Skip to main content
SpringerLink
Log in

Phosphorus in the Modern Food Supply: Underestimation of Exposure

  • Chapter
  • First Online:
Clinical Aspects of Natural and Added Phosphorus in Foods

Part of the book series: Nutrition and Health ((NH))

  • 837 Accesses

Abstract

Modern food processing techniques, while improving many desirable aspects of processed foods, have introduced unforeseen risk factors linked to renal, bone, and cardiovascular disease in people with chronic kidney disease (CKD). This chapter examines in depth one of these widely used processing tools, the addition of phosphate additives during processing to provide a number of different needed functions that improve processed foods in a variety of ways. We contend that the popularity, convenience, and continued demand for processed foods containing one or more phosphate additive is increasing their presence in the market place. This change in the modern food supply limits food choices and provides no means of identifying foods with added phosphates. Consequently, this adversely impacts the 20 million Americans with CKD who need to limit their phosphorus intake in order to avoid the hormonal repercussions of a disordered mineral balance. Phosphate additive use also contributes to the phosphorus intake of the general healthy population, which currently exceeds nutrient needs for the majority of adults and disrupts the delicate balance between calcium and phosphorus intake. In this chapter, we offer compelling evidence of the need for mandatory labeling of total phosphorus content on the Nutrition Facts Panel of processed foods, which would capture both naturally present and added phosphorus content. Such mandatory labeling would enable CKD patients and regulatory scientists to accurately measure phosphorus exposure and determine true potential individual and population health risks.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Alonso A, Steffen LM, Folsom AR. Dairy intake and changes in blood pressure over 9 years: the ARIC Study. Eur J Clin Nutr. 2009;63:1272.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Alonso A, Nettleton JA, Ix JH, de Boer IH, Folsom AR, Bidulescu A, Kestenbaum BR, Chambless LE, Jacobs Jr DR. Dietary phosphorus, blood pressure, and incidence of hypertension in the atherosclerosis risk in communities study and the multi-ethnic study of atherosclerosis. Hypertension. 2010;55:776.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Ahuja JKA, Montville JB, Omolewa-Tombi G, Heendeniya KY, Martin CL, Steinfeldt LC, Anand J, Adler ME, LaComb RP, Moshfegh AJ. USDA Food and Nutrient Database for Dietary Studies, 5.o. Beltsville: US Department of Agriculture, Agricultural research Service, Food Survey research Group; 2012.

    Google Scholar 

  4. American Heart Association. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HeartSmartShopping/Heart-Check-Mark-for-Food-Manufacturers-Trade-Associations_UCM_300866_Article.jsp.

  5. Antoniucci DM, Yammahita T, Portale AA. Dietary phosphorus regulates serum fibroblast growth factor-23 concentrations in healthy men. J Clin Endocrinol Metabol. 2006;91:3144–9.

    Article  CAS  Google Scholar 

  6. Bao Y, Han J, Hu FB, Giovannucci EL, Stampfer MJ, Willet WC, Fuchs CS. Association of nut consumprion with total and cause-specific mortality. N Engl J Med. 2013;369(21):​2000–11.

    Article  Google Scholar 

  7. Benini O, D’Alessandro C, Gianfaldoni D, Cupisti A. Extra-phosphate load from food additives in commonly eaten foods: a real insidious danger from renal patients. J Ren Nutr. 2011;21:303–8.

    Article  CAS  PubMed  Google Scholar 

  8. Beydown MA, Gary TL, Caballero BH, Lawrence RS, Cheskin LJ, Wang Y. Ethnic differences in dairy and related nutrient consumption among US adults and their association with obesity, central obesity and metabolic syndrome. Am J Clin Nutr. 2008;87:1914–25.

    Google Scholar 

  9. Block GA, Ix JH, Kettler M, Martin KJ, Thadhani RI, Tonelli M, Wolf M, Jṻppner H, Hruska K, Wheeler DC. Phosphate homeostasis in CKD: report of a scientific symposium sponsored by National Kidney Foundation. Am J Kidney Dis. 2013;62(3):457–73.

    Article  PubMed  Google Scholar 

  10. Burnett SM, Gunawardene SC, Bringhurst FR, Jṻppner H, Lee H, Finkelstein JS. Regulation of c-terminal and intact FGF-23 by dietary phosphate in men and women. J Bone Miner Res. 2006;21(8):1187–96.

