Industrial Use of Phosphate Food Additives: A Mechanism Linking Ultra-Processed Food Intake to Cardiorenal Disease Risk?

The consumption of ultra-processed food (UPF) keeps rising, and at the same time, an increasing number of epidemiological studies are linking high rates of consumption of UPF with serious health outcomes, such as cardiovascular disease, in the general population. Many potential mechanisms, either in isolation or in combination, can explain the negative effects of UPF. In this review, we have addressed the potential role of inorganic phosphate additives, commonly added to a wide variety of foods, as factors contributing to the negative effects of UPF on cardiorenal disease. Inorganic phosphates are rapidly and efficiently absorbed, and elevated serum phosphate can lead to negative cardiorenal effects, either directly through tissue/vessel calcification or indirectly through the release of mineral-regulating hormones, parathyroid hormone, and fibroblast growth factor-23. An association between serum phosphate and cardiovascular and bone disease among patients with chronic kidney disease is well-accepted by nephrologists. Epidemiological studies have demonstrated an association between serum phosphate and dietary phosphate intake and mortality, even in the general American population. The magnitude of the role of inorganic phosphate additives in these associations remains to be determined, and the initial step should be to determine precise estimates of population exposure to inorganic phosphate additives in the food supply.

Perspective: School Meal Programs Require Higher Vitamin D Fortification Levels in Milk Products and Plant-Based Alternatives-Evidence from the National Health and Nutrition Examination Surveys (NHANES 2001-2018)

Poor vitamin D status impairs bone growth and immune defense in school-aged children and adolescents, particularly in minorities. Vitamin D insufficiency/deficiency increases the risk of acute viral respiratory infection, underscoring the need for adequate vitamin D intakes during school sessions when viral exposure may be greatest. We studied available vitamin D-related survey data and published findings based on NHANES (2001-2018) to assess the dependency of vitamin D status {25-hydroxyvitamin D [25(OH)D]; in nmol/L} on vitamin D intake (μg/d) in elementary school-aged children (4-8 y), middle school children (9-13 y), and high school adolescents (14-18 y). We sought evidence supporting the need for school programs to facilitate vitamin D adequacy. Usual vitamin D intakes from food and beverages by children/adolescents (NHANES 2015-2018) examined at the 50th percentile intake by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) showed all age groups consumed less than half of the Estimated Average Requirement (EAR) for vitamin D (10 μg/d), independent of race/ethnicity. NHANES (2001-2010) analyses show evidence of lower vitamin D status in school-aged children that is linked to lower intakes of fortified milk varying over race/ethnicity and age. Adolescents had lower vitamin D status and milk intake than younger children. A total of 22-44% of vitamin D intakes occurred away from home, with larger percentages of total intakes at breakfast and lunch, at times consistent with school meals. Ever-present inadequate vitamin D intakes with a large percentage consumed away from home together with well-established benefits to growth, bone, and immune defense from enriched vitamin D-fortified milk in school intervention trials provide strong justification to require enriched vitamin D-fortified foods in school meals. An easy to implement plan for improving vitamin D intakes is possible through the FDA's amendment allowing higher vitamin D fortification levels of dairy and plant-based milk alternatives that could increase vitamin D intakes beyond the EAR with just 2 daily servings.

Perspective: Plant-based Whole-Grain Foods for Chronic Kidney Disease: The Phytate-Phosphorus Conundrum

Restriction of dietary phosphorus intake is an important component of good clinical practice in kidney failure patients, particularly after dialysis initiation. Greater consumption of predominantly plant-based diets, including phytate-rich foods, is increasingly recommended for health maintenance/disease prevention in this population, with the implicit assumption that phytate-phosphorus in whole-grain cereals, legumes, pulses, and nuts is poorly absorbed. Review of human interventions with diets high in phytate-phosphorus indeed suggests an absorption of at least 50%, still less than animal protein-bound phosphorus, but higher than the generally believed 10-30%. Factors largely ignored up to now, but of potential influence on phytate-phosphorus bioavailability, include effect of food processing in releasing phosphorus, action of colonic bacteria that are able to release inorganic phosphorus, and capacity of the colon to absorb phosphorus. These issues may become increasingly important as new plant-based alternatives to meats, all containing phytate, are being rapidly introduced in the market.

Dietary Phosphate and the Forgotten Kidney Patient: A Critical Need for FDA Regulatory Action

Careful dietary management that reduces high phosphate intake is recommended to slow the progression of chronic kidney disease (CKD) and prevent complications of CKD and may help reduce chronic disease risks such as incident CKD associated with high phosphate intake in the healthy general population. For patients treated with maintenance dialysis, control of serum phosphorus levels is considered a marker of good care and requires a coordinated plan that limits dietary phosphate intake, uses oral phosphate binders, and provides an adequate dialysis prescription. Even with traditional thrice-weekly hemodialysis or peritoneal dialysis, use of phosphate binders, and a concerted effort to limit dietary phosphate intake, adequately controlled serum phosphorus levels are not possible in all dialysis patients. Efforts to limit phosphate intake are thwarted by the underestimated and unquantified phosphate content of processed foods and some medications due to the hidden presence of phosphate additives or excipients added during processing or drug formulation. Effectively limiting phosphate intake could potentially be achieved through simple US Food and Drug Administration regulatory actions. Mandatory labeling of phosphate content on all packaged foods and drugs would enable identification of healthy low-phosphate foods and medications and permit critically important control of total phosphate intake. Simple changes in regulatory policy and labeling are warranted and would enable better management of dietary intake of phosphate at all stages of kidney disease, as well as potentially reduced health risks in the general population.

Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries

Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.

Rationale and Plan for Vitamin D Food Fortification: A Review and Guidance Paper

Vitamin D deficiency can lead to musculoskeletal diseases such as rickets and osteomalacia, but vitamin D supplementation may also prevent extraskeletal diseases such as respiratory tract infections, asthma exacerbations, pregnancy complications and premature deaths. Vitamin D has a unique metabolism as it is mainly obtained through synthesis in the skin under the influence of sunlight (i.e., ultraviolet-B radiation) whereas intake by nutrition traditionally plays a relatively minor role. Dietary guidelines for vitamin D are based on a consensus that serum 25-hydroxyvitamin D (25[OH]D) concentrations are used to assess vitamin D status, with the recommended target concentrations ranging from ≥25 to ≥50 nmol/L (≥10-≥20 ng/mL), corresponding to a daily vitamin D intake of 10 to 20 μg (400-800 international units). Most populations fail to meet these recommended dietary vitamin D requirements. In Europe, 25(OH)D concentrations <30 nmol/L (12 ng/mL) and <50 nmol/L (20 ng/mL) are present in 13.0 and 40.4% of the general population, respectively. This substantial gap between officially recommended dietary reference intakes for vitamin D and the high prevalence of vitamin D deficiency in the general population requires action from health authorities. Promotion of a healthier lifestyle with more outdoor activities and optimal nutrition are definitely warranted but will not erase vitamin D deficiency and must, in the case of sunlight exposure, be well balanced with regard to potential adverse effects such as skin cancer. Intake of vitamin D supplements is limited by relatively poor adherence (in particular in individuals with low-socioeconomic status) and potential for overdosing. Systematic vitamin D food fortification is, however, an effective approach to improve vitamin D status in the general population, and this has already been introduced by countries such as the US, Canada, India, and Finland. Recent advances in our knowledge on the safety of vitamin D treatment, the dose-response relationship of vitamin D intake and 25(OH)D levels, as well as data on the effectiveness of vitamin D fortification in countries such as Finland provide a solid basis to introduce and modify vitamin D food fortification in order to improve public health with this likewise cost-effective approach.

A Retrospective Study in Adults with Metabolic Syndrome: Diabetic Risk Factor Response to Daily Consumption of Agaricus bisporus (White Button Mushrooms)

Adults with metabolic syndrome from different race/ethnicities are often predisposed to developing type 2 diabetes (T2D); however, growing evidence suggests that healthy diets and lifestyle choices can significantly slow or prevent progression to T2D. This poorly understood relationship to healthy dietary patterns and prevention of T2D motivated us to conduct a retrospective analysis to determine the potential impact of a minor dietary lifestyle change (daily mushroom consumption) on known T2D risk factors in racially diverse adults with confirmed features of the metabolic syndrome. Retrospectively, we studied 37 subjects who had participated in a dietary intervention focused on vitamin D bioavailability from white button mushrooms (WBM). All 37 had previously completed a 16-week study where they consumed 100 g of WBM daily and were then followed-up for one month during which no mushrooms were consumed. We analyzed differences in serum risk factors from baseline to 16-week, and from baseline to one-month follow-up. Measurement of serum diabetic risk factors included inflammatory and oxidative stress markers and the antioxidant component naturally rich in mushrooms, ergothioneine. Significant beneficial health effects were observed at 16-week with the doubling of ergothioneine from baseline, increases in the antioxidant marker ORAC (oxygen radical absorption capacity) and anti-inflammatory hormone, adiponectin and significant decreases in serum oxidative stress inducing factors, carboxymethyllysine (CML) and methylglyoxal (MG), but no change in the lipid oxidative stress marker 8-isoprostane, leptin or measures of insulin resistance or glucose metabolism. We conclude that WBM contain a variety of compounds with potential anti-inflammatory and antioxidant health benefits that can occur with frequent consumption over time in adults predisposed to T2D. Well-controlled studies are needed to confirm these findings and identify the specific mushroom components beneficial to health.

Is phosphorus intake that exceeds dietary requirements a risk factor in bone health?

Phosphorus intake in excess of the nutrient needs of healthy adults is thought to disrupt hormonal regulation of phosphorus (P), calcium (Ca), and vitamin D, contributing to impaired peak bone mass, bone resorption, and greater risk of fracture. Elevation of extracellular phosphorus due to excessive intake is thought to be the main stimulus disrupting phosphorus homeostasis in healthy individuals, as it is in renal disease even when intake is modest. If high serum phosphorus is the critical link to the effect of high phosphorus intake on bone health, the issue could be addressed through epidemiologic or dietary studies. However, several confounding factors, including problems estimating accurate phosphorus intake, the influence of a low dietary Ca:P ratio, the acidic nature of phosphorus, the rapid rate of absorption and greater phosphorus bioavailability from processed food such as cola drinks, and circadian fluctuation in serum phosphorus, make this question difficult to address using conventional study designs. These confounding factors are considered in this review, exploring whether phosphorus intake exceeding nutrient needs in healthy individuals disrupts phosphorus regulation and negatively affects bone accretion or loss. Specific attention is given to phosphorus intake from processed foods rich in phosphorus additives, which significantly contribute to phosphorus intake.

