might predispose to hypertension. As this combination of dietary intakes is common in
Asian countries, public health interventions against this
dietary pattern may have major impact on the incidence
and prevalence of hypertension in this most populous part of
the world.
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