    Article  CAS  Google Scholar 

  11. Camalier CE, Yi M, Yu LR, Hood BL, Conrads KA, Lee VJ, Garneys LM, Bouloux GF, Young MR, Veenstra TD, Stephens RM, Colburn NH, Conrads TP, Beck Jr GR. An integrated understanding of the physiological response to elevated extracellular phosphate. J Cell Physiol. 2013;228(7):1536–50.

    Article  CAS  PubMed Central  Google Scholar 

  12. Calvo MS, Kumar R, Heath III H. Persistently elevated parathyroid hormone secretion and action in young women after four weeks of ingesting high phosphorus low calcium diets. J Clin Endocrinol Metab. 1990;70(5):1334–40.

    Article  CAS  PubMed  Google Scholar 

  13. Calvo MS, Park YK. Changing phosphorus content of the US diet: potential for adverse effects on bone. J Nutr. 1996;126(4 Suppl):1168S–80.

    CAS  PubMed  Google Scholar 

  14. Calvo MS. The effects of high phosphorus intake on calcium homeostasis. Adv Nutr Res. 1994;9:183–207.

    CAS  PubMed  Google Scholar 

  15. Calvo MS, Uribarri J. Public health impact of dietary phosphorus excess on bone and cardiovascular health in the general population. Am J Clin Nutr. 2013;98:6–15.

    Article  CAS  PubMed  Google Scholar 

  16. Calvo MS, Uribarri J. Contributions to total phosphorus intake: all sources considered. Semin Dial. 2013;26(1):54–61.

    Article  PubMed  Google Scholar 

  17. Calvo MS, Tucker KL. Is phosphorus intake that exceeds dietary requirements a risk factor in bone health? Ann N Y Acad Sci. 2013;1301:29–35. Epub ahead of press at doi: 10.1111/nyas.12300.

    Article  CAS  PubMed  Google Scholar 

  18. Calvo MS, Moshfegh AJ, Tucker KL. Assessing the health impact of phosphorus in the food supply: issues and considerations. Adv Nutr. 2014;5(1):104–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Cupisti A, Comar F, Benini O, Lupett S, Dalessandro C, Barsotti G, Gianfaldoni D. Effect of boiling on dietary phosphate and nitrogen intake. J Ren Nutr. 2006;16:36–40.

    Article  PubMed  Google Scholar 

  20. Ellam TJ, Chico TJ. Phosphate: the new cholesterol? The role of the phosphate axis in non-uremic vascular disease. Atherosclerosis. 2012;220:310.

    Article  CAS  Google Scholar 

  21. FDA 2013. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm363474.htm. Accessed it on 12-04-2013.

  22. Fukagawa M, Komaba H, Miyamoto K. Source matters: from phosphorus load to bioavailability. Clin J Am Soc Nephrol. 2011;6:239–40.

    Article  PubMed  Google Scholar 

  23. GRAS Substances (SCOGS) Database, US Food and Drug Administration, October 2006 Alphabetical list of SCOGS Substances accessed at http://www.fda.gov/Food/FoodIngredientsPackaging/GenerallyRecognizedasSafe/GRAS/GRASSubstancesSCOGSDatabase/ucm084104.htm. Last accessed 3-15-2012.

  24. Greger JL, Krystofiak M. Phosphorus intake of Americans. Food Technol. 1982;36:78–84.

    Google Scholar 

  25. Gutierrez OM, Katz R, Peralta CA, de Boer IH, Siscovik S, Wolf M, Diez Roux A, Kestenbaum B, Nettleton JA, Ix JH. Associations of the socioeconomic status and processed food intake with serum phosphorus concentration in community-living adults: the Multi-Ethnic Study of Atherosclerosis (MESA). J Ren Nutr. 2012;22(5):480–90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Gutierrez OM. Sodium- and phosphorus-based food additives: persistent but surmountable hurdles in the management of nutrition in chronic kidney disease. Adv Chronic Kidney Dis. 2013;20(3):150–6.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington, DC: National Academy Press; 1997.

    Google Scholar 

  28. Itkonen ST, Ekholm PJ, Kemi VE, Lamberg-Allardt C. Analysis of invitro digestible phosphorus content in selected processed rye, wheat and barley products. J Food Comp Analysis. 2012;25(2):185–9.

