Diet for Patients with Hypokalemic Periodic Paralysis

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Designed by the National Institutes of Health    

This information is based on a diet designed at the National Institutes of Health in the 1960s for a young man with Hypokalemic Periodic Paralysis (HypoKPP). According to the NIH physicians and dietician Mary R. Emerson, plus many other medical authorities, those with HypoKPP should follow a diet which is high in protein, low in carbohydrate, and low in sodium.

Drawing on my training as a nutrition instructor I have adapted the diet Ms. Emerson planned to better meet today's patient, taking into account current knowledge of both HypoKPP and nutrition, and the changes in food culture over the years. In addition this article begins with information which explains the rationale behind the diet to those who may be learning how to manage HypoKPP.

What is “Blood Sugar” and Where Does It Come From?

Blood sugar, also known as blood glucose, is the body’s fuel. It feeds the brain, nervous system, muscles and other tissues. The body makes glucose from the carbohydrates we eat, but also from proteins and fats. We would not be able to function without glucose.

As food is digested it is converted to glucose which is released into the blood. Some glucose is stored in the liver, as insurance against low blood sugar. Maintaining a stable blood glucose level is important to everyone's health and performance, but it is absolutely essential to those with Hypokalemic Periodic Paralysis.

The Goal of the HypoKPP Diet Is to Keep Your Blood Sugar Stable

How Blood Sugar Level Affects Muscle Strength

After eating, blood sugar rises. The pancreas produces a hormone called insulin which allows glucose to move into the tissues, including the muscles. The higher the blood sugar rises the more insulin is produced, the more glucose moves into the muscles, and the faster it moves. As each molecule of glucose enters the muscle it takes an ion of potassium (K+) with it, lowering the amount of potassium in the blood serum. As serum potassium drops the muscles become weak. 

Sodium (Na+) intensifies this effect by speeding up the movement of glucose and K+ into muscle via the Na+-K+ pump. It takes an ion of Na+ to move a molecule of glucose into the cell. When a molecule of glucose and an ion of Na+ attach to the binding sites of the Na+-K+ pump they are immediately transported into the cell.

Low blood sugar is also common trigger for episodes. 

When you go for too long without eating blood sugar drops. If it drops too low the liver releases stored glucose into the blood, an effect which could be compared to drinking syrup.

This release of glucose spurs a release of insulin, and the movement of the stored glucose and potassium into the muscle can be enough to cause weakness in many patients.  For this reason it's best to snack between meals and keep your blood sugar from dropping.  

On this web page you will find:

  • Foods to omit from the diet; foods high in carbohydrate and salt.
  • Foods to be used in limited amounts; higher in carbohydrate, but necessary to a balanced diet.
  • Foods that may be used as desired. These are high in protein
  • Vegetables which contain carbohydrate, in small amounts. These vegetables are necessary in the diet to furnish minerals, vitamins, and fiber.

What does "Carbohydrate" Mean?

Carbohydrates are organic compounds found in living tissues. They contain hydrogen and oxygen, plus starch, sugars and cellulose (fiber). There are three simple carbohydrates; Glucose; Fructose and Lactose. Glucose is the only form the brain and muscle can use as fuel. Fructose and Lactose must be digested and broken down into glucose before they can be used, so they raise blood sugar more slowly than glucose.

What Foods Have Carbohydrates in Them?

Glucose is found in grains and vegetables. Fructose is found in fruit. Lactose is found in milk and milk products.

On food labels carbohydrates are the ingredients ending in the letters – OSE, including but not limited to: Glucose, sucrose, fructose, dextrose and maltose.

HypoKPP Diet Principles

All patients with HypoKPP should drink an adequate amount of fluid every day, to avoid kidney stones. Water is the very best drink, with green tea a close second. Coffee seems to provoke symptoms in some patients, and ease them in others. But two cups of coffee a day is the healthy limit for anyone.

Unsalted butter and unsaturated salad oils may be used if needed for calories. Most people need to avoid extra calories, so caution is advised with the use of fats.

The free use of sugar is to be avoided. Sugar substitutes Equal, Splenda and Stevia may be used as desired, though some patients report that these still provoke some glucose-like effects. 

