sium intake and cardiovascular reactivity in

with risk factors for essential hypertension

roof MD, Alex Forman, PA, MeH, Nancy Cole, BA, John M. Jemerin, MD, and
t~ Curtis Morris, MD

Objectives: Our study objectives were as follows: (1) to determine whether urinary Both genetic and environmental factors may
excretion of potassium is lower in black than in white children, (2) to determine participate in the pathogenesis of essential
whether cardiovascular reactivity (CVR) varies inversely with dietary intake of potas- hypertension. The risk of essential hyperten-
sium, and (3) to confirm that CVR is greater in black than in white children, and in sion is greater in black subjects than in white
subjects 1, 2 and in individuals who have a
children with a family history of hypertension than in those without such a history.
family history of hypertension than in those
Study design: Baseline measurements included 2 4 - h o u r urinary sodium, potassium, with no such history. 3-5 In normotensive
and ereatinine levels and food intake (by questionnaire). Resting and stress blood pres- children and adults, both risk factors have
sures were measured during blood sampling, cold water foot immersion, and a video been associated with an acute cardiovascu-
game before and after 1 week each of supplementation with potassium citrate, 1.5 lar response to stress that is enhanced, T M
mmol/kg per day, and placebo administered in random order. which itself may predict higher resting blood
pressure values and the occurrence of essen-
Results: Thirty-nine children aged 7 to 15 years were studied. White subjects had
tial hypertension. 22"25 Such enhancement
higher baseline excretion of potassium than black subjects (p < 0.001) and higher veg-
may be so predictive because the increased
etable intake (p < 0.01), which were positively correlated (r = 0.53, p < 0.001). At base- adrenergic activity that mediates it26' 27 may
line, the 24-hour urinary potassium/creafinine ratio varied inversely with diastolic CVR be an important pathogenetic determinant of
to the video game stressor in white children (r = -0.55, p = 0.02). Cardiovascular reac- essential hypertension. 28 Thus black race
tivity was not attenuated measurably by potassium supplementation compared with and a positive family history of hypertension
placebo. The CVR was greater in children with a family history of hypertension than in might both be risk factors for hypertension
those without, but was not greater in black children than in white children. in part through the agency of enhanced
adrenergic activity.
{2onlusions: The urinary potassinm/creatinine ratio is higher in white than black chil-
dren because their intake of vegetables is greater; dietary potassium intake may modu-
late CVR, particularly in white children with a family history of hypertension, but may
need to be supplemented for more than 1 week to demonstrate attenuation of CVR;
and a family history of hypertension may be a stronger predictor of enhanced CVR
than is race. (J Pediatr 1997; 131:87-94)

From the Departments of Pediatrics,Medicine, and Radiology, and GeneralCh)zicalResearch Center, Universityof In short-term studies of both hyperten-
California- San Francisco. sive aduks and normotensive young adults
Supported in part by giftsfrom the Church and Dwight Corporationand the EmilMossbacher,Jr. with F H +, adrenergically mediated car-
Foundation; U.S. PublicHealth Service,NationalHeart Lung and BloodInstitute grant No. RO1- diovascular phenomena are enhanced by
HL47943; and grant No. 5 MO1 RR-00079 from the GeneralClinicalResearchCenter and Pediatric potassium restriction and attenuated by its
ClinicalResearch Center, Divisionof Research Resources,Universityof California-San Francisco.
supplementation for periods of 6 to 14
Submittedfor publicationJune 11, 1996; acceptedNov. 18, 1996.
clays.29-31 Supplementation of dietary
Reprint requests:Jonathan Sorof, MD, Texas Children'sHospital,6621 Fannin St. MC 3-2482, Houston,
TX 77030-2399. potassium can abolish the racial differ-
Copyright 1997by Mosby-YearBook, Inc. ences (black vs white) in cardiovascular
0022-3476/97/$5.00 + 0 9/21/79369 reactivity to stress in previously potassi-

87
 SOROF ET AL.
