Sodium- and Phosphorus-Based Food Additives: Persistent but Surmountable Hurdles in the Management of Nutrition in Chronic Kidney Disease

  • Orlando M. Gutiérrez
    Address correspondence to Orlando M. Gutiérrez, MD, MMSc, University of Alabama at Birmingham, ZRB 614, 1720 2nd Ave S., Birmingham, AL, 35294-0006.
    Division of Nephrology, Department of Medicine, and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
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      Sodium- and phosphorus-based food additives are among the most commonly consumed nutrients in the world. This is because both have diverse applications in processed food manufacturing, leading to their widespread use by the food industry. Since most foods are naturally low in salt, sodium additives almost completely account for the excessive consumption of sodium throughout the world. Similarly, phosphorus additives represent a major and “hidden” phosphorus load in modern diets. These factors pose a major barrier to successfully lowering sodium or phosphorus intake in patients with CKD. As such, any serious effort to reduce sodium or phosphorus consumption will require reductions in the use of these additives by the food industry. The current regulatory environment governing the use of food additives does not favor this goal, however, in large part because these additives have historically been classified as generally safe for public consumption. To overcome these barriers, coordinated efforts will be needed to demonstrate that high intake of these additives is not safe for public consumption and as such should be subject to greater regulatory scrutiny.

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        • Macgregor G.
        • de Wardener H.E.
        Salt, Diet and Health: Neptune's Poisoned Chalice: The Origins of High Blood Pressure.
        Cambridge University Press, Cambridge, UK1998
        • Ritz E.
        Salt–friend or foe?.
        Nephrol Dial Transplant. 2006; 21: 2052-2056
        • Shelef L.A.
        • Seiter J.
        Indirect and Miscellaneous Antimicrobials.
        in: Davidson P.M. Sofos J.N. Larry B.A. Antimicrobials in Food. 3rd ed. Taylor and Francis, Boca Raton, FL2005: 573-598
        • He F.J.
        • Macgregor G.A.
        Dietary Salt, High Blood Pressure and Other Harmful Effects on Health.
        in: Kilcast D. Angus F. Reducing Salt in Foods: Practical Strategies. Woodhead, Cambridge, UK2007: 18-54
        • Breslin P.A.
        • Beauchamp G.K.
        Salt enhances flavour by suppressing bitterness.
        Nature. 1997; 387: 563
        • Gillette M.
        Flavor effects of sodium chloride.
        Food Technol. 1985; 39: 47-52
        • Intersalt Cooperative Research Group
        Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion.
        BMJ. 1988; 297: 319-328
        • Anderson C.A.
        • Appel L.J.
        • Okuda N.
        • et al.
        Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: the INTERMAP study.
        J Am Diet Assoc. 2010; 110: 736-745
        • Mattes R.D.
        The taste for salt in humans.
        Am J Clin Nutr. 1997; 65: 692S-697S
        • Committee on Strategies to Reduce Sodium Intake
        Strategies to Reduce sodium Intake in the United States.
        Institute of Medicine, The National Academies Press, Washington, DC2010
        • Blackburn H.
        • Prineas R.
        Diet and hypertension: anthropology, epidemiology, and public health implications.
        Prog Biochem Pharmacol. 1983; 19: 31-79
        • James W.P.
        • Ralph A.
        • Sanchez-Castillo C.P.
        The dominance of salt in manufactured food in the sodium intake of affluent societies.
        Lancet. 1987; 1: 426-429
        • Stamler J.
        • Elliott P.
        • Dennis B.
        • et al.
        INTERMAP: background, aims, design, methods, and descriptive statistics (nondietary).
        J Hum Hypertens. 2003; 17: 591-608
        • He F.J.
        • MacGregor G.A.
        A comprehensive review on salt and health and current experience of worldwide salt reduction programmes.
        J Hum Hypertens. 2009; 23: 363-384
        • Meneton P.
        • Jeunemaitre X.
        • de Wardener H.E.
        • MacGregor G.A.
        Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases.
        Physiol Rev. 2005; 85: 679-715
        • Aaron K.J.
        • Campbell R.C.
        • Judd S.E.
        • Sanders P.W.
        • Muntner P.
        Association of dietary sodium and potassium intakes with albuminuria in normal-weight, overweight, and obese participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
        Am J Clin Nutr. 2011; 94: 1071-1078
        • Forman J.P.
        • Scheven L.
        • de Jong P.E.
        • Bakker S.J.
        • Curhan G.C.
        • Gansevoort R.T.
        Association between sodium intake and change in uric acid, urine albumin excretion, and the risk of developing hypertension.
        Circulation. 2012; 125: 3108-3116
        • Cook N.R.
        • Cutler J.A.
        • Obarzanek E.
        • et al.
        Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP).
        BMJ. 2007; 334: 885-888
        • He F.J.
        • MacGregor G.A.
        Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health.
        J Hum Hypertens. 2002; 16: 761-770
        • Forte J.G.
        • Miguel J.M.
        • Miguel M.J.
        • de Padua F.
        • Rose G.
        Salt and blood pressure: a community trial.
        J Hum Hypertens. 1989; 3: 179-184
        • Sacks F.M.
        • Svetkey L.P.
        • Vollmer W.M.
        • et al.
        Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group.
        N Engl J Med. 2001; 344: 3-10
        • Sanders P.W.
        Vascular consequences of dietary salt intake.
        Am J Physiol Ren Physiol. 2009; 297: F237-F243
        • Roos J.C.
        • Koomans H.A.
        • Dorhout Mees E.J.
        • Delawi I.M.
        Renal sodium handling in normal humans subjected to low, normal, and extremely high sodium supplies.
        Am J Physiol. 1985; 249: F941-F947
        • Cianciaruso B.
        • Bellizzi V.
        • Minutolo R.
        • et al.
        Renal adaptation to dietary sodium restriction in moderate renal failure resulting from chronic glomerular disease.
        J Am Soc Nephrol. 1996; 7: 306-313
        • Koomans H.A.
        • Roos J.C.
        • Dorhout Mees E.J.
        • Delawi I.M.
        Sodium balance in renal failure. A comparison of patients with normal subjects under extremes of sodium intake.
        Hypertension. 1985; 7: 714-721
        • Krikken J.A.
        • Laverman G.D.
        • Navis G.
        Benefits of dietary sodium restriction in the management of chronic kidney disease.
        Curr Opin Nephrol Hypertens. 2009; 18: 531-538
      1. Food Additives Amendment of 1958. Public Law 85-929; 72 Stat 1784.

