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Proposed Changes to the Nutrition Facts Label and the Chronic Kidney Disease Patient

      For individuals with kidney disease, the most challenging part of the treatment may be the renal diet. Although most Americans need to increase their intake of potassium and calcium, patients with kidney disease need to limit these nutrients. In 2009, Hager et al.
      • Hager M.H.
      • Geiger C.
      • Hill L.F.
      • Martin C.
      • Weiner S.
      • Chianchiano D.
      Usefulness of nutrition facts label for persons with chronic kidney disease.
      published results from a survey evaluating the usefulness of nutrition fact label (NFL) in the chronic kidney disease (CKD) population. Eighty-nine percent of the 317 respondents indicated the need to have potassium content available on all food labels, and 24% were not able to correctly interpret the % Daily Value (%DV) for calcium.
      Since the original NFL was introduced in 1994, the public health profile of the U.S. population has changed, and there has been greater understanding between dietary intake and chronic disease. Although the NFL has been an important tool to help consumers make better food choices, the only major change has been the inclusion of trans fats in 2006. The changes being considered for the proposed rules are based on new dietary recommendations, consensus reports, national survey data, and citizen petitions, which include modifications to the required nutrients, updated serving size requirements, and new labeling requirements for certain package sizes as well as a refreshed design (Table 1). Unfortunately, the Food and Drug Administration (FDA) did not make any proposed changes regarding disclosing phosphorus content on the food label. So what will the proposed changes to the NFL mean for the chronic kidney disease patient?
      The prevalence of obesity across the life span has increased over the past 20 years because of consumption of foods that are high in calories. The 2010 Dietary Guidelines for Americans states that increased consumption of added sugar contributes to obesity, diabetes, and other health problems and should be reduced.
      U.S. Department of Agriculture and U.S. Department of Health and Human Services
      Dietary Guidelines for Americans, 2010.
      Therefore, the FDA included placing “added sugars” on the proposed label to help consumers differentiate between naturally occurring sugar and what portion of sugar is being added to the product. The total carbohydrate designation on the label has been replaced by “total carbs,” which includes the added sugar declaration. The proposed NFL will no longer list the total calories provided from fat but will continue to list the amounts of total fat, saturated fat, and trans fats in a food. Current research suggests that the type of fat in the diet is more critical to health than the number of calories associated from fat.
      The original NFL focused on calcium, iron, vitamin A, and vitamin C, which were problem nutrients at the time. Most of the U.S. population currently has adequate intakes of both vitamin A and vitamin C, so labeling of these nutrients will be voluntary. However, recent consensus reports and national survey data indicate that certain population groups were deficient in calcium, iron, vitamin D, and potassium. These nutrients play an important role in the prevention of chronic diseases and will be mandatory on the revised NFL. The FDA also plans to update the %DV for certain nutrients. The %DV helps consumers understand the nutrition information on the product label in the context of the total diet. The %DVs for sodium and calcium are being revised to agree with current Dietary Reference Intakes.
      Institute of Medicine (IOM) of the National Academies
      Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, Chapter 6: Sodium and Chloride.
      Institute of Medicine (IOM) of the National Academies
      Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride.
      The maximum intake for sodium will be lowered from 2400 mg to 2300 mg, and calcium will increase from 1000 mg to 1300 mg. In addition to updating the %DVs, the FDA has decided to convert international units to a metric measure, which would affect the labeling of vitamins A, E, and D. Persons with kidney disease will benefit from the listing of vitamins and minerals in absolute amounts in addition to the %DV on the NFL.
      As outlined in the 1993 final regulations for the NFL, serving sizes must be based on amounts of food and beverages that are being consumed.

      Federal Register. Rules and Regulations. 1993;58(3):2431-2447. http://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/foodadvisorycommittee/ucm248506.pdf. Accessed June 1, 2015.

      The reference amounts customarily consumed, or RACCs was based on food consumption surveys dating back to the 1970s and 1980s. The package size affects how much people eat and drink. The FDA is currently modifying the reference standards used by the food industry to make serving sizes more realistic and reflect what people really eat and drink. In addition, the FDA will require food items containing 150% to 200% of the RACCs previously labeled as more than 1 serving be labeled as a single serving item. For example, a 20-ounce soft drink label would be adjusted to be a single serving size because the product is generally consumed in 1 sitting. Certain food products containing at least 200% of the RACC and ≤400% of the RACC would require dual-column NFL labeling, listing information per serving and per package (Table 2). Packaging containing more than 400% of the RACC would not require dual-column labeling.
      The iconic NFL will remain the same but have a refreshed design with greater emphasis on information important to health. The calorie content and serving sizes will increase in font size, be highlighted, and printed in bold. The %DV will be shifted to the left-hand side of the NFL, and the specific amount of a nutrient would also be listed. This could be helpful to kidney patients requiring lesser amounts of nutrients such as sodium, potassium, and calcium.
      The proposed changes to the NFL were published in the Federal Register, and the comment period has closed. When all comments have been read and considered, the FDA will release a final rule. The compliance date to implement changes to the NFL is 2 years after the effective date of the rule. This time line will allow the food industry ample time to revise labeling to comply with any new labeling requirements.

      References

        • Hager M.H.
        • Geiger C.
        • Hill L.F.
        • Martin C.
        • Weiner S.
        • Chianchiano D.
        Usefulness of nutrition facts label for persons with chronic kidney disease.
        J Ren Nutr. 2009; 19: 204-210
        • U.S. Department of Agriculture and U.S. Department of Health and Human Services
        Dietary Guidelines for Americans, 2010.
        7th ed. U.S. Government Printing Office, Washington DC2010 (http://www.health.gov/DietaryGuidelines/ Accessed June 1, 2015)
        • Institute of Medicine (IOM) of the National Academies
        Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, Chapter 6: Sodium and Chloride.
        National Academies Press, Washington, DC2004 (http://fnic.nal.usda.gov/dietary-guidance/dri-nutrient-reports/water-potassium-sodium-chloride-and-sulfate Accessed June 1, 2015)
        • Institute of Medicine (IOM) of the National Academies
        Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride.
        National Academies Press, Washington, DC1997 (http://www.ncbi.nlm.nih.gov/books/NBK109825/7 Accessed June 1, 2015)
      1. Federal Register. Rules and Regulations. 1993;58(3):2431-2447. http://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/foodadvisorycommittee/ucm248506.pdf. Accessed June 1, 2015.