Document Detail

Lack of awareness among future medical professionals about the risk of consuming hidden phosphate-containing processed food and drinks.
Jump to Full Text
MedLine Citation:
PMID:  22220204     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
Phosphate toxicity is an important determinant of mortality in patients with chronic kidney disease (CKD), particularly those undergoing hemodialysis treatments. CKD patients are advised to take a low phosphate-containing diet, and are additionally prescribed with phosphate-lowering drugs. Since these patients usually seek guidance from their physicians and nurses for their dietary options, we conducted a survey to determine the levels of awareness regarding the high phosphate content in commercially processed food and drinks among medical and nursing students at the Hirosaki University School of Medicine in Japan. For this survey, 190 medical and nursing students (average age 21.7±3 years) were randomly selected, and provided with a list of questions aimed at evaluating their awareness of food and drinks containing artificially added phosphate ingredients. While 98.9% of these students were aware of the presence of sugar in commercially available soda drinks, only 6.9% were aware of the presence of phosphate (phosphoric acid). Similarly, only 11.6% of these students were aware of the presence of phosphate in commercially processed food, such as hamburgers and pizza. Moreover, around two thirds of the surveyed students (67.7%) were unaware of the harmful effects of unrestricted consumption of phosphate-containing food and drinks. About 28% of the surveyed students consume such "fast food" once a week, while 40% drink at least 1∼5 cans of soda drinks/week. After realizing the potential long-term risks of consuming excessive phosphate-containing food and drinks, 40.5% of the survey participants considered reducing their phosphate intake by minimizing the consumption of commercially processed "fast food" items and soda drinks. Moreover, another 48.4% of students showed interest in obtaining more information on the negative health effects of consuming excessive amounts of phosphate. This survey emphasizes the need for educational initiative to raise awareness of the health risks posed by excessive consumption of phosphate additives.
Authors:
Yoshiko Shutto; Michiko Shimada; Maiko Kitajima; Hideaki Yamabe; Mohammed S Razzaque
Related Documents :
16689954 - Behaviourally mediated indirect effects: interference competition increases predation m...
18088174 - Use of multiple den sites by eurasian badgers, meles meles, in a mediterranean habitat.
8865614 - Bayesian analysis of foraging by pigeons (columba livia).
12834804 - Foraging behavior and physiological changes in precocial quail chicks in response to lo...
22118984 - S-shape relationship between customer satisfaction and willingness to pay premium price...
23222444 - Careful cachers and prying pilferers: eurasian jays (garrulus glandarius) limit auditor...
Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural     Date:  2011-12-29
Journal Detail:
Title:  PloS one     Volume:  6     ISSN:  1932-6203     ISO Abbreviation:  PLoS ONE     Publication Date:  2011  
Date Detail:
Created Date:  2012-01-05     Completed Date:  2012-04-25     Revised Date:  2013-06-26    
Medline Journal Info:
Nlm Unique ID:  101285081     Medline TA:  PLoS One     Country:  United States    
Other Details:
Languages:  eng     Pagination:  e29105     Citation Subset:  IM    
Affiliation:
Department of Health Promotion, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Adult
Beverages / adverse effects*
Fast Foods / adverse effects*
Feeding Behavior*
Female
Food Habits
Health Care Surveys
Health Knowledge, Attitudes, Practice*
Humans
Male
Phosphates / adverse effects*
Risk Factors
Students, Medical / statistics & numerical data*
Students, Nursing / statistics & numerical data*
Young Adult
Grant Support
ID/Acronym/Agency:
R01-077276//PHS HHS
Chemical
Reg. No./Substance:
0/Phosphates
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): PLoS One
Journal ID (publisher-id): plos
Journal ID (pmc): plosone
ISSN: 1932-6203
Publisher: Public Library of Science, San Francisco, USA
Article Information
Download PDF
Shutto et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received Day: 30 Month: 8 Year: 2011
Accepted Day: 21 Month: 11 Year: 2011
collection publication date: Year: 2011
Electronic publication date: Day: 29 Month: 12 Year: 2011
Volume: 6 Issue: 12
E-location ID: e29105
ID: 3248402
PubMed Id: 22220204
Publisher Id: PONE-D-11-18391
DOI: 10.1371/journal.pone.0029105

