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Improving Estimates of Phosphorus Additive Content: Manufacturers Needed

2016; Elsevier BV; Volume: 26; Issue: 5 Linguagem: Inglês

10.1053/j.jrn.2016.07.002

1532-8503

Caitlin Krekel, Scott T. McClure, Alex R. Chang,

Magnesium in Health and Disease

Dietary phosphorus restriction is a common feature of medical nutrition therapy for patients with chronic kidney disease or end-stage renal disease.1Academy of Nutrition and Dietetics. Nutrition Care Manual®. March 30, 2016. Available at: http://www.nutritioncaremanual.org. Accessed June 13, 2016.Google Scholar Mean phosphorus intake in the general American population is estimated at 1655 mg/day for men and 1190 mg/day in women as reported by 2009-2010 National Health and Nutrition Survey data.2Calvo M.S. Moshfegh A.J. Tucker K.L. Assessing the health impact of phosphorus in the food supply: issues and considerations.Adv Nutr. 2014; 5: 104-113Crossref PubMed Scopus (119) Google Scholar Although specific limits may be individualized, a maximum of 800-1000 mg of dietary phosphorus per day is commonly used in clinical practice.1Academy of Nutrition and Dietetics. Nutrition Care Manual®. March 30, 2016. Available at: http://www.nutritioncaremanual.org. Accessed June 13, 2016.Google Scholar Restricting dietary phosphorus can be quite challenging, particularly for patients on dialysis who have increased protein requirements. Naturally occurring sources of phosphorus include dairy products, fish, poultry, meat, and whole grains. Patients are often encouraged to consume these types of foods as part of a healthy diet, and thus, giving advice to reduce phosphorus from natural sources becomes challenging. Adding to the difficulty of restricting dietary phosphorus is the increasing contribution of phosphorus from food additives.3Leon J.B. Sullivan C.M. Sehgal A.R. The prevalence of phosphorus-containing food additives in top-selling foods in grocery stores.J Ren Nutr. 2013; 23: 265-270.e2Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar In a recent study examining phosphorus content of the most popular food items purchased in Northeast Ohio, Leon et al. found that 44% of products contained phosphorus additives. Furthermore, a diet composed of products with phosphorus additives contained 67 ± 14 mg phosphorus/100 g more than a comparable diet composed of products without phosphorus additives. Moreover, although only 40%-60% of naturally occurring phosphorus is typically absorbed, up to 80%-100% of phosphorus additives may be absorbed.3Leon J.B. Sullivan C.M. Sehgal A.R. The prevalence of phosphorus-containing food additives in top-selling foods in grocery stores.J Ren Nutr. 2013; 23: 265-270.e2Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Currently, manufacturers are not required to report phosphorus on nutrition facts panels.4U.S. Food and Drug AdministrationA Food Labeling Guide: Guidance for Industry.2013http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm2006828.htmGoogle Scholar Several studies have demonstrated higher phosphorus content in foods containing phosphorus additives and inaccuracies in nutritional databases' reporting of the phosphorus content of these processed food and beverage products.3Leon J.B. Sullivan C.M. Sehgal A.R. The prevalence of phosphorus-containing food additives in top-selling foods in grocery stores.J Ren Nutr. 2013; 23: 265-270.e2Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 5Sherman 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: 18-23Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 6Moser M. White K. Henry B. et al.Phosphorus content of popular beverages.Am J Kidney Dis. 2015; 65: 969-971Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In Table 1, we present data from a recent study6Moser M. White K. Henry B. et al.Phosphorus content of