Assessing the health impact of phosphorus in the food supply: issues and considerations

The Western dietary pattern of intake common to many Americans is high in fat, refined carbohydrates, sodium, and phosphorus, all of which are associated with processed food consumption and higher risk of life-threatening chronic diseases. In this review, we focus on the available information on current phosphorus intake with this Western dietary pattern, and new knowledge of how the disruption of phosphorus homeostasis can occur when intake of phosphorus far exceeds nutrient needs and calcium intake is limited. Elevation of extracellular phosphorus, even when phosphorus intake is seemingly modest, but excessive relative to need and calcium intake, may disrupt the endocrine regulation of phosphorus balance in healthy individuals, as it is known to do in renal disease. This elevation in serum phosphate, whether episodic or chronically sustained, may trigger the secretion of regulatory hormones, whose actions can damage tissue, leading to the development of cardiovascular disease, renal impairment, and bone loss. Therefore, we assessed the health impact of excess phosphorus intake in the context of specific issues that reflect changes over time in the U.S. food supply and patterns of intake. Important issues include food processing and food preferences, the need to evaluate phosphorus intake in relation to calcium intake and phosphorus bioavailability, the accuracy of various approaches used to assess phosphorus intake, and the difficulties encountered in evaluating the relations of phosphorus intake to chronic disease markers or incident disease.

Dietary phosphorus excess: a risk factor in chronic bone, kidney, and cardiovascular disease?

There is growing evidence in the nephrology literature supporting the deleterious health effect of excess dietary phosphorus intake. This issue has largely escaped the attention of nutrition experts until this symposium, which raised the question of whether the same health concerns should be extended to the general population. The potential hazard of a high phosphorus intake in the healthy population is illustrated by findings from acute and epidemiologic studies. Acute studies in healthy young adults demonstrate that phosphorus intakes in excess of nutrient needs may significantly disrupt the hormonal regulation of phosphorus contributing to disordered mineral metabolism, vascular calcification, bone loss, and impaired kidney function. One of the hormonal factors acutely affected by dietary phosphorus loading is fibroblast growth factor-23, which may be a key factor responsible for many of the cardiovascular disease (CVD) complications of high phosphorus intake. Increasingly, large epidemiological studies suggest that mild elevations of serum phosphorus within the normal range are associated with CVD risk in healthy populations. Few population studies link high dietary phosphorus intake to mild changes in serum phosphorus due to study design issues specific to phosphorus and inaccurate nutrient composition databases. The increasing phosphorus intake due to the use of phosphorus-containing ingredients in processed food and the growing consumption of processed convenience and fast foods is an important factor that needs to be emphasized.

Survey of current vitamin D food fortification practices in the United States and Canada

Widespread poor vitamin D status in all age and gender groups in the United States (USA) and Canada increases the need for new food sources. Currently ∼60% of the intake of vitamin D from foods is from fortified foods in these countries. Those groups in greatest need are consuming significantly lower amounts of commonly fortified foods such as milk. Both countries allow voluntary vitamin D fortification of some other foods, although in Canada this practice is only done on a case-by-case basis. Novel approaches to vitamin D fortification of food in both countries now include "bio-addition" in which food staples are fortified through the addition of another vitamin D-rich food to animal feed during production, or manipulation of food post-harvest or pre-processing. These bio-addition approaches provide a wider range of foods containing vitamin D, and thus appeal to differing preferences, cultures and possibly economic status. An example is the post-harvest exposure of edible mushrooms to ultraviolet light. However, further research into safety and efficacy of bio-addition needs to be established in different target populations. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Public health impact of dietary phosphorus excess on bone and cardiovascular health in the general population

This review explores the potential adverse impact of the increasing phosphorus content in the American diet on renal, cardiovascular, and bone health of the general population. Increasingly, studies show that phosphorus intakes in excess of the nutrient needs of a healthy population may significantly disrupt the hormonal regulation of phosphate, calcium, and vitamin D, which contributes to disordered mineral metabolism, vascular calcification, impaired kidney function, and bone loss. Moreover, large epidemiologic studies suggest that mild elevations of serum phosphate within the normal range are associated with cardiovascular disease (CVD) risk in healthy populations without evidence of kidney disease. However, few studies linked high dietary phosphorus intake to mild changes in serum phosphate because of the nature of the study design and inaccuracies in the nutrient composition databases. Although phosphorus is an essential nutrient, in excess it could be linked to tissue damage by a variety of mechanisms involved in the endocrine regulation of extracellular phosphate, specifically the secretion and action of fibroblast growth factor 23 and parathyroid hormone. Disordered regulation of these hormones by high dietary phosphorus may be key factors contributing to renal failure, CVD, and osteoporosis. Although systematically underestimated in national surveys, phosphorus intake seemingly continues to increase as a result of the growing consumption of highly processed foods, especially restaurant meals, fast foods, and convenience foods. The increased cumulative use of ingredients containing phosphorus in food processing merits further study given what is now being shown about the potential toxicity of phosphorus intake when it exceeds nutrient needs.

Vitamin D2 from light-exposed edible mushrooms is safe, bioavailable and effectively supports bone growth in rats

Widespread poor vitamin D status, a health risk for bone disease, increases the need for new food sources of vitamin D. Light-exposed edible mushrooms synthesize vitamin D(2). Bioavailability, safety, and efficacy of high levels of vitamin D(2) from mushrooms to support bone health was established in chronically fed growing rats.