The diet should be low in sodium, no more than three-fourths of a tsp total daily. Look for the sodium content on labels. Foods that have less than 140 mg or 5% of the Daily Value [DV] of sodium are low in salt.

Fresh or plain frozen vegetables (those frozen without added sauces) and limited amounts of whole grains may be used.

Canned vegetables are almost always too high in sodium for regular inclusion in the HypoKPP diet. Foods which are on the "List to omit" (below) because of high sodium content should not be used.

The diet should also be high in potassium. Bananas, orange juice, milk, and potatoes are all high in potassium. However, these foods must be eaten only in limited amounts because of their higher carbohydrate content.

Get Your Protein!

Protein is your friend, eat plenty every day! Each meal and snack should include a palm-sized portion of protein which is as thick as a deck of cards.

The best protein sources are: lean meats, fish, poultry without the skin, eggs, low salt cheese and cottage cheese, tofu & a wide variety of beans. Muscle meat is also high in potassium which helps meet the need for potassium.

For health reasons, choose low fat cooking options, i.e. broil, grill or poach rather than frying. Protein foods make good snacks when you are hungry.

Proteins which can be eaten freely

Lean beef, Bison, Chicken, Turkey, Duck, Lamb, Veal, Pork (lean cuts), Fresh fish, Eggs, Unsalted cottage cheese, low salt cheese. Soy beans as tofu, temph or boiled green (edamame), roasted unsalted peanuts,  "Natural" style unsalted, no-sugar added peanut butter, unsalted nuts. 

Other Unlimited Foods

Fresh coconut; Avocado; Lemon and lime juice; Vegetables from the "A" list (found below); Diet gelatin; Vinegar; Tea; Spices, but not packaged sauces which are high in sodium.

Fruit Exchange List

Eat three items daily from this list; the carb content of each item below is about 10 grams.

1 small apple or ½ c unsweetened applesauce; 2 fresh apricots; ½ banana; 1 c strawberries, blackberries, or raspberries; 2/3 cup blueberries; ¼ cantaloupe; 10 large fresh cherries; ½ grapefruit or ½ c grapefruit juice; 12 grapes; ¼ c grape juice; 2 kiwi; 1 nectarine; 1 small orange; ½ c orange juice; 1 med peach; 1 small pear; ½ c fresh or unsweetened canned pineapple or 1/3 c pineapple juice; 2 medium plums; 2 dried prunes; 1 large tangerine; 1 cup watermelon.

“A” List Vegetables

Eat generous portions of:

Asparagus; Bean sprouts; Broccoli; Brussels sprouts; Cabbage; Bok Choi; Cauliflower; Celery; Collards; Cucumber; Eggplant; Green beans; Green onions; New red potatoes; Kale; Leeks; Mushrooms; Okra; Onion; Daikon radish; Pea pods; Peppers (all varieties); Radishes; Rutabaga; Soybeans; Spinach; Summer squash; Swiss chard; Tomato; Vegetable juice cocktail; Zucchini.

“B” List Vegetables

Eat only small (¼ c.) portions:

Baking potatoes; Carrots; Peas; Pumpkin; Beets; Turnips; Sweet potato; Winter squash; Parsnip.

Bread Exchange List

Eat three items daily from this list; in only the amount specified. Each item listed has about 15 grams of carbs.

1 slice of whole grain bread; 1 small whole grain hamburger bun; 1 biscuit or 1 roll; 1 small piece of cornbread; 2 graham crackers; 1 small brown potato; ½ cup cooked brown rice or whole grain pasta (noodles, spaghetti, macaroni); ½ cup mashed potatoes; ½ cup corn or lima beans; ½ cup cooked dried peas (split, crowder, blackeye, etc.); ½ cup parsnips; ¼ cup sweet potatoes.

Grains of Wisdom

Choose whole-grains, refining grain removes vitamins, minerals and other nutrients – including 78% of its fiber. “White” bread contains a high level of glucose which raises blood sugar quickly. Whole-grain bread has the same amount of glucose, but the fiber content slows the rise of bread sugar. Small portions of whole grain products are OK, large ones are not.