Table L Clinical and physiologic characteristics of subjects at baseline
Table IL Relationship of urinary electrolytes and food frequency to race and family his-
tory of hypertension
urn-restricted, normotensive men, 52 re-
duce blood pressure in adults with essen-
tial hypertension, 33-39 and slow the nor-
mal age-related rate of rise of blood
pressure in adolescent girls who follow
salt-restricted diets,g0 Urinary excretion
of potassium is inversely related to (1)
resting blood pressure in adults, (2) the
rate of the age-related rise of blood pres-
sure in normal children, and (3) the inci-
dence of essential hypertension, 41-45 and,
in the United States, is lower in black
subjects than in white subjects beginning
in childhood. 11, 46-50 Accordingly, a long-
term reduced dietary intake of potassium
might enhance adrenergic-mediated car-
diovascular phenomena over the long
term, particularly in n0rmotensive black
88
subjects and in F H individuals, and
thereby increase their risk of hyperten-
sion. To further consider this hypothesis,
we determined the following in nor-
motensive children: (1) whether dietary
intake and urinary excretion of potassium
are less in black children than i n white
children on the West coast, (2) whether
the acute cardiovascular response to
stress varies inversely with urinary excre-
tion of potassium, (3) whether dietary
potassium supplementation can attenuate
an enhanced cardiovascular response,
and (4) whether the acute cardiovascular
response to stress is greater in black chil-
dren than in white children, and in chil-
dren with F H than in children with no
family history of hypertension.
THE JOURNAL OF PEDIATmCS
JULY 1997
METHODS
Subject Recruitment
Subjects were recruited from the San
Francisco area by circulation of flyers to
local schools and to local pediatric clinics
affiliated with the University of Califor-
n i a - S a n Francisco. Inclusion criteria
were as follows: 7 to 15 years of age, black
or white race (each of four grandparents
of same self-described ethnicity as the
subject), normal serum concentration of
creatinine, and no concurrent medication
use during the duration of the study.
Subjects were categorized by the pres-
ence or absence of a family histo W of es-
sential hypertension (defined as at least
one parent or grandparent with essential
hypertension by parental report). Es-
sential hypertension was defined as hy-
pertension in the absence of secondary
causes such as primary renal disease or di-
abetes, or that developed before the age of
65. Consent forms for parents and age-ap-
propriate assent forms for subjects were
approved b y the Committee on Human
Research at the University of Califor-
nia-San Francisco and were signed at the
first visit. Each subject received $120 re-
imbursement for completing the 2-week
study.
Hemodynamic Measurements
and Experimental Stressors
Three visits, 1 week apart, were made
to the Pediatric Clinical Research Center
at Moffitt Hospital. At each visit, the sub-
jects were seated in a quiet, darkened
room and a blood pressure cuff was
placed on their left arm. After a S-minute
rest period during which the subject
watched an age-appropriate videotape,
four blood pressure and heart rate mea-
surements were made 1 minute apart with
an oscillometric device (Dinamap, John-
son & Johnson Medical, Inc.). The final
three of four sets of measurements were
averaged to give the resting hemodynam-
ic measurements for that visit.
After the resting hemodynamic mea-
surements were made, three different ex-
perimental stressors were administered:
blood sampling, cold pressor, and video
THE JOURNAL OF PEDIATRICS
Volume 13 I, N u m b e r I, Part I
game. Blood sampling refers to the stress
associated with the anticipation of phle-
botomy. Subjects were told that blood
was about to be obtained with a needle,
a 23-gauge butterfly needle was pre-
pared for use, and an alcohol wipe was
applied to the skin. Immediately before
the insertion of the needle, two consec-
utive hemodynamic measurements were
recorded and blood was then obtained.
This was followed by a 5-minute rest
period. Coldpressor refers to the stress of
immersing an extremity in a cold water
bath. Subjects were asked to immerse a
foot up to the ankle into a 10" C (50 F)
water bath for as long as they could en-
dure for up to 1 minute, but were told
that the foot could be removed at any
time. Hemodynamic measurements
were made and recorded at 15 and 45
seconds of foot immersion. The foot was
removed at 1 minute and immediately
warmed and dried. This was followed
by a 5-minute rest period. Video game
refers to the stress associated with play-
ing a computer game for financial incen-
tive. Subjects played a 4-minute stan-
dardized computer memory game that
required memorizing a random se-
quence displayed on the computer
screen and then reproducing it by press-
ing keys on the keyboard in the same se-
quence. This video memory task was se-
lected because of its high test-retest
reliability as described elsewhere, sl For
each correct response, subjects received
25 cents up to a total of 5 dollars per
game. Hemodynamic measurements
were made and recorded after 30 sec-
onds and then every 1 minute thereafter
for a total of 4 sets of measurements.
The order in which the stressors were
administered was the same for each
study visit.
Dietary Questionnaires
A list was compiled of the foods that
comprise the top 50 sources of potassium
in the American d i e t 9 Subjects were
asked to report the frequency of intake of
each food on the llst by clay, week, month,
or year. Subjects who could not complete
the questionnaires by themselves were as-
SOROF ET AL.