INTRODUCTION

Poor vitamin D status from reduced sun exposure is made worse by limited access to vitamin D-containing foods. Exposing white button mushrooms to ultraviolet B (UVB) light markedly increases their vitamin D(2) content, creating a new food source of vitamin D. We used a growing rat model to determine safety, bioavailability, and efficacy in support of bone growth by vitamin D(2) from UVB-exposed mushrooms.

METHODS

We fed 150 weanling female rats one of five diets for 10 weeks, all formulated on AIN-93 G. Control diets contained no mushrooms either with or without vitamin D(3). Other diets contained 2.5% and 5.0% of UVB-exposed or -unexposed mushrooms. Safety of the high levels of vitamin D(2) from mushrooms was assessed by animal growth and by Von Kossa staining for soft tissue calcification. Bioavailability was determined from changes in circulating levels of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH). Efficacy in support of bone growth was determined from measures of femur bending properties, size, mineralization, and microarchitecture.

RESULTS

Diets containing 2.5% and 5.0% light-exposed mushrooms significantly raised 25(OH)D and suppressed PTH levels compared to control-fed rats or rats fed 5.0% mushroom unexposed to light. Microarchitecture and trabecular mineralization were only modestly higher in the light-treated mushroom-fed rats compared to the controls. Von Kossa staining revealed no soft tissue calcification despite very high plasma 25(OH)D.

CONCLUSIONS

Vitamin D(2) from UVB-exposed mushrooms is bioavailable, safe, and functional in supporting bone growth and mineralization in a growing rat model without evidence of toxicity.

Contributions to total phosphorus intake: all sources considered

High serum phosphorus is linked to poor health outcome and mortality in chronic kidney disease (CKD) patients before or after the initiation of dialysis. Dietary intake of phosphorus, a major determinant of serum phosphorus, seems to be systematically underestimated using the available software tools and generalized nutrient content databases. Several sources of dietary phosphorus including the addition of phosphorus ingredients in food processing, and phosphorus content of vitamin and mineral supplements and commonly used over-the-counter or prescription medications are not fully accounted for by the nutrient content databases and software programs in current clinical use or used in large population studies. In this review, we explore the many unknown sources of phosphorus in the food supply to identify all possible contributors to total phosphorus intake of Americans that have escaped inclusion in past intake estimates. Our goal is to help delineate areas for future interventions that will enable tighter control of dietary phosphorus intake, a critical factor to maintaining health and quality of life in CKD and dialysis patients.

Modern India and the vitamin D dilemma: evidence for the need of a national food fortification program

India is located between 8.4 and 37.6 degrees N latitude with the majority of its population living in regions experiencing ample sunlight throughout the year. Historically, Indians obtained most of their vitamin D through adequate sun exposure; however, darker skin pigmentation and the changes which have accompanied India's modernization, including increased hours spent working indoors and pollution, limit sun exposure for many. Inadequate sun exposure results in reduced vitamin D synthesis and ultimately poor vitamin D status if not compensated by dietary intake. Dietary vitamin D intake is very low in India because of low consumption of vitamin D rich foods, absence of fortification and low use of supplements. All these factors contribute to poor vitamin D status as measured by low circulating levels of 25-hydroxy vitamin D. Our review searches the published literature specific to India for evidence that would confirm the need to fortify food staples with vitamin D or stimulate public health policies for vitamin D supplementation and dietary guidelines tailored to the Indian diet. This review documents findings of widespread vitamin D deficiency in Indian populations in higher and lower socioeconomic strata, in all age groups, in both genders and people in various professions. Moreover, poor vitamin D status in India is accompanied by increased bone disorders including osteoporosis, osteomalacia in adults and rickets and other bone deformities in children. Without a concerted national effort to screen for vitamin D status, to implement policies or guidelines for vitamin D fortification and/or supplementation and to re-assess recommended dietary intake guidelines, dramatic increase in the number of bone disorders and other diseases may lie ahead.

Despite mandatory fortification of staple foods, vitamin D intakes of Canadian children and adults are inadequate

Vitamin D is largely obtained through sun-induced skin synthesis and less from dietary sources, but during Canadian winters, skin synthesis is non-existent. The objective of this study was to estimate vitamin D intakes in Canadians from food sources. Data used in this study included food intakes of Canadians reported in the 2004 Canadian Community Health Survey Cycle 2.2 (CCHS 2.2), a nationally representative sample of 34,789 persons over the age of 1 year. The mean+/-SD dietary intake of vitamin D from food of Canadians was 5.8+/-0.1 microg/day, with males 9-18 years having the highest mean intakes (7.5+/-0.2 microg/day) and females 51-70 years having the lowest intakes (5.2+/-0.3 microg/day). Males in all age groups had higher intakes than females and White Canadians had higher vitamin D intakes than Non-Whites in most age sex groups. Milk products contributed 49% of dietary vitamin D followed by meat and meat-alternatives (31.1%). The majority of Canadians consume less than current recommended intake of vitamin D from food. Consideration should be given to strategies to improve vitamin D intake of Canadians by increasing both the amount of vitamin D added to foods and range of foods eligible for fortification.