 

Higher Carbohydrate Foods to Eat Daily

1 qt of skim milk (8 oz. glass = 12 grams carbs x 4 = 48 g carbs)

3 items daily from the bread exchange list. (about 45 g. carbs total)

3 items daily from fruit exchange list. (about 30 g. carbs)

1 serving from list of "B" vegetables (5 – 10 g. carbs)

 

 

Hot Potatoes

We all cheat on our diets sometimes. The impact of high carbohydrate foods can be slowed by adding fat. Add butter & sour cream to baked potato. Choose French-fries rather than boiled potato. Choose full-fat ice cream rather than sherbet or ice milk. Thin-crust pizza is better than thick-crust. Put butter or margarine on bread.

How Much Potassium per Day?

3,500 - 4,000 mg daily is recommended for normal people. The diets of hunter-gatherers include about 7,000 - 8,000 mg daily, so increased intake is healthy, but discuss your potassium intake with your doctor if you are on a K+-sparing diuretic!

Find K+ in:

  • Dairy Products: Milk; Yogurt;
  • Fruit: Apricots; Avocado; Cantaloupe; Nectarines; Prunes; Apples; Grapefruit; Oranges; Peaches; Strawberries; Melons;
  • Vegetables: Carrots; Celery; Beets; Dark leafy greens; Broccoli; Spinach; Tomato; Zucchini;
  • Proteins: Chicken; Fresh fish; Turkey; Beef; Lamb; Fresh Pork; Nuts.

Foods to avoid due to high sodium content

Bacon; Ham; Potato chips; Pretzels; Sausage; Seasoned salt; Frankfurters; Soya sauce; Lunch meats; Sauerkraut; Corned beef; Salted nuts; Pickles; Olives; Feta cheese; Rollmops; Bouillon cubes; Salted Crackers; Salted popcorn; Pizza; French onion soup mix; Deli salads and soups; canned vegetables; regular canned soups; packaged foods like Hamburger Helper and Side dishes.

Foods to avoid due to high carbohydrate content

Sugar; Syrup; Honey; Jam; Jelly; Sweet rolls; Doughnuts; Ice cream (except to substitute); Candy; Jello; Cookies; Cream of Wheat; Regular soft drinks; Puddings; Cake; Pastries; Grits; Minute Rice; Instant oatmeal; Sweetened or sugar-coated cereals; Frozen or canned fruit with sugar added.

Occasionally, if desired, 1 doughnut OR 1/2 cup of ice cream may be substituted for 1 item on "bread exchange list".

Menu Planning

The HypoKPP “diet” is a very healthy one. Low in unhealthy saturated fats, sodium and “junk” foods, it is high in fresh, healthful fruits, vegetables and protein sources. Know yourself. You are unique and your diet must meet your needs, not a formula. Some people require more sodium, some require more calories. Individuals vary in their tolerance for carbohydrates, but the general rule is that a diet low in sodium and carbs results in more strength and fewer attacks.

Meal Planning

Menus are easy to plan. Each meal and snack should contain a serving of protein equal to the size of your palm and as thick as a deck of cards.

Meals should also include:

  • 1 or more “A” list vegetables.
  • 1 “B” list veggie,
  • A serving of milk.

During the day you also need:

  • Three bread exchanges
  • Three fruit exchanges.

Choose health for yourself and your whole family with a good diet!

So the daily menu is built like this.

  • Breakfast: protein + fruit exchange + milk.
  • Mid-morning snack: protein + fruit exchange.
  • Lunch: protein, 1-3 “A” list veggies + 1 “B” list veggie + milk + bread exchange.
  • Mid-afternoon snack: protein + bread exchange.
  • Dinner: protein, 1-3 “A” list veggies + 1 “B” list veggie + milk + bread exchange.
  • Evening snack: protein + “A” list veggie.