Lack of Awareness among Future Medical Professionals about the Risk of Consuming Hidden Phosphate-Containing Processed Food and Drinks Alternate Title:Awareness on Phosphate-Containing Food
Yoshiko Shutto1
Michiko Shimada2
Maiko Kitajima2
Hideaki Yamabe2
Mohammed S. Razzaque3*
Emmanuel A. Burdmannedit1 Role: Editor
1Department of Health Promotion, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
2Department of Cardiology, Respiratory Medicine and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
3Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, United States of America
University of Sao Paulo Medical School, Brazil
Correspondence: * E-mail: mrazzaque@hms.harvard.edu
Contributed by footnote: Conceived and designed the experiments: YS HY MSR. Performed the experiments: YS MS MK. Analyzed the data: YS MS MK HY. Contributed reagents/materials/analysis tools: YS MS MK HY. Wrote the paper: YS HY MSR.

Introduction

Phosphate is an essential mineral component of the human body, and therefore, its dysregulation can affect the functionality of almost all the organ systems [1], [2], [3], [4], [5], [6], [7], [8], [9]. Phosphate is routinely consumed through food. Both organic and inorganic forms of phosphate are present in regularly consumed foods such as meats, fish, eggs, milk/dairy products, and vegetables. The amount of total phosphate ingestion can be significantly augmented by the consumption of processed food and drinks, as phosphate metabolites are used as additives in these commercially processed food and drinks. In recent years the amount of phosphate intake increased worldwide, especially in countries with a high consumption of processed food. Of particular importance, phosphate, present in the additive is almost entirely absorbed, whereas about 60% is absorbed from naturally available sources.

Recent experimental studies have convincingly demonstrated the risk of increase serum phosphate levels in the development of premature ageing to reno-vascular diseases [8], [9], [10], [11]. Particularly in patients with CKD, hyperphosphatemia is the single most important determinant of mortality [12], [13] perhaps by inducing cardiovascular complications [14], [15], [16]. Since reducing hyperphosphatemia in patients with CKD is one of the main therapeutic priorities, the patients are often advised to consume a low phosphate-containing diet and additionally prescribed with phosphate-lowering drugs. Therefore, healthcare providers, who will be dealing with CKD patients, should be especially aware of the dangers of commercially processed food and drinks, which are often rich in phosphate content.

Developing such awareness is becoming even more important for two main reasons. First, unlike sodium and other food components, phosphate is usually not listed as an ingredient per se, thus making it difficult for patients to avoid phosphate-rich food and drinks. Second, recently, the increased use of phosphate as a preservative has significantly increased in a wide range of drinks and food, complicating the patients' ability to minimize phosphate intake. Healthcare providers including physicians and nurses should provide sufficient guidance and information to their CKD patients to help them reduce their total phosphate intake.

Notably, the number of CKD patients is increasing despite recent progress in biomedical science. In Japan, there are around 13.3 million patients with CKD, while the global prevalence of CKD is estimated to be as high as 500 million [17], [18]. Providing the right guidance by the medical professionals to patients in avoiding phosphate-rich diet could help in decreasing or delaying serious complications of CKD patients with impaired mineral ion metabolism. Therefore, this survey assessed the level of awareness among future medical professionals on artificially added phosphate-containing food and drinks, in a single educational center in Japan.