Activation of the 2-5OAS/RNase L pathway in CVB1 or HAV/18f infected FRhK-4 cells does not require induction of OAS1 or OAS2 expression

The latent, constitutively expressed protein RNase L is activated in coxsackievirus and HAV strain 18f infected FRhK-4 cells. Endogenous oligoadenylate synthetase (OAS) from uninfected and virus infected cell extracts synthesizes active forms of the triphosphorylated 2-5A oligomer (the only known activator of RNase L) in vitro and endogenous 2-5A is detected in infected cell extracts. However, only the largest OAS isoform, OAS3, is readily detected throughout the time course of infection. While IFNbeta treatment results in an increase in the level of all three OAS isoforms in FRhK-4 cells, IFNbeta pretreatment does not affect the temporal onset or enhancement of RNase L activity nor inhibit virus replication. Our results indicate that CVB1 and HAV/18f activate the 2-5OAS/RNase L pathway in FRhK-4 cells during permissive infection through endogenous levels of OAS, but contrary to that reported for some picornaviruses, CVB1 and HAV/18f replication is insensitive to this activated antiviral pathway.

Trends in mineral metabolism: Kidney Early Evaluation Program (KEEP) and the National Health and Nutrition Examination Survey (NHANES) 1999-2004

BACKGROUND

Chronic kidney disease (CKD) is associated with mineral metabolism dysregulation, cardiovascular disease, and premature mortality. No study specifically examined mineral metabolism trends in a generalizable sample of patients at increased CKD risk.

METHODS

This cross-sectional analysis from November 1, 2005, to December 31, 2006, of calcium, phosphorus, and parathyroid hormone (PTH) includes 2,646 individuals with estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2) in the National Kidney Foundation Kidney Early Evaluation Program (KEEP), a community-based health-screening program targeting individuals 18 years and older with diabetes, hypertension, or family history of kidney disease, diabetes, or hypertension. A parallel analysis of National Health and Nutrition Examination Survey (NHANES) 1999-2004 data was performed.

RESULTS

In KEEP, as eGFR decreased from 55 to less than 60 mL/min/1.73 m(2) to less than 30 mL/min/1.73 m(2), calcium level decreased (9.55 +/- 0.47 to 9.34 +/- 0.62 mg/dL; P < 0.001), phosphorus level increased (3.70 +/- 0.59 to 4.15 +/- 0.80 mg/dL; P < 0.001), and PTH level increased (66.3 +/- 36.3 to 164 +/- 109 pg/mL; mean, 80.8 +/- 57.0 pg/mL; P < 0.001). NHANES 1999-2004 showed similar trends, with PTH values not as high. Individuals within opinion-based Kidney Disease Outcomes Quality Initiatives targets from the highest to the lowest eGFR group were as follows: calcium, 93.0% to 92.3% (KEEP) and 97.4% to 89.6% (NHANES); phosphorus, 90.4% to 90.3% (KEEP) and 91.6% to 87.1% (NHANES); and PTH, 46.1% to 31.2% (KEEP) and 56.4% to 36.1% (NHANES).

CONCLUSIONS

In a community-based CKD screening population, increased PTH level occurs early in patients with stage 3, typically with normal calcium and phosphorus levels. These findings support the importance of including PTH with calcium and phosphorus monitoring for individuals with eGFR less than 60 mL/min/1.73 m(2).

Vitamin D intakes in North America and Asia-Pacific countries are not sufficient to prevent vitamin D insufficiency

Worldwide, vitamin D status is suboptimal relative to circulating levels of 25-hydroxyvitamin D (25OHD) needed to prevent a variety of chronic conditions, however, it has long been assumed that dietary intake is sufficient to meet needs when sun exposure is limited. In the USA, mean vitamin D intake from foods is close to 5 microg, the Dietary Reference Intake (DRI) recommendation for persons up to 50 years; however, the amount of vitamin D needed to maintain a sufficient 25OHD level during winter is >12.5 microg, and that needed for darkly pigmented, veiled, or sun protected persons is >50 microg. In the USA, most vitamin D intake from foods is provided by fortification. Canada and New Zealand have fewer fortified choices, and intakes are correspondingly lower. Supplement use can increase mean intake to >12.5 microg but does not always reach those who need it most. Serum 25OHD levels in New Zealand reveal much more insufficiency than expected, especially for Pacific people and Mäori; low serum 25OHD concentrations are seen throughout the Asia-Pacific region. Fortification and supplementation may be effective to achieve intakes of 12.5 microg vitamin D in some of the population, but for many achieving the amount needed in the absence of skin synthesis requires intakes above the current upper level for vitamin D of 50 microg.

Public health strategies to overcome barriers to optimal vitamin D status in populations with special needs

In North America, there is increasing public health awareness of the importance of adequate vitamin D intake to the maintenance of optimal vitamin D status and overall health. Experts now define this as circulating levels of 25-hydroxyvitamin D of 75-80 nmol/L. This serum level and high levels of dietary intake have been associated with significantly reduced risk of chronic diseases, such as osteoporosis, cardiovascular disease, diabetes, and some cancers. All of these diseases are more prevalent in the elderly of all races, and some are more prevalent and of greater severity among blacks than whites. Our objective is to review recent actions to increase public awareness of the health importance of maintaining optimal circulating 25(OH)D and potential strategies to increase vitamin D intake. Clinicians and educators are encouraged to promote improved vitamin D intake and status, particularly among the elderly and blacks. This will largely depend on combined efforts to judiciously fortify our food supply and to develop individual supplementation protocols for supplements or controlled use of UV light exposure to maintain optimal serum 25(OH)D, especially in high-risk groups. Growing evidence supports a low risk of toxicity with vitamin D use in fortification or supplementation, despite its past reputation of potential toxicity in excess. The cost to fortify food or supplements with vitamin D is relatively inexpensive compared with developing drugs used to treat or prevent chronic diseases; moreover, there is significant potential for broad health benefits in the reduced risk and prevention of multiple chronic diseases.