0.1 !
o
o o
o o o
0.08
0
E 0.06
E
L_ "D 2 ~ 00
0 0.04
o
0
0.02
r = 0.53, p <0.001
0 , t , I
0 400 800 1,200 1,600
Vegetable Intake (portions/year)
White (n=17) Black (n=19)
0
F~g. I. Relationship between vegetable intake and urinary excretion of potassium. Open
circles, white subjects; solid circles,black subjects.
sisted by their parents. The number of study, subjects were randomly assigned
portions per year of each food on the list to receive either an oral solution of potas-
was calculated to provide a yearly fre- sium citrate, 1.5 mmol/kg per day in 2 di-
quency for each individual food. Each vided doses, or a solution of cherry syrup
food was assigned to one of four main placebo. During the second week of the
food categories (meats, vegetables, study, the supplement was switched to
fruits, and dairy), and each category was the one not yet received, so that on com-
then expressed in portions per year. pletion of the study each subject had re-
Portions per year of meats, vegetables, ceived 1 week of both potassium and
fruits, and dairy were compared for placebo. Both the subjects and the inves-
black and white children, and for F H - tigators were unaware of the order of ad-
and F H children. ministration of the solutions. The potas-
sium citrate solution was diluted 2:1 with
Potassium Supplementation cherry syrup to mask the taste of the sup-
Before the first study visit, each sub- plement, and the placebo solution was
ject collected urine for 24 hours; the sam- diluted 2:1 with 1% acetic acid to give a
ples were analyzed for the concentra- slightly bitter taste. Compliance was as-
tions of sodium, potassium, and sessed by measuring the residual vol-
creatinine. During the first week of the umes in the bottles of supplement at the
89
 SOROF ET AL.
Table IIL Cardiovascularreactivity stressors at baseline
end of each week, and by 12-hour
overnight urine collections on the even-
ings before both the second and third
study visits.
Data Analysis
For each experimental stressor, CVR
was expressed as both the maximum he-
modynamic response, and as the change
from the resting state to the maximum re-
sponse for systolic blood pressure, dias-
tolic blood pressure, mean arterial pres-
sure, and HR. Urinary electrolyte values
were expressed as milliequivalents per
milligram of creatinine. Dietary frequen-
cies were expressed as portions per year.
A two-tailed t test was used for racial
(black vs white children) and family his-
tory of hypertension (FH- vs F H ) com-
parisons. A Spearman correlation test as-
sessed the association between 26-hour
baseline urinary potassium/creatinine
ratio and both food portions peryear and
stress cardiovascular responses. Analysis
of variance for repeated measures was
used to compare the cardiovascular re-
sponse for the study periods of baseline
versus placebo versus potassium for each
subject. All statistical analyses were per-
formed with the STATISTICA for
Windows software package (release 4.3,
StatSoft, Inc.). Data are expressed as
mean SD.
90
RESULTS
Subject Demographics
Thirty-nine children (22 girls, 17 boys)
completed the study from June 1994 to
November 1994. Four other children
were not included in the study because
they did not comply with the supplemen-
tation solutions. Race, family history of
hypertension, and sex were evenly dis-
tributed in the study group, and age,
weight, and resting hemodynarnic para-
meters at the first visit did not differ be-
tween black and white children, or be-
tween F H - and F H + children (Table I).
None of the children was hypertensive at
rest by commonly accepted defmitions of
hypertension in children. The prevalence
of a family history of hypertension did not
differ between black and white subjects.
Urinary Electrolyte Levels and
Dietary Questionnaire
The 24-hour UK+/Cr was greater in
white children than in black children
(0.062 vs 0.041, p < 0.001), and the 24-
hour urinary sodium/potassium ratio was
greater in black children than white chil-
dren (3.96 vs 2.51, p < 0.001)(Table II).
The 24-hour urinary sodiurn/creatinine
ratio was not different between black and
white children. The portions per year of
vegetables was greater in white chil-
THE JOURNALOF PEDIATRICS
JULY 1997
dren than in black children (722 vs 392,
p < 0.01). The portions per year of meats,
fruits, or dairy products did not differ be-
tween black and white children. Vege-
table intake correlated positively with 24-
hour UK+/Cr (r = 0.53,p < 0.001) (Fig. 1),
and negatively with 24-hour urinary sodi-
um/potassium ratio (-0.37, p < 0.05). The
24-hour UNa+/Cr did not correlate with
portions per year of vegetables, meats,
fruits, or dairy products.