popular beverages.Am J Kidney Dis. 2015; 65: 969-971Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar examining phosphorus content in beverages containing phosphorus-based additives and compare measured values (Medallion Laboratories, Minneapolis, MN) with those reported by the Nutrient Data System for Research (NDSR) software version 2014. We also searched the USDA Standard Nutrient Reference Database,7U.S. Department of Agriculture, Agricultural Research Service. USDA Food Composition Database, Release 28. Available at: https://ndb.nal.usda.gove/ndb/search. Accessed June 13, 2016.Google Scholar manufacturer websites,8The Coca-Cola Company. What is in Coca Cola? A briefing on our ingredients. 2011. Available at: http://www.coca-colahellenic.gr/Download.aspx?ResourceID=122476. Accessed December 4, 2015.Google Scholar, 9PepsiCo Inc. The Facts about Your Favorite Beverages: About Phosphorus. Available at: https://www.pepsicobeveragefacts.com/home/phosphorus. Accessed December 4, 2015.Google Scholar, 10Sunny Delight Beverages Co. SunnyD FAQ. 2015. Available at: http://promo.sunnyd.com/about/index.html#. Accessed June 13, 2016.Google Scholar and 2 popular calorie tracking websites11CalorieKing Wellness Solutions, Inc. CalorieKingTM Food Search. Available at: http://www.calorieking.com/. Accessed April 29, 2016.Google Scholar, 12MyFitnessPal, Inc. MyFitnessPal Food Search. Available at: http://www.myfitnesspal.com/food/calorie-chart-nutrition-facts. Accessed April 29, 2016.Google Scholar to further investigate the extent of publically available data on phosphorus content for these beverages.Table 1Measured Phosphorus Content and Reference Values of Popular BeveragesBeverageMeasured Phosphorus (mg per 8 fl oz)NDSR 2014 Reference Values for Phosphorus (mg per 8 fl oz)USDA Reference Values for Phosphorus (mg per 8 fl oz)Manufacturer Website Values (mg per 8 fl oz)Nutrition Panel Point Estimate or Range Estimate (min, max) (mg per 8 fl oz)Carbonated drinks Coke37.5 (0.2)252240.69— Cherry Coke33.8 (0)2522—7.16 Dr Pepper25.9 (0.2)2527—— Diet Dr Pepper27.1 (0.5)2121—— Pepsi31.2 (0.7)252235— Diet Pepsi24.1 (0.3)212130— AMP Energy30.9 (0.8)4039∗Exact match available in NDSR; for all other products closest substitute was selected.34—Fruit-flavored drinks Crystal Light, Classic Orange†Prepared from powder or concentrated liquid according to package instructions.100.5 (16.0)109—51.5-154.5 Crystal Light, Raspberry Ice†Prepared from powder or concentrated liquid according to package instructions.2.4 (0.1)104—0-15.5 Crystal Light, Fruit Punch†Prepared from powder or concentrated liquid according to package instructions.10.9 (0.5)1016—0-15.5 Tang, Orange†Prepared from powder or concentrated liquid according to package instructions.91.1 (5.0)3951—102-208 Kool-Aid, Tropical Punch†Prepared from powder or concentrated liquid according to package instructions.2.7 (0.3)00—0-15.5 Kool-Aid, Black Cherry†Prepared from powder or concentrated liquid according to package instructions.2.4 (0.1)00—0-15.5 Kool-Aid, Grape†Prepared from powder or concentrated liquid according to package instructions.4.7 (0.6)00—0-15.5 Hawaiian Punch, Fruit Juicy Red77.4 (0.3)70—68.9-103.3 Sunny-D, Tangy Original68.8 (0)41090‡Maximum phosphorus content per manufacturer's website.— Sunny-D, Smooth69.0 (0.5)41090‡Maximum phosphorus content per manufacturer's website.—Coffee drinks Starbucks Doubleshot Energy, Mocha§Exact match unavailable in NDSR; closest substitute was selected.131.2 (0.2)13156—110-164.1 Starbucks Doubleshot Energy, Vanilla§Exact match unavailable in NDSR; closest substitute was selected.130.2 (1.5)13140—110-164.1Iced Teas Gold Peak Iced Tea, Sweet Tea§Exact match unavailable in NDSR; closest substitute was selected.6.7 (0.2)20—— Gold Peak Iced Tea, Lemon§Exact match unavailable in NDSR; closest substitute was selected.2.5 (0.2)23∗Exact match available in NDSR; for all other products closest substitute was selected.