Dietary recommendations to meet both endocrine and autocrine needs of Vitamin D

In the most recent revision of the dietary recommendations for Americans and Canadians in 1997, a recommended intake for Vitamin D was set in the absence of an estimation of mean requirements. There are now new data to estimate average requirements; however, there must be consideration of factors affecting need in populations and of total body tissue needs including the prevention and treatment of cancer. A recent study provides dietary dose-response data in the absence of sun exposure, and a mean requirement of 12.5microg (500IU) was found for Caucasian men. A seasonal build up (summer) and waning (winter) of Vitamin D stores implies that the requirement of Vitamin D in complete absence of yearly summertime sun exposure would approach levels of intake that mimic Vitamin D gained from sun exposure. High prevalence of Vitamin D insufficiency and the re-emergence of rickets have been observed worldwide. For many countries without mandatory staple food fortification, Vitamin D intake is often too low to sustain healthy circulating levels of 25 hydroxyvitamin D. Even in some countries that require (mandatory) or allow fortification (optional), Vitamin D intakes are low in some groups due to their unique dietary patterns, such as low milk consumption, vegetarian diet, limited or no use of dietary supplements, or changes away from traditional food consumption. Supplement use can significantly increase Vitamin D intakes across all age and gender groups but the benefit is primarily gained in persons whose intakes are close to adequate. African American men and women have greater prevalence of Vitamin D insufficiency, which may be a factor in their susceptibility to certain cancers. New recommendations for Vitamin D should be made for the otherwise healthy populations in greatest need of dietary Vitamin D due to lack of adequate sun exposure.

Vitamin D intake: a global perspective of current status

Global high prevalence of vitamin D insufficiency and re-emergence of rickets and the growing scientific evidence linking low circulating 25-hydroxyvitamin D to increased risk of osteoporosis, diabetes, cancer, and autoimmune disorders have stimulated recommendations to increase sunlight (UVB) exposure as a source of vitamin D. However, concern over increased risk of melanoma with unprotected UVB exposure has led to the alternative recommendation that sufficient vitamin D should be supplied through dietary sources alone. Here, we examine the adequacy of vitamin D intake worldwide and evaluate the ability of current fortification policies and supplement use practices among various countries to meet this recommendation. It is evident from our review that vitamin D intake is often too low to sustain healthy circulating levels of 25-hydroxyvitamin D in countries without mandatory staple food fortification, such as with milk and margarine. Even in countries that do fortify, vitamin D intakes are low in some groups due to their unique dietary patterns, such as low milk consumption, vegetarian diet, limited use of dietary supplements, or loss of traditional high fish intakes. Our global review indicates that dietary supplement use may contribute 6-47% of the average vitamin D intake in some countries. Recent studies demonstrate safety and efficacy of community-based vitamin D supplementation trials and food staple fortification introduced in countries without fortification policies. Reliance on the world food supply as an alternative to UVB exposure will necessitate greater availability of fortified food staples, dietary supplement use, and/or change in dietary patterns to consume more fish.

Dietary recommendations for vitamin D: a critical need for functional end points to establish an estimated average requirement

From its inaugural value in 1941, the Recommended Dietary Allowance (RDA) for adults for vitamin D has remained close to 400 IU (10 microg) level. This original recommended intake was based on the observation that the amount of vitamin D activity in a teaspoon of cod liver oil was sufficient to prevent rickets in infants. Since that time until 1997, determination of vitamin D requirements and status was more conjecture than science. In 1997, when the recommended intake level of vitamin D was set as an adequate intake value rather than an RDA, much has been learned about metabolism of vitamin D. The circulating metabolite 25-hydroxyvitamin D is the major static indicator of vitamin D status. Using its response to diet in the absence of sun exposure, a dose-response study suggests a mean requirement of at least 500 IU (12.5 microg) from which an RDA could be set. Other factors may need adjustment, such as sun exposure and body fat. However, functional indicators of status are needed. The role of vitamin D in calcium metabolism (i.e., calciotropic functions) is better understood; bone turnover and parathyroid hormone are potential indicators. Vitamin D has noncalciotropic functions arising from extrarenal synthesis of the active metabolite 1,25 dihydroxyvitamin D involving cell proliferation and immunity, from which function indicators of status may be derived. Despite gaps in our knowledge, there are data from which new dietary reference intake values for vitamin D may be set.

