The FDA’s proposed revamp of the Nutrition Facts panel misses a public health opportunity to mandate disclosure of phosphorus content on nutrition labels, despite the micronutrient’s association with adverse outcomes among kidney patients and growing evidence linking it to health problems in healthy people, claims the Academy of Nutrition and Dietetics(AND).
Phosphorus labeling is currently voluntary, and FDA’s proposed rule doesn’t plan any changes, but in comments submitted on the new labels, AND recommended FDA make labeling mandatory, ideally subdividing it into naturally occurring vs. added (similar to sugar content vs. added sugar).
In its comments, AND quoted FDA’s own rule determining whether mandatory or voluntary labeling should be used on an ingredient: “‘First we consider whether there is evidence of a relationship between the nutrient and a chronic disease, health-related condition, or health-related physiological endpoint. Second, we consider whether there is evidence of a problem related to health in the general US population.’ Under that rubric, the Academy believes FDA should require mandatory declaration of phosphorus on the Nutrition Facts label.”
An essential mineral for cell structure and function, phosphorus is found naturally in foods such as dairy, meat, fish, eggs, nuts and legumes. Inorganic phosphates are commonly used to flavor and preserve food, with common usage examples being flavored water, cola, deli meat and chicken. Though generally recognized as safe, phosphates’ safety as food additives is being called into question, with research linking elevated serum phosphate levels to higher mortality in people with chronic renal failure and increased risk of cardiovascular disease in healthy people. A 2013 study in the American Journal of Clinical Nutrition found that high phosphorus intake was associated with increased death rates in a nationally representative, healthy US population.
The worry is that inorganic phosphorus may be even more readily absorbed than naturally occurring sources, validated further by a recent study in the Journal of Renal Nutrition, which found that 44% of the best-selling grocery products in the US contain phosphorus additives, based on a sample of 2,394 branded grocery items. According to NHANES data, over a third of Americans consume more than 1400 mg per day, which is twice the recommended intake level. (Separately, AND also recommended FDA establish an upper intake limit of safety for the micronutrient.)
“Consumers probably are not aware of the ubiquity of phosphorous in foods, because not only is the content not required to be listed on the label, but as mentioned in a study in Advances in Chronic Kidney Disease, ‘phosphorus additives are typically unaccounted in the estimated phosphorus content of processed foods because food manufacturers are not required to list their quantities’,” Pepin Tuma, director of regulatory affairs at the Academy of Nutrition and Dietetics (AND), told FoodNavigator-USA.
Kidney disease patients unable to discern phosphorus levels
Restricting phosphorus intake is already a key therapeutic strategy used on patients with kidney disease, but because quantities aren't mandated on product labels, AND maintains that it becomes harder for patients and their families to adhere to these recommendations.
While the percentage of manufacturers that voluntarily disclose phosphorus on labels is unknown, the results of a joint survey by AND and the National Kidney Foundation of individuals with chronic kidney disease and their families showed that the participants found it “so difficult to know the phosphorous content in products that they avoided products altogether that contained it,” Tuma said.
He admitted that the lack of addressing phosphorus is likely tied to the fact that research on its effects is still emerging. “The potentially harmful effects of phosphorous on the general population and those with kidney disease are on FDA’s and USDA’s radar screen, but substantial research on the subject is really only emerging now. As additional data is collected and consensus conclusions are reached, we are confident that both USDA and FDA will act appropriately.”
In order to see regulatory changes, AND and other healthcare experts will have to work with both FDA and the US Department of Agriculture to develop consensus. But in the meantime, additional research on the topic is crucial to build a strong case for mandatory labeling. “It is critical to expand the body of research looking at both consumption and health impacts on both healthy populations and those with cardiovascular disease and chronic kidney disease and to make sure FDA understands the implications of not requiring disclosure of phosphorous content on packaging.”