        • Bernstein A.M.
        • Willett W.C.
        Trends in 24-h urinary sodium excretion in the United States, 1957-2003: a systematic review.
        Am J Clin Nutr. 2010; 92: 1172-1180
        • Sherman R.A.
        • 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: 1370-1373
        • Sherman R.A.
        • 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
        • Uribarri J.
        • Calvo M.S.
        Hidden sources of phosphorus in the typical American diet: does it matter in nephrology?.
        Semin Dial. 2003; 16: 186-188
        • Uribarri J.
        Phosphorus additives in food and their effect in dialysis patients.
        Clin J Am Soc Nephrol. 2009; 4: 1290-1292
        • Molins R.A.
        Phosphates in Food.
        CRC Press, Inc., Boca Raton, FL1991
        • Stahl J.L.
        • Ellinger R.H.
        The Use of Phosphate In the Cereal and Baking Industry.
        in: Deman J.M. Melnychyn P. Symposium: Phosphate in Food Processing. The Avi Publishing Company, Inc., Westport, CT1971: 194-212
      2. GRAS (Generally Recognized as Safe) Food Ingredients—Phosphates. The Franklin Institute Research Labs, Philadelphia, PA1972
        • Murphy-Gutekunst L.
        Hidden phosphorus in popular beverages.
        Nephrol Nurs J. 2005; 32: 443-445
      3. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. The National Academies Press, Washington, DC1997
      4. US Department of Agriculture, Agricultural Research Service. Nutrient Intakes from Food: Mean Amounts Consumed per Individual, by Race/Ethnicity and Age. What We Eat in America; NHANES 2009-2010. Available at: Accessed November 4, 2012.