Materials and Methods

We randomly selected 190 medical (n = 62) and nursing (n = 128) students who are currently enrolled at the Medical and Nursing Schools in Hirosaki City, Japan. The average age of the medical and nursing students was 24.7±4 and 20.1±1 years, respectively. Out of the total 190 students, 65 were male, 123 were female; two students declined to reveal their gender. Both medical and nursing students completed their 12 years of schooling prior entering to the Medical and Nursing Schools. However, in contrast to the four years of Nursing School, the medical students in Japan need to complete six years of education before dealing with the patients. Japanese medical students are taught Renal Physiology in 3rd year, while, Renal Medicine in 4th year of their course; as for nursing students, Renal Physiology is taught in their 1st year and Renal Medicine in 2nd year of their course, although, the content of the syllabus, especially, Renal Medicine is more detailed for the medical students than the nursing students. All our surveyed medical students were 4th year students, while the nursing students ranged from 2nd to 4th years of their course. All students participated voluntarily on the assurance of anonymity, and none refused to answer the survey questions, although students withhold the answer of a particular question when they were not certain of their response. The questionnaire, assessing each student's levels of awareness of phosphate-containing food and drinks, consisted of seven separate questions (Table S1). This survey was conducted during May 2011. In designing the questionnaire, we choose not to examine student's knowledge regarding foods with natural phosphate ingredients; instead, we focused on food and drinks that have phosphate ingredients artificially added as a preservative, such as hamburgers, pizza and soda drinks. Although there are numerous Japanese food items that contain artificially added phosphate ingredients, including commonly consumed instant cup noodles, but to keep this survey simple and uniform, we requested information from the students on hamburgers, pizza or fried chicken, and referred these commonly consumed items as “fast food”. We have clarified the inclusion criteria of “fast food” to the surveyed students beforehand. Study design was approved by the Hirosaki University ethical committee, and all the participants provided informed consent, and participated in this survey voluntarily. The results of the survey were analyzed by Microsoft Excel 2007 and IBM SPSS Statistics 19 software. Mann-Whitney U test was used for comparison between the groups, and p<0.05 was considered as significant.


Results and Discussion

To determine the levels of awareness of future medical professionals regarding the artificially added phosphate-containing food and drinks, we conducted a survey on medical and nursing students currently enrolled at the Medical and Nursing Schools in Hirosaki City, Japan. As patients with CKD are required to maintain a low phosphate-containing diet, healthcare providers should be fully aware of high phosphate-containing “fast food” (hamburgers, pizza or fried chicken) and carbonated soda drinks. Although such awareness is becoming more important, consumers are often uninformed of the phosphate content in such food and drinks or do not truly understand the detrimental effect of a high phosphate-containing diet. Based on this survey, 98.9% of medical and nursing students were aware of the high sugar content in the commercially available soda drinks, while only 6.9% were aware of the presence of phosphate (phosphoric acid) in such drinks. Similarly, only 11.6% of students were aware of the fact that artificially added phosphate, in the form of a preservative, is routinely added in processed food, such as hamburgers and pizza (Figure 1). More importantly, 67.7% were not at all aware of the potential harmful consequences of consuming excessive amounts of phosphate for a prolonged period of time.

Among the surveyed population, 37.9% of students consumed 1∼5 cans of soda drinks per week, while 2.1% consumed 6∼10 cans of soda drinks per week. Similarly, 28% of students consumed some type of “fast food” (hamburgers, pizza, etc.) once a week, while 36% consumed them once a month (Figure 2). We found a clear gender difference in the survey, with a significantly higher proportion of male students consumed soda (p<0.01) and “fast food” (p<0.05); for instance, more than half of the male students consuming 1∼5 cans of soda per week, compared to less than one third of female students. The gender difference found in the consumption of soda drinks and “fast food” is remarkable, given the fact that almost 65% of our surveyed student population is female (Table S2).

Notably, the majority (60%) of students did not consume any soda drinks (Figure 2). One of the reasons for such a high percentage may be the strong preference for green tea in Japan. One study reported a daily consumption of green tea in 86.7% of Japanese adults (40 to 69 years; n = 13,916) [19]. Such consumption of green tea is not confined only to the elderly individuals, as a study conducted on more than 350 junior high school students in Japan, found that around 40% of students took more than 1 cup of green tea per day during winter [20]. Therefore, provisions of such an alternative healthy drink could minimize the consumption of high sugar- and phosphate-containing soda drinks.