—— Lipton Brisk Iced Tea, Sweet Tea§Exact match unavailable in NDSR; closest substitute was selected.105.2 (0.8)23126— Lipton Brisk Iced Tea, Lemon§Exact match unavailable in NDSR; closest substitute was selected.56.9 (0.5)26465.2— Lipton Brisk Iced Tea, Raspberry§Exact match unavailable in NDSR; closest substitute was selected.83.6 (3.8)26493.2—Lemonade Crystal Light, Raspberry Lemonade†Prepared from powder or concentrated liquid according to package instructions.8.0 (0.7)1018—0-15.5 Country Time, Lemonade§Exact match unavailable in NDSR; closest substitute was selected.15.8 (0.0)018—0-18.4 Country Time, Pink Lemonade§Exact match unavailable in NDSR; closest substitute was selected.14.1 (0.2)018—0-23 Kool-Aid, Pink Lemonade†Prepared from powder or concentrated liquid according to package instructions.7.3 (0.1)018—0-15.5Vitamin Water, Power C Dragonfruit1.0 (0)00—0-11.1Vitamin Water, Revive Fruit Punch261.4 (1.7)00∗Exact match available in NDSR; for all other products closest substitute was selected.—138.6-277.2Vitamin Water, Focus Kiwi Strawberry0.9 (0)00—0-11.1Vitamin Water, Essential Orange-Orange63.4 (0.7)00—18.48-55.44Vitamin Water, Defense Raspberry Apple§Exact match unavailable in NDSR; closest substitute was selected.1.5 (0.1)00—0-11.1Vitamin Water Zero, Squeezed Lemonade§Exact match unavailable in NDSR; closest substitute was selected.86.2 (1.2)00—20.6-72.9Vitamin Water Zero, Rise Orange§Exact match unavailable in NDSR; closest substitute was selected.97.7 (1.7)00—12.36-92.54Mio Fit, Arctic Grape †Prepared from powder or concentrated liquid according to package instructions.§Exact match unavailable in NDSR; closest substitute was selected.12.4 (2.1)820—7.29-27.7Mio Fit, Berry Blast†Prepared from powder or concentrated liquid according to package instructions.§Exact match unavailable in NDSR; closest substitute was selected.14.4 (1.6)820—7.29-27.7SoBe Lifewater, Blood Orange Mango§Exact match unavailable in NDSR; closest substitute was selected.43.9 (0.5)0045.6—Aquafina Flavor Splash, Mixed Berry§Exact match unavailable in NDSR; closest substitute was selected.56.3 (0.7)62062.4—Propel Zero, Berry54.9 (0.3)5959∗Exact match available in NDSR; for all other products closest substitute was selected.59.2—Sports drinks Gatorade, Frost Glacier Freeze (powder)†Prepared from powder or concentrated liquid according to package instructions.20.9 (3.2)02824.7— Gatorade, Orange (powder)†Prepared from powder or concentrated liquid according to package instructions.21.0 (4.4)028∗Exact match available in NDSR; for all other products closest substitute was selected.24.7— Powerade Zero, Fruit Punch§Exact match unavailable in NDSR; closest substitute was selected.18.0 (0.2)240—19.01 Powerade Zero, Orange§Exact match unavailable in NDSR; closest substitute was selected.18.6 (0.1)240—19.01 Powerade, Fruit Punch18.7 (0.2)242—19.01 Powerade, Orange18.9 (0.1)242—19.01NDSR, Nutrient Data System for Research.Means and standard deviations presented for each beverage, using 2 samples for each beverage except for Crystal Light, Classic Orange (5 samples).∗ Exact match available in NDSR; for all other products closest substitute was selected.† Prepared from powder or concentrated liquid according to package instructions.‡ Maximum phosphorus content per manufacturer's website.