Vitamin D fortification in the United States and Canada: current status and data needs

Most circulating 25-hydroxyvitamin D originates from exposure to sunlight; nevertheless, many factors can impair this process, necessitating periodic reliance on dietary sources to maintain adequate serum concentrations. The US and Canadian populations are largely dependent on fortified foods and dietary supplements to meet these needs, because foods naturally rich in vitamin D are limited. Fluid milk and breakfast cereals are the predominant vehicles for vitamin D in the United States, whereas Canada fortifies fluid milk and margarine. Reports of a high prevalence of hypovitaminosis D and its association with increased risks of chronic diseases have raised concerns regarding the adequacy of current intake levels and the safest and most effective way to increase vitamin D intake in the general population and in vulnerable groups. The usual daily intakes of vitamin D from food alone and from food and supplements combined, as estimated from the US third National Health and Nutrition Examination Survey, 1988-1994, show median values above the adequate intake of 5 microg/d for children 6-11 y of age; however, median intakes are generally below the adequate intake for female subjects > 12 y of age and men > 50 y. In Canada, there are no national survey data for estimation of intake. Cross-sectional studies suggest that current US/Canadian fortification practices are not effective in preventing hypovitaminosis D, particularly among vulnerable populations during the winter, whereas supplement use shows more promise. Recent prospective intervention studies with higher vitamin D concentrations provided evidence of safety and efficacy for fortification of specific foods and use of supplements.

Hidden sources of phosphorus in the typical American diet: does it matter in nephrology?

Elevated serum phosphorus is a major, preventable etiologic factor associated with the increased cardiovascular morbidity and mortality of dialysis patients. An important determinant of serum phosphorus is the dietary intake of this mineral; this makes dietary restriction of phosphorus a cornerstone for the prevention and treatment of hyperphosphatemia. The average daily dietary intake of phosphorus is about 1550 mg for males and 1000 mg for females. In general, foods high in protein are also high in phosphorus. These figures, however, are changing as phosphates are currently being added to a large number of processed foods including meats, cheeses, dressings, beverages, and bakery products. As a result, and depending on the food choices, such additives may increase the phosphorus intake by as a much as 1 g/day. Moreover, nutrient composition tables usually do not include the phosphorus from these additives, resulting in an underestimate of the dietary intake of phosphorus in our patients. Our goal is to convey an understanding of the phosphorus content of the current American diet to better equip nephrologists in their attempt to control hyperphosphatemia.

Prevalence of vitamin D insufficiency in Canada and the United States: importance to health status and efficacy of current food fortification and dietary supplement use

Several recent studies have identified a surprisingly high prevalence of vitamin D insufficiency in otherwise healthy adults living in Canada and the United States. Most striking are the effects of latitude, season, and race. Also noteworthy is that dietary vitamin D is not reaching the population in greatest need, nor is it very protective against insufficiency. Fluid milk, as the predominant vehicle for vitamin D fortification, is apparently not very effective in staving off vitamin D insufficiency in adults in all populations at all times of the year.

Patterns of osteocalcin and bone specific alkaline phosphatase by age, gender, and race or ethnicity

A variety of biochemical markers of bone turnover that assess bone formation or resorption are now available for research and clinical application. However, our understanding of the usual pattern of these measures over age in the general population is limited. Therefore, values of two bone formation markers, serum osteocalcin (Oc) and bone specific alkaline phosphatase (bone ALP), were compared by age, gender, and race or ethnicity using serum obtained from a subsample of blacks, whites, and Mexican Americans from the third National Health and Nutrition Examination Survey (NHANES). In all racial and ethnic groups, mean values of both serum Oc and bone ALP were lower in women than in men <50 years old. In individuals > or =50 years of age, Oc was significantly higher in women than in men. When analyzed in these two broad age groups, Oc was lower in older black men than in white or Mexican American men, but bone ALP was not different among the groups. In women, Oc levels tended to be lower in the black women than in white or Mexican American women. In contrast, bone ALP tended to be lower in white women than in black or Mexican American women. On the other hand, when analyzed by decade, patterns differed between the two markers in both men and women. In women, both Oc and bone ALP rose postmenopausally. However, bone ALP plateaued in the sixth through eighth decades, whereas Oc levels tended to increase further. In men, Oc was highest in the 20-29 year age group, declined and stabilized, then increased again in the seventh decade. In contrast, mean bone ALP did not differ by decade in men. Our data document differences in levels of circulating Oc and bone ALP by age, gender, and race/ethnicity. The age patterns reflected by the two markers are not concordant and distinctions are most evident in the latter decades. Our findings suggest that the specific osteoblast activity reflected by these markers responds differently to the physiologic changes that occur later in life.

Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III

Subclinical vitamin D deficiency may be common in certain subgroups in the U.S., but to date vitamin D data from other groups in the population have not been available. We used serum 25-hydroxyvitamin D (25-OHD) data from 18,875 individuals examined in the Third National Health and Nutrition Examination Survey (NHANES III 1988-1994) to assess the vitamin D status of selected groups of the noninstitutionalized U.S. adolescent and adult population. Serum 25-OHD levels were measured by a radioimmunoassay kit (DiaSorin, Inc., Stillwater, MN; normal range 22.5-94 nmol/L). Because physical exams are performed in mobile vans in NHANES, data could not be collected in northern latitudes during the winter; instead data were collected in northern latitudes during summer and in southern latitudes in winter. To address this season-latitude aspect of the NHANES design, we stratified the sample into two seasonal subpopulations (winter/lower latitude and summer/higher latitude) before examining vitamin D status. Less than 1% of the winter/lower latitude subpopulation had vitamin D deficiency (25-OHD <17.5 nmol/L). However, the prevalence of vitamin D insufficiency in this group ranged from 1%-5% with 25-OHD <25 nmol/L to 25%-57% with 25-OHD <62.5 nmol/L, even though the median latitude for this subsample (32 degrees N) was considerably lower than the latitude at which vitamin D is not synthesized during winter months (approximately 42 degrees N). With the exception of elderly women, prevalence rates of vitamin D insufficiency were lower in the summer/higher latitude subpopulation (<1%-3% with 25-OHD <25 nmol/L to 21%-49% with 25-OHD <62.5 nmol/L). Mean 25-OHD levels were highest in non-Hispanic whites, intermediate in Mexican Americans, and lowest in non-Hispanic blacks. Our findings suggest that vitamin D deficiency is unlikely in the two seasonal subpopulations of noninstitutionalized adolescents and adults that can be validly assessed in NHANES III. However, vitamin D insufficiency is more common in these two seasonal subpopulations. Of particular interest is that insufficiency occurred fairly frequently in younger individuals, especially in the winter/lower latitude subsample. Our findings support continued monitoring of this vitamin in the U.S. population.