    Article  CAS  Google Scholar 

  29. Itkonen S, Karp HJ, Kemi V, Kokkonene E, Saarnio EM, Pekkinene MH, Kärkkäinen MUM, Laitinen EK, Turanlahti M, Lamberg-Allardt CJE. Associations among total and food additive phosphorus intake an carotid intima-media thickness—a cross-sectional study in middle –age population in Southern Finland. Nutr J. 2013;6:257–64.

    Google Scholar 

  30. Kalantar-Zadeh K, Gutekunst L, Mehrotra R, Kovesfy CP, Bross R, Shinaberger CS, et al. Understanding sources of dietary phosphorus in the treatment of patients with chronic renal disease. Clin J Am Soc Nephrol. 2010;5:519–30.

    Article  CAS  PubMed  Google Scholar 

  31. Karp HJ, Vaiha KP, Kärkkäinen MUM, Niemisto MJ, Lamberg-Allardt CJE. Acute effects of different phosphorus sources on calcium and bone metabolism in young women: a whole-foods approach. Calcif Tissue Int. 2007;80:251–8.

    Article  CAS  PubMed  Google Scholar 

  32. Karp H, Ekholm P, Kemi V, Itkonen S, Hirovonenn T, Närkki D, Lamberg-Allardt C. Differences among total and in vitro digestible phosphorus content of plant foods and beverages. J Ren Nutr. 2012;22(4):416–22.

    Article  CAS  PubMed  Google Scholar 

  33. Karp H, Ekholm P, Kemi V, Hirvonen T, Lamberg-Allardt CJE. Difference among total and in vitro digestible phosphorus content of meat and milk products. J Ren Nutr. 2012;22(3):344–9.

    Article  CAS  PubMed  Google Scholar 

  34. Karp HJ, Kemi VE, Lamberg-Alardt CEJ, Karkkainen MUM. Mono- and polyphosphates have similar effects on calcium and phosphorus metabolism in healthy young women. Eur J Nutr. 2013;52:991–6.

    Article  CAS  PubMed  Google Scholar 

  35. Kemi VE, Rita HJ, Karkkainen MU, Viljakainen HT, Laaksonen MM, Outila TA, Lamberg-Allardt C. Habitual high phosphorus intakes and foods with phosphate additives negatively affect serum parathyroid hormone concentration: a cross-sectional study on healthy premenopausal women. Public Health Nutr. 2009;12:1885–92.

    Article  PubMed  Google Scholar 

  36. Kemi VE, Kärkkäinen MUM, Rita HJ, Laaksonen MM, Outila TA, Lamberg-Allardt CJE. Low calcium:phosphorus ratio in habitual diets affects serum parathyroid hormone concentration and calcium metabolism in healthy women with adequate intake. Br J Nutr. 2010;103:561–8.

    Article  CAS  PubMed  Google Scholar 

  37. Lampila LE, Godber JP. Food Additives. AL Branen, PM Davidson, S Salminen, and JH Thorngate (eds.) Marcel Dekker, Inc. New York, NY. 2001. p. 809–96.

    Google Scholar 

  38. Lampila LE. Applications of food-grade phosphates. Ann N Y Acad Sci. 2013;1301:37–44. Epub ahead of print at doi:10.1111/nyas.12230.

    Article  CAS  PubMed  Google Scholar 

  39. Maffini MV, Alger HM, Olson ED, Neltner TG. Looking back to look forward: a review of FDA’s food additives safety assessment and recommendations for modernizing its program. Compr Rev Food Sci Food Saf. 2013;12:439–53.

    Article  Google Scholar 

  40. Magnuson B, Munro I, Abbot P, Baldwin N, Lopez-Garcia R, Ly K, McGirr L, Roberts A, Socolovsky S. Review of the regulation and safety assessment of the food substances in various countries and jurisdictions. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2013;30(7):1147–220 (Monograph published by Taylor and Frances).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Moe SM, Zidehsarai MP, Chambers MA, Jackman LA, Radcliffe JS, Trevino LL, Donahue SE, Asplin JR. Vegetarian compared with meat protein source and phosphorus homeoatasis in chronic kidney disease. Clin J Am Soc Nephrol. 2011;6:257–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Moshegh A, Goldman J, Ahuja JK, Rhodes D, LaComb, R. What we eat in America. NHANES 2005–2006. In: Usual nutrient intakes from food and water compared to 1997 dietary reference intake for vitamin D calcium, phosphorus and magnesium. Beltsville Human Nutrition Research Center Food Surveys Research Group. Beltsville, Maryland, USA. 2009.