§ Exact match unavailable in NDSR; closest substitute was selected. Open table in a new tab NDSR, Nutrient Data System for Research. Means and standard deviations presented for each beverage, using 2 samples for each beverage except for Crystal Light, Classic Orange (5 samples). Exact matches were found for 28 (61%) of the 46 beverages in NDSR. Phosphorus content was underestimated by NDSR for 78% of the beverages analyzed.6Moser M. White K. Henry B. et al.Phosphorus content of popular beverages.Am J Kidney Dis. 2015; 65: 969-971Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The USDA Standard Nutrient Reference Database only had product-specific information for 11%5Sherman 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: 18-23Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar of the beverages. Neither MyFitnessPal nor CalorieKing™ had any product-specific information on any of the products.11CalorieKing Wellness Solutions, Inc. CalorieKingTM Food Search. Available at: http://www.calorieking.com/. Accessed April 29, 2016.Google Scholar, 12MyFitnessPal, Inc. MyFitnessPal Food Search. Available at: http://www.myfitnesspal.com/food/calorie-chart-nutrition-facts. Accessed April 29, 2016.Google Scholar Manufacturer-reported data were available for 14 (30%) of the beverages and were very similar to measured values.8The Coca-Cola Company. What is in Coca Cola? A briefing on our ingredients. 2011. Available at: http://www.coca-colahellenic.gr/Download.aspx?ResourceID=122476. Accessed December 4, 2015.Google Scholar, 9PepsiCo Inc. The Facts about Your Favorite Beverages: About Phosphorus. Available at: https://www.pepsicobeveragefacts.com/home/phosphorus. Accessed December 4, 2015.Google Scholar, 10Sunny Delight Beverages Co. SunnyD FAQ. 2015. Available at: http://promo.sunnyd.com/about/index.html#. Accessed June 13, 2016.Google Scholar Finally, for products lacking manufacturer reported data, we determined phosphorus content based on reported values of cation(s) (e.g., calcium) on the nutrition facts label, if provided (Table 1). Results for calculations that could be done were very close to what was measured and occasionally outperformed values from NDSR. Note that in some cases, only ranges were able to be calculated as manufacturers may write calcium phosphate on the label, which could include monocalcium, dicalcium, or tricalcium phosphate. Example calculation: Product X contains tricalcium phosphate and no other ingredients that contain a significant amount of phosphorus or calcium. Product nutrition label lists 10% Daily Value (DV) calcium in 1 serving.Determine mass ratio for tricalcium phosphate.Calcium = Ca = 40.08 amu; Phosphorus = P = 30.97 amu; Tricalcium phosphate = Ca3O8P2 (310.17 g/mol).Calculate mass ratio of calcium in tricalcium phosphate = 40.08 g/mol × 3/310.17 g/mol = 38.76%.Calculate mass ratio of phosphorus in tricalcium phosphate = 30.97 g/mol × 2/310.17 g/mol = 19.97%.Calculate mass of tricalcium phosphate that contains 100 mg of calcium.100 mg calcium/38.76% = 258.00 mg of tricalcium phosphate.Calculate mass of phosphorus in 258.00 mg of tricalcium phosphate258.00 mg tricalcium phosphate × 19.97% = 51.5 mg phosphorus in one serving In conclusion, consumer- and research-grade nutritional databases lack product-specific information and may not accurately capture the phosphorus content of foods and beverages containing phosphorus additives. We found that manufacturer websites that reported phosphorus values tended to be accurate and also propose an alternative method to calculate phosphorus content for products that contain phosphorus only from additives. Although our alternative method was able to approximate phosphorus content for some of the products analyzed, it has limited utility for clinical practice. Performing the calculations is time consuming, can only be performed in products without other sources of phosphorus, and even in those cases, may only provide a range if the manufacturer does not specify the numeric prefix for the ionic compound. Increasing awareness among food manufacturers about the importance of dietary phosphorus restriction in patients with kidney disease may help encourage self-reporting of phosphorus content and consequently improve the quality of dietary phosphorus content information available to both researchers and consumers.