In general, the majority (67.7%) of the students in our survey did not appear to appreciate the risk of consuming unrestricted amounts of high phosphate-containing food and drinks (Figure 3). Only 6.9% were aware of the fact that most commercially available soda drinks contain phosphate substrate (phosphoric acid). Phosphate-containing soda drinks can influence functionality of different organ systems, as was first reported more than a century ago [21]. Despite such findings, future medical professionals appear to lack awareness regarding the dangers of artificially added phosphate-containing food and drinks. However, 48.4% of them were eager to obtain phosphate-related information, and 40.5% were willing to consider reducing their artificial phosphate intake by minimizing consumption of processed food and soda drinks (Figure 4).

There was a clear difference in the approach of male versus female students: around 54% of male students wanted to know more phosphate-related information before taking additional measures. In contrast, about 45% female students were willing to reduce their artificially added phosphate intake by minimizing consumption of processed food and soda drinks. Whether such a flexible approach of female individuals in modifying their dietary habits reflects an overall survival advantage is yet unclear. Notably, the average longevity of Japanese female is 86.4 years, compared to their male counterpart at 79.5 years (source: 2009 statistics compiled and published by the Ministry of Health, Labor and Welfare, Japan).

Even though our survey was conducted on a relatively small population of 190 students in a single educational institute with a higher female ratio (65.4%), the results implicate the necessity of educating future medical professionals about dietary items that contain high levels of artificial phosphate ingredients. Informed healthcare providers will be better equipped to guide their CKD patients to make healthier food choices to reduce complications related to abnormal mineral ion metabolism [22], [23], [24], [25]. Finally, instead of placing nutritionists alone with the task of educating patients to make good food choices, physicians, nutritionists and nurses, in a combined effort, should educate and motivate their patients to consume healthier diet for more effective results.

One important unresolved issue is whether unrestricted phosphate consumption is only detrimental for CKD patients, or whether it has long-term consequences in healthy individuals. In a recent National Health and Nutrition Examination Survey, 11% of elderly people over the age of 65 and without any obvious renal diseases had almost 60% reduced renal function, as compared to non-elderly individuals [26]. As the kidney is a major organ involved in phosphate turnover, consuming excessive phosphate is likely to put additional burden on kidneys in the elderly with compromised renal functions [27]. Moreover, normal kidney function is essential to maintain water, electrolyte and mineral ion balance and to eliminate metabolic waste. Kidneys overburdened with excessive and prolonged consumption of phosphate may become impaired leading to effects on their other essential functions. In fact, studies have convincingly shown that providing high phosphate diet to the healthy individuals could markedly increase fractional urinary excretion of phosphate (FEPi) to maintain homeostatic balance. For instance, compared to the 18.6±5 FEPi for the healthy individuals who consumed 1500 g/day of dietary phosphate, a 30.4±10 FEPi was detected in the same individuals when provided with 2300 g/day dietary phosphate, clearly showing additional workloads by the kidneys to maintain phosphate balance following higher consumption of phosphate [28]. In extreme situations, irreversible renal failure may result in the absence of therapeutic intervention, as reported in a 4-year-old chronically constipated girl with normal renal function who was rectally administered hypertonic phosphate solution that resulted in phosphate toxicity (23 mg/dL) with breathing difficulties and a depressed level of consciousness, even without the presence of predisposing risk factors [29].

Finally, the results of the survey highlight two important points: medical and nursing students, future medical professionals, who will soon assume the role of patient management: 1) are insufficiently aware of the risks related to prolonged high amount of phosphate intake and 2) are insufficiently aware of the food and drinks that contain artificially added phosphate ingredients. This survey on future medical professionals exposed the need for an educational initiative to raise awareness of risk posed by dietary items with hidden phosphate ingredients.


Supporting Information Table S1

List of questioner.

(DOC)


Click here for additional data file (pone.0029105.s001.doc)

Table S2

The survey results compiled separately for medical and nursing students.

(DOC)


Click here for additional data file (pone.0029105.s002.doc)


Notes

Competing Interests: The authors have declared that no competing interests exist.

Funding: Funded by NIH grant No. R01-077276. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Thanks are due to Dr. Satoko Osuka (MD), for help in finding the sources of Japanese phosphate-containing food and drinks. We also express our gratitude to Dr. Syed Rafi (PhD) for critically reading the manuscript and offering useful suggestions.


References
1. Razzaque MS. Year: 2011Phosphate toxicity: new insights into an old problem.Clin Sci (Lond)120919720958267
2. Econs MJ. Year: 1999New insights into the pathogenesis of inherited phosphate wasting disorders.Bone2513113510423038
3. Razzaque MS. Year: 2011Osteo-renal regulation of systemic phosphate metabolism.IUBMB Life6324024721438115
4. Snively CS,Gutierrez C. Year: 2004Chronic kidney disease: prevention and treatment of common complications.Am Fam Physician701921192815571058
5. Razzaque MS. Year: 2009The FGF23-Klotho axis: endocrine regulation of phosphate homeostasis.Nat Rev Endocrinol561161919844248
6. Terai K,Nara H,Takakura K,Mizukami K,Sanagi M,et al. Year: 2009Vascular calcification and secondary hyperparathyroidism of severe chronic kidney disease and its relation to serum phosphate and calcium levels.Br J Pharmacol1561267127819302594
7. Razzaque MS. Year: 2009FGF23-mediated regulation of systemic phosphate homeostasis: is Klotho an essential player?Am J Physiol Renal Physiol296F47047619019915
8. Ohnishi M,Razzaque MS. Year: 2010Dietary and genetic evidence for phosphate toxicity accelerating mammalian aging.FASEB J243562357120418498
9. Razzaque MS. Year: 2011The dualistic role of vitamin D in vascular calcifications.Kidney Int7970871420962746
10. Ohnishi M,Nakatani T,Lanske B,Razzaque MS. Year: 2009In vivo genetic evidence for suppressing vascular and soft-tissue calcification through the reduction of serum phosphate levels, even in the presence of high serum calcium and 1,25-dihydroxyvitamin d levels.Circ Cardiovasc Genet258359020031638
11. Ohnishi M,Kato S,Razzaque MS. Year: 2011Genetic induction of phosphate toxicity significantly reduces the survival of hypercholesterolemic obese mice.Biochem Biophys Res Commun doi:10.1016/j.bbrc.2011.1010.1076.
12. Kestenbaum B,Sampson JN,Rudser KD,Patterson DJ,Seliger SL,et al. Year: 2005Serum phosphate levels and mortality risk among people with chronic kidney disease.J Am Soc Nephrol1652052815615819
13. Eddington H,Hoefield R,Sinha S,Chrysochou C,Lane B,et al. Year: 2010Serum phosphate and mortality in patients with chronic kidney disease.Clin J Am Soc Nephrol52251225720688884
14. Kanbay M,Goldsmith D,Akcay A,Covic A. Year: 2009Phosphate - the silent stealthy cardiorenal culprit in all stages of chronic kidney disease: a systematic review.Blood Purif2722023019176951
15. Block G,Port FK. Year: 2003Calcium phosphate metabolism and cardiovascular disease in patients with chronic kidney disease.Semin Dial1614014712641878
16. Hruska K,Mathew S,Lund R,Fang Y,Sugatani T. Year: 2011Cardiovascular risk factors in chronic kidney disease: does phosphate qualify?Kidney Int SupplS91321346719
17. Barsoum RS. Year: 2006Chronic kidney disease in the developing world.N Engl J Med35499799916525136
18. Imai E,Horio M,Watanabe T,Iseki K,Yamagata K,et al. Year: 2009Prevalence of chronic kidney disease in the Japanese general population.Clin Exp Nephrol1362163019513802
19. Tokunaga S,White IR,Frost C,Tanaka K,Kono S,et al. Year: 2002Green Tea Consumption and Serum Lipids and Lipoproteins in a Population of Healthy Workers in Japan.Ann Epidemiol1215716511897173
20. Honda M,Adachi M. Year: 1989Green tea consumption and meals-a case of junior high school in Sakado, Saitama.Jpn J Nutr47241249
21. Haig A. Year: 1889Influence of phosphate of soda on the excretion of uric acid and some of the conditions which prevent its action.Med Chir Trans72399406
22. Molony DA,Stephens BW. Year: 2011Derangements in phosphate metabolism in chronic kidney diseases/endstage renal disease: therapeutic considerations.Adv Chronic Kidney Dis1812013121406297
23. Ahlenstiel T,Pape L,Ehrich JH,Kuhlmann MK. Year: 2010Self-adjustment of phosphate binder dose to meal phosphorus content improves management of hyperphosphataemia in children with chronic kidney disease.Nephrol Dial Transplant253241324920308040
24. Sigrist MK,Chiarelli G,Lim L,Levin A. Year: 2009Early initiation of phosphate lowering dietary therapy in non-dialysis chronic kidney disease: a critical review.J Ren Care35Suppl 1717819222735
25. Ketteler M,Biggar PH. Year: 2009Dietary and pharmacological control of calcium and phosphate metabolism in predialysis stages of chronic kidney disease.Blood Purif2734534919295197
26. Coresh J,Astor BC,Greene T,Eknoyan G,Levey AS. Year: 2003Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey.Am J Kidney Dis4111212500213
27. Razzaque MS. Year: 2007Does renal ageing affect survival?Ageing Res Rev621122217662672
28. Antoniucci DM,Yamashita T,Portale AA. Year: 2006Dietary phosphorus regulates serum fibroblast growth factor-23 concentrations in healthy men.J Clin Endocrinol Metab913144314916735491
29. Marraffa JM,Hui A,Stork CM. Year: 2004Severe hyperphosphatemia and hypocalcemia following the rectal administration of a phosphate-containing Fleet pediatric enema.Pediatr Emerg Care2045345615232246