    Google Scholar 

  43. Murphy-Gutekunst L, Uribarri J. Hidden phosphorus enhanced meats. J Ren Nutr. 2005;14:e1–4.

    Google Scholar 

  44. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003;42 suppl 3:S1–201.

    Google Scholar 

  45. National Kidney and Urologic Disease Information Clearinghouse (NKUDIC). Accessed at http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#3.

  46. National Technical Information Service (NTIS) report (NTIS Accession Number PB-262-651/3) that contains details of the safety studies that formed the basis of the opinion made by the SCOGS committee concerning multiple phosphate ingredients including phosphoric acid, SCOGS report 32. Full NTIS report accessed at: http://www.ntis.gov.

  47. Neltner TG, Kulkarni NR, Alger HM, Mafdfini MV, Bongard ED, Fortin ND, Olson ED. Navigating the U.S. food additive regulating program. Compr Rev Food Sci Food Saf. 2011;10(6):342–68.

    Article  Google Scholar 

  48. Neltner TG, Alger HM, Leonard JE, Maffini MV. Data gaps in toxicity testing of the chemicals allowed in food in the United States. Reprod Toxicol. 2013;42:85–94.

    Article  CAS  PubMed  Google Scholar 

  49. Oenning LL, Vogel J, Calvo MS. Accuracy of methods estimating calcium and phosphorus intake in daily diets. J Am Diet Assoc. 1988;88:1076.

    CAS  PubMed  Google Scholar 

  50. Osuka S, Razzaque MS. Can features of phosphate toxicity appear in normophosphatemia? J Bone Miner Metab. 2012;30:10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Pordy W. Excuse me, but which aisle has the kidney-friendly foods? Dialysis & Transplantation 1–3. Guest Editorial. September 2007 issue.

    Google Scholar 

  52. Ritz E, Hahn K, Kettler M, Kuhlmann MK, Mann J. Phosphate additives in food – a health risk. Dtsch Arztebl Int. 2012;109:49–55.

    PubMed  PubMed Central  Google Scholar 

  53. Rose TJ, Liu L, Wissuwa M. Improving phosphorus efficiency in cereal crops: is breeding for reduced grain phosphorus concentration part of the solution? Front Plant Sci. 2013;4:444.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Rulis AM, Levitt JA. FDA’s food ingredient approval process: safety assurance based on scientific assessment. Regul Toxicol Pharmacol. 2008;53:20–31.

    Article  PubMed  Google Scholar 

  55. Scialla JJ, Appel LJ, Wolf M, Yamg W, Zhang XM, Sozio SM, Miller ER, Bazzano LA, Cuevas M, Glenn MJ, Lustigova E, Kallen RR, Porter AC, Townsend RR, Weir MR, Andersen CAM. Plant protein intake is associated with fibroblast growth factor 23 and serum bicarbonates levels of patients with chronic kidney disease: the chronic renal insufficiency cohort study. J Ren Nutr. 2012;22(4):379–88.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Schlemmer U, Frolich W, Rieto RM, Grases F. Phytate in foods and significance in humans: food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food Res. 2009;53:S330–75.

    Article  PubMed  Google Scholar 

  57. Sherman RA, Mehta O. Phosphorus and potassium content of enhanced meat and poultry products: implications for patients who receive dialysis. Clin J Am Soc Nephrol. 2009;4:1370–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Sherman RA, Mehta O. Dietary phosphorus restriction in dialysis patients: potential impact of processed meat, poultry, and fish products as protein sources. Am J Kidney Dis. 2009;54:18–23.

    Article  CAS  PubMed  Google Scholar 

  59. Shuto E, Taketani Y, Tannaka R, Harada N, Isshiki M, Sato M, Nashiki K, Amo K, Yamamoto H, Higashi Y, Nakaya Y, Takeda E. Dietary phosphorus acutely impairs endothelial function. J Am Soc Nephrol. 2009;20:1504–12.

    Article  CAS  PubMed Central  Google Scholar 

  60. Sullivan C, Leon JB, Sehgal AR. Phosphorus-containing food additives and the accuracy of nutrient databases: implications for renal patients. J Ren Nutr. 2007;17:350–4.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Takeda E, Yamamoto H, Yamanaka-Okumura H, Taketari Y. Dietary phosphorus in bone health and quality of life. Nutr Rev. 2012;70(6):311–21.