        • Uribarri J.
        Phosphorus homeostasis in normal health and in chronic kidney disease patients with special emphasis on dietary phosphorus intake.
        Semin Dial. 2007; 20: 295-301
        • Bell R.R.
        • Draper H.H.
        • Tzeng D.Y.
        • Shin H.K.
        • Schmidt G.R.
        Physiological responses of human adults to foods containing phosphate additives.
        J Nutr. 1977; 107: 42-50
        • Calvo M.S.
        Dietary considerations to prevent loss of bone and renal function.
        Nutrition. 2000; 16: 564-566
        • Oenning L.L.
        • Vogel J.
        • Calvo M.S.
        Accuracy of methods estimating calcium and phosphorus intake in daily diets.
        J Am Diet Assoc. 1988; 88: 1076-1080
        • Benini O.
        • D'Alessandro C.
        • Gianfaldoni D.
        • Cupisti A.
        Extra-phosphate load from food additives in commonly eaten foods: a real and insidious danger for renal patients.
        J Ren Nutr. 2011; 21: 303-308
        • Moe S.M.
        • Zidehsarai M.P.
        • Chambers M.A.
        • et al.
        Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.
        Clin J Am Soc Nephrol. 2011; 6: 257-264
        • Antoniucci D.M.
        • Yamashita T.
        • Portale A.A.
        Dietary phosphorus regulates serum fibroblast growth factor-23 concentrations in healthy men.
        J Clin Endocrinol Metab. 2006; 91: 3144-3149
        • Burnett S.M.
        • Gunawardene S.C.
        • Bringhurst F.R.
        • Juppner H.
        • Lee H.
        • Finkelstein J.S.
        Regulation of C-terminal and intact FGF-23 by dietary phosphate in men and women.
        J Bone Miner Res. 2006; 21: 1187-1196
        • Ferrari S.L.
        • Bonjour J.P.
        • Rizzoli R.
        Fibroblast growth factor-23 relationship to dietary phosphate and renal phosphate handling in healthy young men.
        J Clin Endocrinol Metab. 2005; 90: 1519-1524
        • Calvo M.S.
        • Kumar R.
        • Heath 3rd, H.
        Elevated secretion and action of serum parathyroid hormone in young adults consuming high phosphorus, low calcium diets assembled from common foods.
        J Clin Endocrinol Metab. 1988; 66: 823-829
        • Calvo M.S.
        • Kumar R.
        • Heath 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: 1334-1340
        • Calvo M.S.
        • Park Y.K.
        Changing phosphorus content of the U.S. diet: potential for adverse effects on bone.
        J Nutr. 1996; 126: 1168S-1180S
        • Karkkainen M.
        • Lamberg-Allardt C.
        An acute intake of phosphate increases parathyroid hormone secretion and inhibits bone formation in young women.
        J Bone Miner Res. 1996; 11: 1905-1912
        • Karp H.J.
        • Vaihia K.P.
        • Karkkainen M.U.
        • Niemisto M.J.
        • Lamberg-Allardt C.J.
        Acute effects of different phosphorus sources on calcium and bone metabolism in young women: a whole-foods approach.
        Calcif Tissue Int. 2007; 80: 251-258
        • Kemi V.E.
        • Karkkainen M.U.
        • Lamberg-Allardt C.J.
        High phosphorus intakes acutely and negatively affect Ca and bone metabolism in a dose-dependent manner in healthy young females.
        Br J Nutr. 2006; 96: 545-552
        • Kemi V.E.
        • Rita H.J.
        • Karkkainen M.U.
        • et al.
        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: 1885-1892
        • Sullivan C.
        • Sayre S.S.
        • Leon J.B.
        • et al.
        Effect of food additives on hyperphosphatemia among patients with end-stage renal disease: a randomized controlled trial.
        JAMA. 2009; 301: 629-635
        • Seventh report of the Joint FAO/WHO Expert Committee on Food Additives WHO Technical Report Series, No. 281
        Specifications for the Identity and Purity of Food Additives and their Toxicological Evaluation: Emulsifiers, Stabilizers, Bleaching and Maturing Agents.
        World Health Organization, Geneva, Switzerland1964
      5. Food and Agriculture Organization of the United Nations. Evaluation of the Toxicity of a Number of Antimicrobials and Antioxidants. Sixth report of the Joint FAO/WHO Expert Committee on Food Additives (Food and Agriculture Organization of the United Nations) (World Health Organization). WHO Technical Report Series, No. 228. Geneva, Switzerland: World Health Organization; 1962.

      6. Evaluation of the Health Aspects of Phosphates as Food Ingredients Final Report. Bethesda, MD: Federation of American Societies for Experimental Biology, Life Sciences Research Office. NTIS Report No. SCOGS-32;1975. Available at:¼PB262651. Accessed November 4, 2012.

        • Schoppet M.
        • Shroff R.C.
        • Hofbauer L.C.
        • Shanahan C.M.
        Exploring the biology of vascular calcification in chronic kidney disease: what's circulating?.
        Kidney Int. 2008; 73: 384-390
        • Gutierrez O.M.
        Fibroblast growth factor 23 and disordered vitamin D metabolism in chronic kidney disease: updating the “trade-off” hypothesis.
        Clin J Am Soc Nephrol. 2010; 5: 1710-1716
        • El-Abbadi M.M.
        • Pai A.S.
        • Leaf E.M.
        • et al.
        Phosphate feeding induces arterial medial calcification in uremic mice: role of serum phosphorus, fibroblast growth factor-23, and osteopontin.
        Kidney Int. 2009; 75: 1297-1307
        • Faul C.
        • Amaral A.P.
        • Oskouei B.
        • et al.
        FGF23 induces left ventricular hypertrophy.
        J Clin Invest. 2011; 121: 4393-4408
        • Mirza M.A.
        • Larsson A.
        • Lind L.
        • Larsson T.E.
        Circulating fibroblast growth factor-23 is associated with vascular dysfunction in the community.
        Atherosclerosis. 2009; 205: 385-390
        • Yilmaz M.I.
        • Sonmez A.
        • Saglam M.
        • et al.
        Comparison of calcium acetate and sevelamer on vascular function and fibroblast growth factor 23 in CKD patients: a randomized clinical trial.
        Am J Kidney Dis. 2012; 59: 177-185
      7. Autosomal dominant hypophosphataemic rickets is associated with mutations in FGF23.
        Nat Genet. 2000; 26: 345-348
      8. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. The National Academies Press, Washington, DC2005