Updated data on proximal femur bone mineral levels of US adults

This paper describes data on bone mineral levels in the proximal femur of US adults based on the nationally representative sample examined during both phases of the third National Health and Nutrition Examination Survey (NHANES III, 1988-94), and updates data previously presented from phase 1 only. The data were collected from 14,646 men and women aged 20 years and older using dual-energy X-ray absorptiometry, and included bone mineral density (BMD), bone mineral content (BMC) and area of bone scanned in four selected regions of interest (ROI) in the proximal femur: femur neck, trochanter, intertrochanter and total. These variables are provided separately by age and sex for non-Hispanic whites (NHW), non-Hispanic blacks (NHB) and Mexican Americans (MA). NHW in the southern United States had slightly lower BMD levels than NHW in other US regions, but these differences were not sufficiently large to prevent pooling of the data. The updated data provide valuable reference data on femur bone mineral levels of noninstitutionalized adults. The updated data on BMD for the total femur ROI of NHW have been selected as the reference database for femur standardization efforts by the International Committee on Standards in Bone Measurements.

Prevalence of low femoral bone density in older U.S. adults from NHANES III

Most estimates of osteoporosis in older U.S. adults have been based on its occurrence in white women, even though it is known to affect men and minority women. In the present study, we used dual-energy X-ray absorptiometry measurements of femoral bone mineral density (BMD) from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) to estimate the overall scope of the disease in the older U.S. population. Specifically, we estimate prevalences of low femoral BMD in women 50 years and older and explore different approaches for defining low BMD in older men in that age range. Low BMD levels were defined in accordance with an approach proposed by an expert panel of the World Health Organization and used BMD data from 382 non-Hispanic white (NHW) men or 409 NHW women ages 20-29 years from the NHANES III dataset. For women, estimates indicate 13-18%, or 4-6 million, have osteoporosis (i.e., BMD > 2.5 standard deviations [SD] below the mean of young NHW women) and 37-50%, or 13-17 million, have osteopenia (BMD between 1 and 2.5 SD below the mean of young NHW women). For men, these numbers depend on the gender of the reference group used to define cutoff values. When based on male cutoffs, 3-6% (1-2-million) of men have osteoporosis and 28-47% (8-13 million) have osteopenia; when based on female cutoffs, 1-4% (280,000-1 million) have osteoporosis and 15-33% (4-9 million) have osteopenia. Most of the older U.S. adults with low femur BMD are women, but, regardless of which cutoffs are used, the number of men is substantial.

Molecular basis and clinical application of biological markers of bone turnover

An ideal battery of tests would include indices of bone resorption and formation. They should be unique to bone, reflect total skeletal activity, and should correlate with traditional measures of bone remodeling activity, such as radiocalcium kinetics, histomorphometry, or changes in bone mass. Factors that confound their measurement, such as circadian rhythms, diet, age, sex, bone mass, liver function, and kidney clearance rates, should be clearly defined (Fig. 9). To date, no bone marker has been established to meet all these criteria, and each marker may have its own specific advantages and limitations. There are still questions that must be answered before there can be complete confidence in the information gained from measurement of any of the bone markers. Furthermore, it should be emphasized that none of the markers are diagnostic for any particular bone disease and cannot be used for this purpose in individual patients. Nevertheless, recent advances in research and development have provided assays with increased specificity, sensitivity, and availability. Because of this, bone markers can be used for a variety of important purposes: as tools for basic bone biology research, for defining general physiological phenomenon in clinical studies or drug trials, and for following individual patients.

Changing phosphorus content of the U.S. diet: potential for adverse effects on bone

The dietary intake of phosphorus in the United States is high relative to calcium. Intake estimates from the 1989-1991 Continuing Surveys of Food Intakes by Individuals conducted by the U.S. Department of Agriculture show that for both men and women, median calcium intakes do not meet the 1989 Recommended Dietary Allowances (RDAs) for most age groups over 10 y of age, whereas phosphorus intakes exceed the RDAs for most age groups. The use of phosphorus-containing food additives in the processing of foods contributes substantially to the daily phosphorus intake, and their use is increasing. Because much of the phosphorus through food additive use is not reflected in the estimates of phosphorus intakes derived from national food consumption surveys, these estimates underestimate true dietary intakes of phosphorus. High phosphorus intake has been shown to cause secondary hyperparathyroidism and bone loss in several animal models. High phosphorus, low calcium consumption consistent with current observed intake levels resulted in changes in calcium-regulating hormones that were not conducive to optimizing peak bone mass in young women. Evidence that such high phosphorus intakes may impair synthesis of the active metabolite of vitamin D and disrupt calcium homeostasis particularly in older women are discussed.