Figures

[Figure ID: pone-0029105-g001]
doi: 10.1371/journal.pone.0029105.g001.
Figure 1  The survey participants were asked whether they were aware of the sugar and phosphate content in commercially available soda drinks.

The majority (98.9%) of the participants were aware of the presence of sugar, while only 6.9% were aware of the presence of phosphate (phosphoric acid), showing a huge awareness gap related to phosphate among the participants.



[Figure ID: pone-0029105-g002]
doi: 10.1371/journal.pone.0029105.g002.
Figure 2  The participants were asked to describe their soda drink and fast food consumption habits.

The majority (60%) of participants (average age: 22 years) does not consume soda drinks, while 36% do not eat fast food.



[Figure ID: pone-0029105-g003]
doi: 10.1371/journal.pone.0029105.g003.
Figure 3  The survey participants were asked whether they were aware of the possible harmful effects of unrestricted consumption of a high phosphate diet for a prolonged period.

The majority (67.7%) of participants was unaware of such detrimental effects.



[Figure ID: pone-0029105-g004]
doi: 10.1371/journal.pone.0029105.g004.
Figure 4  The survey participants were asked whether they were willing to modify their artificially added phosphate-containing diet.

Around 48% of the participants wanted to have more phosphate-related information, 41% were willing to reduce their artificial phosphate intake by minimizing consumption of processed food and soda drinks, while the remaining (around 11%) showed no further interest related to phosphate.



Article Categories:
  • Research Article
Article Categories:
  • Medicine
    • Clinical Research Design
      • Survey Research
    • Nephrology
      • Chronic Kidney Disease
      • Mineral Metabolism and the Kidney
    • Non-Clinical Medicine
      • Health Care Policy
        • Health Education and Awareness
      • Medical Education
    • Nursing Science
      • Nursing Education
    • Nutrition


Previous Document:  Resveratrol protects rats from A?-induced neurotoxicity by the reduction of iNOS expression and lipi...
Next Document:  Kv4.2 mediates histamine modulation of preoptic neuron activity and body temperature.