Breakfast Ideas

Breakfast One

  • ½ grapefruit (fruit exchange)
  • 1 serving bran buds (bread exchange)
  • Scrambled egg(s)
  • 8 oz of milk
  • Sweetener

Breakfast Two

  • 4 oz orange juice (fruit exchange)
  • Scrambled egg(s) with mushrooms and parsley
  • 1 slice whole wheat toast with butter
  • 8 ounces of milk

Breakfast Three

  • Poached egg(s)
  • 1 slice whole wheat toast with butter
  • 8 oz of milk

More than cereal and eggs!

You can eat anything for breakfast. Low sodium cottage cheese with fruit is a nice choice in the summer. A minute steak is great for breakfast, with a small serving of hash browns, and a serving of berries and/or an "A" List veggie. How about a tuna melt, or "sloppy Joe" (see recipe below) on whole wheat toast?

Protein Smoothie

Protein Smoothies are easily made in your own kitchen. There are two versions to this recipe, the tofu/soy one and the dairy/milk one. Choose your preference. The method is the same.

One - 375 gram (12 oz) box of 'silken' (Japanese style) tofu. Put it in the blender with 4 cups soy milk. Soy is great for this because it has a very low glycemic index. (Alternately use 1 ½ cups 2% cottage cheese and 4 cups skim milk.)

Blend till smooth. Add a banana & 1 cup unsweetened berries (or a fresh nectarine and peach cut into pieces). Add 1 tsp vitamin C powder or two crushed 1000 mg vitamin C tablets. Add milk as you blend. You may also add 2 Tbs. safflower oil for essential omega fatty acids.

¾ of a cup is a serving. This makes an excellent breakfast with a piece of fruit. A ½ cup serving can also be used as a mid-meal and bedtime snack.

Snacking is good!

Mid-morning, mid-afternoon & before bed, a snack will keep blood sugar stable. Typical snacks might be:

  • ½ cup Protein shake,
  • 2 – 3 oz (50 - 100 g) unsalted nuts; ½ banana,
  • Cubes of Swiss cheese and an apple or pear,
  • Boiled egg and celery/carrot sticks with ranch dressing dip,
  • Celery sticks with peanut butter or cream cheese filling, milk,
  • Cubed chicken, cherry tomatoes & ranch dip,
  • Tea, edamame (baby soybeans),
  • 2 graham crackers, ½ banana, milk.

Lunch Suggestions

Hamburger patty, small whole wheat burger bun with mustard or catsup, large serving lettuce and tomato, onion slice; ½ avocado with vinegar and oil dressing, ½ banana, 8 oz (240 ml) of milk.

Salad of cold turkey or chicken; carrots, cucumber, red kidney beans, green pepper, on lettuce or mixed greens, onions and salad dressing.

Fish, poultry or lean red meat, Swiss cheese, 1 slice whole wheat bread, a cup of broccoli, fruit exchange.

Rice wraps filled with bean sprouts, chicken, cashews, grated ginger, slivered vegetables, spicy dipping sauce.

Ringing the dinner bell!

Try these suggestions:

Baked chicken breast, 1/4 cup herbed rice, peas with butter, cole slaw; dressing: 1 tsp mayo, 1 tsp vinegar & ½ tsp Splenda, 8 oz milk, strawberries.

Steak, small baked potato & sour cream, carrots, celery sticks with cream cheese, 8 oz of milk.

Chili, made with lean beef, onions, tomatoes, & pinto beans, served with a salad and bread exchange.

Ginger-lime marinated chicken breast, broiled or grilled, cottage-cheese stuffed tomatoes, steamed broccoli, 1 bread exchange

Sloppy Joe

1 lb (500 g) extra lean ground beef
1 onion diced
1/4 cup ketchup
1/2 cup water
2 Tbs vinegar
2 Tbs Splenda
2 tsp mustard
2 tsp garlic powder

Brown ground beef with chopped onion and drain.

Add remaining ingredients, stir and let simmer for 15-20 min.

Serve on buns or bread.

Lessons we've learned

Make dietary changes over weeks, rather than days. Change one thing at a time, so you can track what is helping and what may not be right for you. Try new foods & recipes, and try not to think of it as “denial” eating. You can still have anything you like, in adapted quantities. Foods tolerated by others may be a trigger for you. Use common sense.

 

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