Phosphate additives in food - A health risk

Nierenzentrum Heidelberg, 69120 Heidelberg, Germany.
Deutsches Ärzteblatt International (Impact Factor: 3.52). 01/2012; 109(4):49-55. DOI: 10.3238/arztebl.2012.0049
Source: PubMed

ABSTRACT Hyperphosphatemia has been identified in the past decade as a strong predictor of mortality in advanced chronic kidney disease (CKD). For example, a study of patients in stage CKD 5 (with an annual mortality of about 20%) revealed that 12% of all deaths in this group were attributable to an elevated serum phosphate concentration. Recently, a high-normal serum phosphate concentration has also been found to be an independent predictor of cardiovascular events and mortality in the general population. Therefore, phosphate additives in food are a matter of concern, and their potential impact on health may well have been underappreciated.
We reviewed pertinent literature retrieved by a selective search of the PubMed and EU databases (,, with the search terms "phosphate additives" and "hyperphosphatemia."
There is no need to lower the content of natural phosphate, i.e. organic esters, in food, because this type of phosphate is incompletely absorbed; restricting its intake might even lead to protein malnutrition. On the other hand, inorganic phosphate in food additives is effectively absorbed and can measurably elevate the serum phosphate concentration in patients with advanced CKD. Foods with added phosphate tend to be eaten by persons at the lower end of the socioeconomic scale, who consume more processed and "fast" food. The main pathophysiological effect of phosphate is vascular damage, e.g. endothelial dysfunction and vascular calcification. Aside from the quality of phosphate in the diet (which also requires attention), the quantity of phosphate consumed by patients with advanced renal failure should not exceed 1000 mg per day, according to the guidelines.
Prospective controlled trials are currently unavailable. In view of the high prevalence of CKD and the potential harm caused by phosphate additives to food, the public should be informed that added phosphate is damaging to health. Furthermore, calls for labeling the content of added phosphate in food are appropriate.

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Available from: Kai Hahn, Sep 29, 2015
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    • "This process is potentially preventable as dietary phosphate restriction in murine models of secondary hyperparathyroidism prevents endothelial damage [21], [22]. Population studies demonstrate that increased dietary phosphate intake is correlated with increased serum phosphate; particularly phosphate additives in processed foods [23], [24]. "
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    ABSTRACT: Serum phosphate is a known risk factor for cardiovascular events and mortality in people with chronic kidney disease (CKD), however data on the association of these outcomes with serum phosphate in the general population are scarce. We investigate this relationship in people with and without CKD in a large community-based population. Three groups from an adult cohort of the Quality Improvement in Chronic Kidney Disease (QICKD) cluster randomised trial (ISRCTN56023731) were followed over a period of 2.5 years: people with normal renal function (N = 24,184), people with CKD stages 1-2 (N = 20,356), and people with CKD stages 3-5 (N = 13,292). We used a multilevel logistic regression model to determine the association between serum phosphate, in these groups, and a composite outcome of all-cause mortality, cardiovascular events, and advanced coronary artery disease. We adjusted for known cardiovascular risk factors. Higher phosphate levels were found to correlate with increased cardiovascular risk. In people with normal renal function and CKD stages 1-2, Phosphate levels between 1.25 and 1.50 mmol/l were associated with increased cardiovascular events; odds ratio (OR) 1.36 (95% CI 1.06-1.74; p = 0.016) in people with normal renal function and OR 1.40 (95% CI 1.09-1.81; p = 0.010) in people with CKD stages 1-2. Hypophosphatemia (<0.75 mmol/l) was associated with fewer cardiovascular events in people with normal renal function; OR 0.59 (95% CI 0.36-0.97; p = 0.049). In people with CKD stages 3-5, hyperphosphatemia (>1.50 mmol/l) was associated with increased cardiovascular risk; OR 2.34 (95% CI 1.64-3.32; p<0.001). Other phosphate ranges were not found to have a significant impact on cardiovascular events in people with CKD stages 3-5. Serum phosphate is associated with cardiovascular events in people with and without CKD. Further research is required to determine the mechanisms underlying these associations.
    PLoS ONE 09/2013; 8(9):e74996. DOI:10.1371/journal.pone.0074996 · 3.23 Impact Factor
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    • "Food charts and tables can help patients identify foods low in phosphorus. Reliable estimation of the phosphorus content of chosen foods is possible with the use of comprehensive labelling of phosphorus additives, and a “traffic light” scheme can help to simplify foods into “high,” “intermediate,” or “low” phosphorus content.45 Protein adequacy with lesser phosphorus burden can be facilitated by teaching patients cooking methods that reduce the phosphorus content while preserving protein content, such as boiling chicken or beef.46 "
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    ABSTRACT: This review explores the challenges and solutions in educating patients with chronic kidney disease (CKD) to lower serum phosphorus while avoiding protein insufficiency and hypercalcemia. A literature search including terms "hyperphosphatemia," "patient education," "food fatigue," "hypercalcemia," and "phosphorus-protein ratio" was undertaken using PubMed. Hyperphosphatemia is a strong predictor of mortality in advanced CKD and is remediated via diet, phosphorus binders, and dialysis. Dietary counseling should encourage the consumption of foods with the least amount of inorganic or absorbable phosphorus, low phosphorus-to-protein ratios, and adequate protein content, and discourage excessive calcium intake in high-risk patients. Emerging educational initiatives include food labeling using a "traffic light" scheme, motivational interviewing techniques, and the Phosphate Education Program - whereby patients no longer have to memorize the phosphorus content of each individual food component, but only a "phosphorus unit" value for a limited number of food groups. Phosphorus binders are associated with a clear survival advantage in CKD patients, overcome the limitations associated with dietary phosphorus restriction, and permit a more flexible approach to achieving normalization of phosphorus levels. Patient education on phosphorus and calcium management can improve concordance and adherence and empower patients to collaborate actively for optimal control of mineral metabolism.
    Patient Preference and Adherence 05/2013; 7:379-90. DOI:10.2147/PPA.S43486 · 1.68 Impact Factor
  • Deutsches Ärzteblatt International 07/2012; 109(27-28):492-3; author reply 493. DOI:10.3238/arztebl.2012.0492b · 3.52 Impact Factor
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