Cardiovascular Reactivity to
Stressors at First Visit
For each experimental stressor, SBP,
DBP, MAP, and H R were compared with
respect to race and family history of hy-
pertension (Table III). In F H children
compared with F H - children (Table III),
blood sampling induced a marginally
greater change in SBP (p = 0.055), and
the video game stressor induced a
greater change in SBP (p < 0.05) and
MAP (p < 0.05). White and black children
did not differ in the change in cardiovas-
cular response induced by any of the ex-
perimental stressors (Table II D. In white
children (n = 17), the 24-hour UK/Cr
showed a negative correlation with the
maximum D B P induced by the video
game stressor (r = -0.55, p = 0.02) (Fig. 2),
and marginally negative correlations with
the maximum D B P induced by blood
THE JOURNAL OF PEDIATRICS
Volume 13 I, N u m b e r I, Part I
sampling @ = -0.44, p = 0.08), and the
maximum MAP induced by cold pressor
(r = -0.48, p = 0.06). In white FH +children
(n = 7), the 24-hour UK+/Cr showed a
negative correlation with the maximum
DBP induced by video game (r = -0.82,
p < 0.05) (Fig. 2) and by blood sampling (r
= -0.79, p < 0+05), and a marginally nega-
tive correlation with the maximum DBP (r
= -0.70, p = 0.08) and the maximum MAP
(r = - 0 . 7 5 , / 9 = 0.052) induced by cold
pressor. Cold pressor induced the great-
est change in SBP (p < 0.05), DBP (p <
0.001), and MAP (p < 0.05) cardiovascu-
lar responses of the three stressors (Table
IV).
Potassium Supplementation
The UK+/Cr value was significantly
higher during the potassium supplementa-
tion period than during either the baseline
or placebo period (p < 0.001) for all sub-
jects (Table IV). The cardiovascular re-
sponse to blood sampling was higher dur-
ing the baseline period than during either
the placebo or potassium periods for the
change in SBP, DBP, and MAP (0 < 0.06)
(Table IV). The cardiovascular response
to the video game stressor was higher dur-
ing the baseline period than during the
placebo or potassium periods for the
change in SBP, DBP, and MAP (o < 0.05).
The cardiovascular response to cold pres-
sor did not differ among the baseline,
placebo, or potassium periods. For each of
the stressors, the placebo and potassium
periods did not differ in the change in
CVR when considering all subjects, the
subsets of white and black children, the
subsets of FH- and FH + children, and the
children who excreted less than the mean
24-hour UK/Cr at baseline.
DISCUSSION
Despite its small number of subjects,
our study confirms that black children ex-
crete less potassium but similar amounts
of sodium compared with white chil-
dren, ll, 46-50 and documents the occur-
rence of this phenomenon in a population
of children living on the West coast.
SOROF ET AL.
90
80
.... .. O
%"'%%
"%%oo O
E
E 70
O
0_
m
X O "-.O
60
O "~
50 O
r , I , I
0.02 0.04 0.06 0.08 0.1
UK/Cr (meq/mg)
White (n=17) White FH+ (n=7)
r = - 0.55, p = 0 . 0 2 r = -0.82, p = 0.03
F ~ . 2. Relationshipbetween maximum changein diastolicblood pressureto video game
stressor and urinary excretion of potassium.Open circles and dashed line, white subjects;
solid drcles and solid line, white subjectswith family history of hypertension.
Several studies have found that black sub- the lower urinary excretion of potassium
jects consume fewer potassium-contain- in the black children.
ing foods such as fruits and vegetables White F H children had a lower base-
than do white subjeetsfi 346 By using a line 24-hour UK/Cr than the white F H -
food frequency questionnaire, an instru- children. In the white children, particular-
ment that has been shown to be reliable in ly in those who were FH , many of the
the study of dietary habits in children, 56' 57 maximum cardiovascular responses at the
we found that the frequency of intake of first visit varied inversely with the base-
vegetables in black children was approxi- line 24-hour UK+/Cr. This observation is
mately half that of white children, where- entirely consistent with the findings in
as the intake of meats, fruits, or dairy studies of white normotensive young
products did not differ. The positive cor- adults that supplementation of dietary
relation between vegetable intake and 24- potassium in those subjects who were
hour UK+/Cr suggests that the lower in- FH + attenuates acute adrenergically me-
take of potassium-containing foods such diated cardiovascular phenomena. 29' 50
as fresh vegetables accounts for much of We also confirmed that the acute car-
91
 SOROF ET AL.
Tab& ~ Cardiovascular reactivity and urinary electrolyte levels for each study period
diovascular response to stress was
greater in F H + children than in F H -
children 6, 8, 10, 12, 18, 20; however, this
greater cardiovascular response in F H +
children was significant only in the white
subjects. Some studies, 11' 58, 59 but not
others,60, 61 have found greater CVR in
F H + black children than in F H - black
children.