    Google Scholar 

  62. Uribarri J, Calvo MS. Hidden sources of phosphorus in the typical American Diet. Does it matter in nephrology? Semin Dial. 2003;16:186–8.

    Article  PubMed  Google Scholar 

  63. Uribarri J. Phosphorus homeostasis in normal health and in chronic kidney disease patients with special emphasis on dietary phosphorus intake. Semin Dial. 2007;20(4):295–301.

    Article  PubMed  Google Scholar 

  64. Uribarri J. Phosphorus additives in food and their effect in dialysis patients. Clin J Am Soc Nephrol. 2009;4(8):1290–2.

    Article  PubMed  Google Scholar 

  65. Uribarri J, Calvo MS. Introduction to dietary phosphorus excess and health. Ann N Y Acad Sci. 2013;1301(1):iii–iv: published on line doi:10.1111/nyas.12302.

    Article  PubMed  Google Scholar 

  66. Uribarri J, Calvo MS. Dietary phosphorus excess : a risk factor in chronic bone, kidney and cardiovascular disease? Adv Nutr. 2013;4(5):542–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Vohra A, Satyanarayana T. Phytases: microbial sources, production, purification, and potential biotechnological applications. Crit Rev Biotechnol. 2003;23:29–60.

    Article  CAS  PubMed  Google Scholar 

  68. Wallace TC, Reider C, Fulgoni III VL. Calcium and vitamin D disparities are related to gender, age, race, household income level, and weight classification, but not vegetarian status in the United States: Analysis of the NHANES 2001–2008 data set. J Am Coll Nutr. 2013;32(5):321–30.

    Article  CAS  PubMed  Google Scholar 

  69. Weiner ML, Salminen WF, Larson PR, Barter RA, Kranetz JL, Simon GS. Toxicological review of inorganic phosphates. Food Chem Toxicol. 2001;39:759–86.

    Article  CAS  PubMed  Google Scholar 

  70. Winger R, Uribarri J, Lloyd L. Phosphorus-containing food additives: an insidious danger for people with chronic kidney disease. Trends in Food Sci Technol. 2012;24:92–102.

    Article  CAS  Google Scholar 

  71. Yamamoto KT, Robinson-Cohen C, de Oliveira MC, Kostina A, Nettleton JA, Ix JH, Nguyen H, Eng J, Lima JAC, Siscovick DS, Weiss NS, Kestenbaum B. Dietary phosphorus is associated with greater left ventricular mass. Kidney Int. 2013;83:707–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Formerly, Office of Applied Research and Safety Assessment, Center for Food Safety and Applied Nutrition, US Food and Drug Association, Silver Spring, MD, 20910, USA

    Mona S. Calvo PhD

  2. Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA

    Mona S. Calvo PhD

  3. Department of Nephrology, Dialysis and Transplant, Mount Sinai School of Medicine, The Mount Sinai Medical Center, 5 East 98th Street II Floor, New York, NY, 10029-65474, USA

    Jaime Uribarri MD

Authors
  1. Mona S. Calvo PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jaime Uribarri MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jaime Uribarri MD .

Editor information

Editors and Affiliations

  1. University of Alabama at Birmingham, Department of Medicine, School of Medicine, Birmingham, Alabama, USA

    Orlando M. Gutiérrez

  2. City Tower, Suite 400-ZOT:4088 UCI, School of Medicine, Orange, California, USA

    Kamyar Kalantar-Zadeh

  3. University of Washington, Professor of Medicine, and Section Head Harborview Medical Center, Seattle, Washington, USA

    Rajnish Mehrotra

Additional information

FDA Disclaimer

The findings and conclusions presented in this manuscript are those of the authors and do not necessarily represent the views or opinions of the US Food and Drug Administration. Mention of trade names, product labels, or food manufacturers does not constitute endorsement or recommendations or use by the US Food and Drug Administration.

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer Science+Business Media New York

About this chapter

Cite this chapter

Calvo, M.S., Uribarri, J. (2017). Phosphorus in the Modern Food Supply: Underestimation of Exposure. In: Gutiérrez, O., Kalantar-Zadeh, K., Mehrotra, R. (eds) Clinical Aspects of Natural and Added Phosphorus in Foods. Nutrition and Health. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-6566-3_4

Download citation

  • DOI: https://doi.org/10.1007/978-1-4939-6566-3_4

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-6564-9

  • Online ISBN: 978-1-4939-6566-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation