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Phosphorus

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PHOSPHORUS

Phosphorus is an essential mineral that is required by every cell in the body for normal function (1). The majority of the phosphorus in the body is found as phosphate (PO₄). Approximately 85% of the body's phosphorus is found in bone (2).

FUNCTION

Phosphorus is a major structural component of bone in the form of a calcium phosphate salt called hydroxyapatite. Phospholipids (e.g., phosphatidylcholine) are major structural components of cell membranes.  All energy production and storage are dependent on phosphorylated compounds, such as adenosine triphosphate (ATP) and creatine phosphate. Nucleic acids (DNA and RNA), responsible for the storage and transmission of genetic information, are long chains of phosphate-containing molecules. A number of enzymes, hormones, and cell signaling molecules depend on phosphorylation for their activation.  Phosphorus also helps to maintain normal acid-base balance (pH) in its role as one of the body's most important buffers. The phosphorus-containing molecule 2,3-diphosphoglycerate (2,3-DPG) binds to hemoglobin in red blood cells and affects oxygen delivery to the tissues of the body (1).

Nutrient interactions: 

Calcium and vitamin D: Dietary phosphorus is readily absorbed in the small intestine, and any excess phosphorus absorbed is excreted into urine by the kidneys. The regulation of blood calcium and phosphorus levels are interrelated through the actions of parathyroid hormone (PTH) and vitamin D (see Diagram). A slight drop in blood calcium levels (e.g., in the case of inadequate calcium intake) is sensed by the parathyroid glands resulting in their increased secretion of PTH.  PTH stimulates increased conversion of vitamin D to its active form (calcitriol) in the kidneys. Increased calcitriol levels result in increased intestinal absorption of both calcium and phosphorus.  Both PTH and vitamin D stimulate bone resorption, resulting in the release of bone mineral (calcium and phosphate) into the blood.  Though PTH stimulation results in decreased urinary excretion of calcium, it results in increased urinary excretion of phosphorus. The increased urinary excretion of phosphorus is advantageous in bringing blood calcium levels up to normal because high blood levels of phosphate suppress the conversion of vitamin D to its active form in the kidneys (3).
Is high phosphorus intake detrimental to bone health?  Some investigators are concerned about the increasing amounts of phosphates in the diet which can be attributed to phosphoric acid in soft drinks and phosphate additives in a number of commercially prepared foods (4,5). Because phosphorus is not as tightly regulated by the body as calcium, blood phosphate levels can rise slightly with a high phosphorous diet, especially after meals. High blood phosphate levels reduce the formation of the active form of vitamin D (calcitriol) in the kidneys, reduce blood calcium, and lead to increased PTH release by the parathyroid glands.  However, high blood phosphorus levels also lead to decreased urinary calcium excretion (2).  If sustained, elevated PTH levels could have an adverse effect on bone mineral content, but this effect has only been observed in humans on diets that were high in phosphorus and low in calcium.  Moreover, similarly elevated PTH levels have been reported in diets that were low in calcium without being high in phosphorus (6). At present there is no convincing evidence that the dietary phosphorus levels experienced in the U.S. adversely affect bone mineral density in humans.  However, the substitution of phosphate containing soft drinks and snack foods for milk and other calcium rich foods does represent a serious risk to bone health (see Calcium).

Fructose: A recent study of 11 adult men found that a diet high in fructose (20% of total calories) resulted in increased urinary loss of phosphorus and a negative phosphorus balance (i.e., daily loss of phosphorus was higher than daily intake). This effect was more pronounced if the diet was also low in magnesium (7). A potential mechanism for this effect is the lack of feed back inhibition of the conversion of fructose to fructose-1-phosphate in the liver. In other words, increased accumulation of fructose-1-phosphate in the cell does not inhibit the enzyme that phosphorylates fructose, using up large amounts of phosphate. This phenomenon is known as phosphate trapping (1). This finding is relevant because fructose consumption in the U.S. has been increasing rapidly since the introduction of high fructose corn syrup in 1970, while magnesium intake has decreased over the past century (7).

DEFICIENCY

Inadequate phosphorus intake results in abnormally low blood phosphate levels (hypophosphatemia).  The effects of hypophosphatemia may include loss of appetite, anemia, muscle weakness, bone pain, rickets (in children), osteomalacia (in adults), increased susceptibility to infection, numbness and tingling of the extremities, and difficulty walking.  Severe hypophosphatemia may result in death.  Because phosphorus is so widespread in food, dietary phosphorus deficiency is usually seen only in cases of near total starvation. Other individuals at risk of hypophosphatemia include alcoholics, diabetics recovering from an episode of diabetic ketoacidosis, and starving or anorexic patients on refeeding regimens that are high in calories but too low in phosphorus (1,2).

The RDA: The recommended dietary allowance (RDA) for phosphorus was based on the maintenance of normal blood phosphate levels in adults, which was felt to represent adequate phosphorus intake to meet cellular and bone formation needs (2).

Adult men and women ages 19 through 50 years: 700 milligrams (mg) phosphorus/day
Adult men and women ages 51 years and over: 580 mg phosphorus/day

FOOD SOURCES

Phosphorus is found in most foods because it is a critical component of all living organisms.  Dairy products, meat, and fish are particularly rich sources of phosphorus. Phosphorus is also a component of many polyphosphate food additives, and is present in most soft drinks as phosphoric acid. Dietary phosphorus derived from food additives is not calculated in most food databases, so the total amount of phosphorus consumed by the average person in the U.S. is not entirely clear. A large survey of nutrient consumption in the U.S. found the average phosphorus intake in men to be 1,495 mg daily and the average phosphorus intake in women to be 1,024 mg/day. The Food and Nutrition Board estimates phosphorus consumption in the U.S. has increased 10% to 15% over the past 20 years (2).

The phosphorus in all plant seeds (beans, peas, cereals, and nuts) is present in a storage form of phosphate called phytic acid or phytate.  Only about 50% of the phosphorus from phytate is available to humans because we lack enzymes (phytases) that liberate it from phytate (8). Yeasts possess phytases, so whole grains incorporated into leavened breads have more bioavailable phosphorus than whole grains incorporated into breakfast cereals or flat breads (2).  The table below lists a number of phosphorus rich foods along with their phosphorus content in milligrams (mg). For more information on the nutrient content of foods you eat frequently, search the USDA food composition database.

*A 3-ounce serving is about the size of a deck of cards.
^#Phosphorus from nuts, seeds, and grains is about 50% less bioavailable than phosphorus from other sources (8).

SAFETY

Toxicity: The most serious adverse effect of abnormally elevated blood levels of phosphate (hyperphosphatemia) is the calcification of non-skeletal tissues, most commonly the kidneys.  Such calcium phosphate deposition can lead to organ damage, especially kidney damage. Because the kidneys are very efficient at eliminating excess phosphate from the circulation, hyperphosphatemia from dietary causes is a problem mainly in people with severe kidney failure (end-stage renal disease) or hypoparathyroidism.  When kidney function is only 20% of normal, even typical levels of dietary phosphorus may lead to hyperphosphatemia. Pronounced hyperphosphatemia has also occurred due to increased intestinal absorption of phosphate salts taken by mouth, as well as due to colonic absorption of the phosphate salts in enemas (1). In order to avoid the adverse effects of hyperphosphatemia, the Food and Nutrition Board set an upper level (UL) of oral phosphorus intake for generally healthy individuals (2):

Men and women 19 through 70 years: 4.0 grams (4000 milligrams) of phosphorus/day
Men and women over 70 years: 3.0 grams (3000 milligrams) of phosphorus/day

The lower UL for individuals over 70 years of age reflects the increased likelihood of impaired kidney function above age 70. The UL does not apply to individuals with significantly impaired kidney function or other health conditions known to increase the risk of hyperphosphatemia.

Drug Interactions:

Aluminum-containing antacids reduce the absorption of dietary phosphorus by forming aluminum phosphate, which is unabsorbable. When consumed in high doses, aluminum containing antacids can produce abnormally low blood phosphate levels (hypophosphatemia), as well as aggravate phosphate deficiency due to other causes (9). As little as 1 ounce of aluminum hydroxide gel three times a day for several weeks can diminish blood phosphate levels and lead to increased urinary calcium loss (1,10).

Excessively high doses of calcitriol, the active form of vitamin D, or its analogs may result in hyperphosphatemia (see Toxicity) (2).

Potassium supplements or potassium-sparing diuretics taken together with a phosphate may result in high blood levels of potassium (hyperkalemia). Hyperkalemia can be a serious problem, resulting in life threatening heart rhythm abnormalities (arrythmias).  People on such a combination need to be sure their health care provider is aware of it, and have their blood potassium levels checked regularly (9,10). 

THE LINUS PAULING INSTITUTE RECOMMENDATION

The Linus Pauling Institute supports the recommendation by the Food and Nutrition Board of 700 milligrams (mg) phosphorus/day for adults 50 years of age and younger, and 580 mg/day for adults over the age of 50 years.  Though few multivitamin/multimineral supplements contain more than 15% of the current RDA for phosphorus, a varied diet should easily provide adequate phosphorus for most people. 

Older adults (65 years and older): At present there is no evidence that the phosphorus requirements of older adults differ from the RDA for adults over the age of 50 years (580 mg/day). Though few multivitamin/multimineral supplements contain more than 15% of the current RDA for phosphorus, a varied diet should easily provide adequate phosphorus for most people. 

REFERENCES

1.  Knochel, J.P. Phosphorus. In Shils, M. et al. Eds. Nutrition in Health and Disease, 9th Edition. Baltimore: Williams & Wilkins, 1999: pages 157-167.

2.  Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press, 1997: pages 146-189. (National Academy Press)

3.  Bringhurst, F.R. et al. Hormones and disorders of mineral metabolism. In Wilson, J.D. et al Eds. Williams Textbook of Endocrinology, 9th Edition. Philadelphia: W.B. Saunders Company, 1998: pages 1155-1210.

4.  Calvo, M.S. & Park, Y.K. Changing phosphorus content of the U.S. diet: potential for adverse effects on bone. Journal of Nutrition. 1996; volume 126: pages 1168S-1180S.  (PubMed)

5.  Calvo, M.S. Dietary considerations to prevent loss of bone and renal function. Nutrition. 2000; volume 16: pages 564-566.

6. Weaver, C.M. & Heaney, R.P. Calcium. In Shils, M. et al. Eds. Nutrition in Health and Disease, 9th Edition. Baltimore: Williams & Wilkins, 1999: pages 141-155.

7.  Milne, D.B. & Nielsen, F.H. The interaction between dietary fructose and magnesium adversely affects macromineral homeostasis in men. Journal of the American College of Nutrition. 2000; volume 19: pages 31-37.  (PubMed)

8.  National Research Council, Food and Nutrition Board. Recommended Dietary Allowances, 10th Edition. Washington, DC: National Academy Press, 1989: pages 184-187.

9.  Minerals. In Drug Facts and Comparisons. St. Louis, MO: Facts and Comparisons, 2000: pages 27-51.

10.  Silverman, H. et al. The Vitamin Book, 2nd edition. New York: Bantam Books, 1999: pages 255-265.

Reviewed by:
James P. Knochel, M.D.
Department of Internal Medicine
Presbyterian Hospital
University of Texas Southwestern Medical School

Last updated 01/10/2001    Copyright 2001 by The Linus Pauling Institute

Phosphorus

Calcium and phosphorus are important minerals. They maintain good teeth and bones and keep muscles and nerves working properly. Healthy kidneys help control the amount of calcium and phosphorus in the blood. When the kidneys are not working properly, they cannot remove enough phosphorus from the blood. When the calcium and phosphorus are not balanced and within good levels (between 3.5 and 5.5), bone disease can develop.

High phosphorus levels cause blood calcium levels to drop. When phosphorus levels are high a message is sent to the bones (by a hormone) telling them to release calcium and “bind” the phosphorus, that is, remove the phosphorus from the blood. Bones become brittle due to the loss of the calcium.

If high phosphorus levels remain untreated over a period of time, the following things can occur:

· Itching (arms, legs, back, chest)

· Red eyes

· Continuous bone pain: especially hips, knees, ankles and heels

· Bones that break easily

· Blood vessels become clogged with calcium that should be in the bones. This can cause sores that won’t heal, strokes, and heart attacks.

Sometimes the doctor will prescribe a medication called a phosphate binder (Tums, Phoslo, etc.). This medication will stop the phosphorus in your foods from going into your blood. The calcium in the medication, instead of the calcium in your bones, will bind the phosphorus and keep it from being absorbed. The binder should be taken within a half hour of eating, before or after.

HOW CAN YOU PREVENT BONE DISEASE?

1. Restrict the phosphorus in your diet by choosing foods low in phosphorus.
2. Take phosphate binders regularly with each meal to bind phosphorus from your food.
3. Supplement the diet with calcium as instructed by your doctor.

All foods contain phosphorus, but some have more than others.

FOODS HIGH IN PHOSPHORUS INCLUDE:

Protein foods are also high in phosphorus, but it is important for you to get the protein you need so the phosphorus in these foods are included in your daily allowance.

Remember it’s up to you to control your phosphorus intake. You can keep this intake down by switching from cola drinks to other kinds of soft drinks; limit the amount of cheese you eat; try eating cereals with fruit juice (apple, berry, peach) instead of milk.

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