In the current study, although black chil-
dren did not have a greater cardiovascular
response than white children as has been
reported in other studies, 7' 9, 11, 15-17, 19 a
trend toward a greater response to cold
pressor was observed in black children. A
power analysis of our current data indi-
cates that approximately 100 black and
100 white children would have to be stud-
ied to detect a significant difference in the
cold pressor D B P response. One study
with only 20 subjects in each group de-
tected a greater D B P response in black
children by applying cold stimulus to the
face. 18 The difference in the technique of
cold stimulation in their study compared
with ours (face vs foot) may explain in
part the larger racial difference in the
DBP response (14 mm Hg vs 3 mm Hg)
related to an overall greater D B P re-
sponse in the black subjects (24 mm H g
92
vs 19). However, we neither have nor
know of data that compare the acute car-
diovascular response to cold stimulus to
the face with that to the foot in either
black or white children to support this hy-
pothesis.
After the first visit, repeated exposure
to either blood sampling or the video
game stressor at 1-week intervals was as-
sociated with a decreased cardiovascular
response, independent of whether potassi-
um or placebo was supplemented. By
contrast, the cardiovascular responses to
cold pressor did not change with repeated
exposure. Habituation therefore appeared
to have occurred with the mental stres-
sots, but not with the physical stressor.
The video game stressor did not induce ei-
ther as great an H R response as did blood
sampling (a novel experimental stressor in
the study of CVR in children) or as great
a BP response as cold pressor. This sug-
gests the possibility that video games do
not induce as persistently robust a cardio-
vascular response as do other stressors,
and may therefore not be the best choice
of experimental stressor in the investiga-
tion of CVR in children.
The cardiovascular responses in those
who received potassium supplementation
THE JOURNAL OF PEDIATRICS
JULY 1997
were not different from those who re-
ceived placebo, irrespective of experimen-
tal stressor. To demonstrate attenuation of
the cardiovascular response to stress after
an intervention requires that the response
to that stress be highly reproducible with-
in the same individual throughout the du-
ration of that intervention. Several studies
in children and young adults have found
high test-retest reliability of acute cardio-
vascular response within individuals to
various experimental mental and physical
stressors.24, 51, 62-65 However, the applica-
bility of these results to the current study
is rendered uncertain by both the sub-
stantially longer interval between tests in
most other studies, and the limits of in-
traindividual test-retest reliability. If the
acute cardiovascular response to a stres-
sor depends on the level to which the sub-
ject subjectively experiences acute anxi-
ety, fear, or discomfort, then a decrease in
the intensity of that subjective experience
would tend to attenuate subsequent re-
sponses and thereby decrease the test-
retest correlation. Particularly for the
mental stressors, a shorter interval be-
tween testing periods might speed the ha-
bituation to these stressors and lead to de-
terioration in the test-retest reliability.
Although the video game task used in the
current study was reported to have signif-
icant test-retest correlations in young
adults of 0.87, 0.69, and 0.59 for HR,
SBP, and DBP, respectively,51 these cor-
relations may not be high enough to
demonstrate that potassium supplementa-
tion can attenuate the acute cardiovascu-
lar response to stress with the study de-
sign w e used.
Potassium supplementation may have
failed to measurably attenuate CVR for
other reasons. Subjects may not have
been potassium deficient or deficient
enough for potassium supplementation to
have demonstrated attenuation of their
cardiovascular response. Even if the car-
diovascular response to stress had been
enhanced by potassium deficiency, 1 week
of potassium supplementation may not
have been sufficient to demonstrate atten-
uation of that response. Although collec-
tions of 12-hour overnight urine speci-
mens before each study visit showed a
THE JOURNAL OF PEDIATRICS
Volume 13 I, Number I, Part I
significant increase in potassium excre-
t i o n - i n d i c a t i n g some degree of compli-
ance with the potassium supplement solu-
t i o n - m a n y children complained of its
unpleasant taste. As a result the overnight
urine collections may not have reflected
the degree of compliance for the entire
week, and children may have taken less
than the prescribed amount of the potassi-
um supplement solution.
At this time it may be reasonable to rec-
o m m e n d that black children should in-
crease their intake of potassium-contain-
ing foods such as vegetables; however,
there are insufficient data to suggest that
potassium supplements in the form of
pharmacologic preparations be used.
Further studies should be done to deter-
mine whether potassium supplementation
might prevent or delay the occurrence of
essential hypertension in children with a
genetic predisposition to hypertension
that is reflected b y a family history of hy-
pertension and enhanced C V R to stress.
REFERENCES
Frisancho AR, Leonard WR, Bollettino
LA. Blood pressure in blacks and whites
and its relationship to dietary sodium and
potassium intake. J Chronic Dis 1984;37:
515-9.
2. National Center for Health Statistics.
Blood pressure levels in persons 18-74
years of age in 1976-80 and trends in blood
pressure from 1960 to 1980 in the United
States. Washington, DC: US Government
Printing Office, Public Health Service,
DHHS publication no. 86-1684. ~ t a l and
health stalasties; series 11, no 234).
3. Harlan W, Osbome R. A longitudinal study
of blood Pressure. Circulation 1962;26:530-
43.
4. Bedell-Thomas C, Duszynski KR. Blood
pressure levels in young adulthood as pre-
dictors of hypertension and the fate of the
cold pressor test. Johns Hopkins Med J
1982;151:93-100.
5. Hunt SG, Williams RR, Barlow GK. A
comparison of positive family history defin-
itions for defining risk of future disease, d
Chronic Dis 1986;39:809-21.
6. Falkner B, Onesti G, Angelakos ET,
Fernandes M, Langman C. Cardiovascular
response to mental stress in normal adoles-
cents with hypertensive parents. Hyper-
tension 1979;1:23-30.
7. Voors AW, Webber LS, Berenson GS.
Racial contrasts in cardiovascular response
tests for children from a total community.
Hypertension 1980;2:686-94.
8. Warren P, Fisehbein C. Identification of la-
bile hypertension in children of hyperten-
sive parents. Corm ivied 1980;44:77-9.
9. Alpert BS, Dover EV, Booker DL, Martin
AM, Strong WB. Blood pressure response
to dynamic exercise in healthy children-
black vs white, d Pediatr 1981;99:556-60.
10. Takeshim A, Imaizumi T, Ashihara T,
Yamamoto K, Hoka S, Nakamura M.
Limited maximal vasodilator capacity of
forearm resistance vessels in normotensive
young men with a familial predisposition to
hypertension. Circ Res 1982;50:671-7.
11. Hohn AR, Riopel DA, Keil dE, Loadholt
CB, Margolius HS, Halushka PV, et al.
Childhood familial and racial differences in
physiologic and biochemical factors related
to hypertension. Hypertension 1985;5:56-
70.
12. Falkner B, Kushner H, Khalsa DK,
Canessa M, Katz S. Sodium sensitivity,
growth and family histoly of hypertension
in young blacks. J Hypertens Suppl 1986;
4:5381-3.
13. Murphy JR, Alpert BS, Moes DM, Somes
GW. Race and cardiovascular reactivity: a
neglected relationship. Hypertension 1986;
8:1075-83.
14. Anderson NB, Lane JD, Muranaka M,
Williams RBJ, Houseworth SJ. Racial dif-
ferences in blood pressure and forearm vas-
cular responses to the cold face stimulus.
Psychosom Med 1988;50:57-65.
15. Anderson NB, Lane JD, Taguehi E
Williams RBJ, Houseworth SJ. Race,
parental history of hypertension, and pat-
terns of cardiovascular reactivity in women.
Psychophysiology 1989;26:39-47.
16. Falkner B, Kushner H. Race differences in
stress-induced reactivity in young adults.
Health Psycho11989;8:613-27.
I7. McAdoo WG, Weinberger Nil-I, Miller JZ,
Fineberg NS, Grim CE. Race and gender
influence hemodynamic responses to psy-
chological and physical stimuli. J
Hypertens 1990;8:961-7.
18. Treiber FA, Musante L, Braden D,
Arensman F, Strong WB, Levy M, et al.
Racial differences in hemodynamic respons-
es to the cold face stimulus in children and
adults. Psychosom Med 1990;52:286-96.
19. Murphy JK, Alpert BS, Walker SS.
Ethnicity, pressor reactivity, and children's
blood pressure: five years of observations.
Hypertension 1992;20:327-52.
20. Treiber FA, McCaffrey F, Musante L,
Rhodes T, Davis H, Strong WB, et al.
Ethnicity, family history of hypertension
and patterns of hemodynamic reactivity in
boys, Psychosom Med 1993;55:70-7.
21. Dysart JM, Treiber FA, Pffieger K, Davis
SOROF ET AL.
H, Strong WB. Ethnic differences in the
myocardial and vascular reactivity to stress
in normotensive girls. Am d Hypertens
1994;7:15-22.
22. Wood DL, Sheps SG, Elveback LR,
Schirger A. Cold pressor test as a predictor
of hypertension. Hypertension 1984;6:301-
6.
25. Menkes MS, Matthews KA, Krantz DS,
Lundberg U, Mead LA, Qaqish B, et al.
Cardiovascular reactivity to the cold pres-
sot test as a predictor of hypertension.
Hypertension 1989;14:524-50.
24. Murphy JK, Alpert BS, Walker SS, Wflley
ES. Children's cardiovascular reactivity:
stability of racial differences and relation to
subsequent blood pressure over a one-year
period. Psychophysiology 1991;28:447-57.
25. Matthews KA, Woodall KL, Allen MT.
Cardiovascular reactivity to stress predicts
future blood pressure status. Hypertension
1993;22:479-85.
26. Eisenhofer G, Lambie DG, Johnson RH.
Beta-adrenoceptor responsiveness and
plasma eatecholamines as determinants of
cardiovascular reactivity to mental stress.
Clin Sci 1985;69:483-92.
27. Mills P J, Dimsdale dE, Ziegler MG, Berry
CC, Baln RD. Beta-adrenergic receptors
predict heart rate reactivity to a psychoso-
cial stressor. Psyehosom Med 1990;52:621-
3.
28. Egan B, Panis R, Hinderliter A, Schork N,
Julius S. Mechanism of increased alpha
adrenergic vasoconstriction in human es-
sential hypertension, d Clin Invest 1987;
80:812-7.
29. Skrabal E Aubock J, Hortnagl H. Low
sodium/high potassium diet for prevention
of hypertension: probable mechanisms of
action. Lancet 1981;2:895-900.
30. Bianchetti MG, Weidmann P, Beretta-
Piccoli C, Ferrier C. Potassium and norepi-
nephrine- or angiotensin-mediated pressor
control in pre-hypertension. Kidney Int
1987;31:956-63.
31. Law*on Wd, Fitz AE, Anderson EA,
Sinkey CA, Coleman RA. Effect of dietary
potassium on blood pressure, renal func-
tion, muscle sympathetic nerve activity, and
forearm vascular resistance and flow in nor-
motensive and borderline hypertensive hu-
mans. Circulation 1990;81:173-84.
32. Sudhir K, Forman A, Yi SL, Sorof J,
Schmidlin O, Sebastian A, et al. Reduced
dietary potassium reversibly enhances va-
sopressor response to stress in African-
Americans. Hypertension 1997;29:1085-90.
33. Khaw KT, Thorn S. Randomised double-
blind cross-over trial of potassium on
blood-pressure in normal subjects. Lancet
1982;2:1127-9.
34. MacGregor CA. Dietary sodium and potas-
93
 SOROFETAL.
slum intake and blood pressure. Lancet
1983;1:750-3.
35. Siani A, Strazzullo P, Russo L, Guglielmi S,
Iacoviello L, Ferrara LX, et al. Controlled
trial of long term oral potassium supple-
ments in patients with mild hypertension.
BMJ 1987;294:1453-6.
36. Svetkey LP, Yarger WE, Feussner JR,
DeLong E, Klotman PE. Double-blind,
placebo-controlled trial of potassium chlo-
ride in the treatment of mild hypertension.
Hypertension 1987;9:444-50.
37. Obel AO. Placebo-controlled trial of potas-
sium supplements in black patients with
mild essential hypertension. J Cardiovasc
Pharmaco11989;14:294-6.
38. Cappuccio FP, MacGregor GA. Does
potassium supplementation lower blood
pressure? A meta-analysis of published tri-
als. J Hypertens 1991;9:465-73.
39. Smith SR, Klotman PE, Svetkey LP.
Potassium chloride lowers blood pressure
and causes natriuresis in older patients with
hypertension. J Am Soc Nephrol 1992;2:
1302-9.
40. Sinaiko AR, Gomez-Marin O, Prlneas RJ.
Effect of low sodium diet or potassium sup-
plementafion on adolescent blood pressure.
Hypertension 1993;21:989-94.
41. Walker WG, Whelton PK, Saitu H,
Russell RP, Hermann BS. Relationship be-
tween blood pressure and renin, renin sub-
sirate, angiotensin II, aldosterone and uri-
nary sodium and potassium in 574
ambulatory subjects. Hypertension 1979;1:
287-91.
42. Intersalt Cooperative Research Group.
Intersalt: an international study of elec-
trolyte excretion and blood pressure-re-
suits for 24 hour urinary sodium and potas-
sium excretion. BMJ 1988;297:319-28.
43. Khaw KT, Barrett-Connor E. The associa-
tion between blood pressure, age, and di-
etary sodium and potassium: a population
study. Circulation 1988;77:53-61.
44. Khaw KT, Barrett-Connor E. Increasing
sensitivity of blood pressure to dietary sodi-
um and potassium with increasing age: a
population study using casual urine speci-
mens. Am J Hypertens 1990;3:505-11.
45. Geleijnse JM, Grobbee DE, Hofman A.
Sodium and potassium intake and blood
94
pressure change in childhood. BMJ
1990;300:899-902.
46. Berenson GS, Voors AW, Dalferes ER,
Webber LS, Shuler SE. Creafinine clear-
ance, electrolytes, and plasma renin activity
related to the blood pressure of white and
black children: the Bogalusa Heart Study.
J Lab Clin Med 1979;93:535-48.
47. Grim CE, Luft FC, Miller JZ, Meneely
GR, Battarbee HD,. Haines CG, et al.
Racial differences in blood pressure in
Evans County, Georgia: relationship to
sodium and potassium intake and plasma
renin activity. J Chronic Dis 1980;33:87-
94.
48. Watson RL, Langford HG. Weight, urinary
electrolytes and blood pressure: results of
several community based studies. J
Chronic Dis 1982;35:909-18.
49. Pratt JH, Jones J J, Miller JZ, Wagner
MA, Fineberg NS. Racial differences in al-
dosterone excretion and plasma aldosterone
concentrations in children. N Engl J Med
1989;321:1152-7.
50. Harshfield GA, Alpert BS, Pulliam DA,
Willey ES, Somes GW, Stapleton FB.
Sodium excretion and racial differences in
ambulatory blood pressure patterns.
Hypertension 1991;18:813-8.
51. Kamarck TW, Jennings JR, Debsld TT,
Glickman-Welss E, Johnson PS, Eddy
M J, et al. Reliable measures of behavioral-
ly-evoked cardiovascular reactivity from a
PC-based test battery: results from student
and community samples. Psychophysiology
1992;29:17-28.
52. Block G, Dresser CM, Hartman AM,
Carroll MD. Nutrient sources in the
American diet: quantitative data from the
NHANES II survey. I. Vitamins and min-
erals. Am J Epidemiol 1985;122:13-26.
53. Zemel P, Gualdoni S, Sowers JR. Racial
differences in mineral intake in ambulatory
normotensives and hypertensives. Am J
Hypertens 1988;1:146-85.
64. Grldley G, McLanghlin JK, Block G, Blot
W J, Wmn DM, Greenherg RS, et al. Diet
and oral and pharyngeal cancer among
blacks. Nutr Cancer 1990;14:219-25.
55. Patterson BH, Block G, Rosenberger WF,
Pee D, Kahle LL. Fruit and vegetables in
the American diet: data from the NHANES
THE JOURNALOF PEDIATRICS
JULY 1997
1I survey. Am J Public Health 1990;80:
1443-9.
56. Frank GC, Nicldas TA, Webber LS, Major
C, Miller JF, Berenson GS. A food fre-
quency questionnaire for adolescents:
defining eating patterns. J Am Diet Assoc
1992;92:313-8.
57. Treiber FA, Leonard SB, Frank G,
Musante L, Davis H, Strong WB, et al.
Dietary assessment instruments for
preschool children: reliability of parental re-
sponses to the 24-hour recall and a food fre-
quency questionnaire. J Am Diet Assoc
1990;90:814-20.
58. Musante L, Treiher FA, Strong WB, Levy
M. Family history of hypertension and car-
diovaseular reactivity to forehead cold stim-
ulation in black male children. J Psycho-
som Res 1990;34:111-6.
59. Treiber FA, Davis H, Musante L, Raunikar
RA, Strong WB, McCaffrey E et al.
Ethnicity, gender, family history of myocar-
dial infarction, and hemodynamic responses
to laboratory stressors in children. Health
Psychol 1993;12:6-15.
60. Anderson NB, Williams RBJ, Lane JD,
Houseworth S, Muranaka M. Parental his-
tory of hypertension and cardiovascular re-
sponses to behavioral stress in young black
women. J Psychosom Res 1987;31:723-9.
61. Anderson NB, Lane JD, Taguchi E
Williams RBJ. Patterns of cardiovascular
responses to stress as a function of race and
parental hypertension in men. Health
Psychol 1989;8:525-40.
62. Martuck SB, Garland FN. Stability of indi-
vidual differences in cardiovascular reactiv-
ity: a thirteen month follow-up. Physiol
Behav 1980;24:621-4.
63. Giordani B, Manuck SB, Farmer JK.
Stability of behaviorally induced heart-rate
changes in children after one week. Child
Dev 1981;52:533-7.
64. Kasprowicz AL, Manuck SB, Malkoff SB,
Krantz DS. Individual differences in be-
haviorally evoked cardiovascular response:
temporal stability and hemodynamic pat-
terning. Psychophysiology 1990;27:605-19.
65. Murphy JK, Alpert BS, Walker SS.
Stability of ethnic differences in children's
pressor responses during three annual ex-
aminations. Am J Hypertens 1991;4:630-4.