Stress, income and clothes
We found a significant positive association between the α-Klotho levels after 2 years and the increased household income, possibly related to an increased burden in households with lower income. In a previous study examining psychosocial factors in adults related to α-clotho levels, caregivers with high stress had lower α-clotho levels in serum than patients with low stress . Lower α-clotho levels were also significantly associated with depressive symptoms, a common brain maladaptive response to stress . Other studies have shown that poverty increases stress responses not only in parents  but children  also, both affect physiological  and psychologically  Development from a very young age. Efforts to fight poverty have been suggested in order to improve health outcomes in children . In our LEAD cohort, mothers with higher household incomes may have children who were less exposed to chronic stress and therefore had higher α-Klotho values than children in households with lower incomes and higher stress.
Drinks sweetened with sugar
We found a positive association between SSB intake and higher α-clotho levels, which supports a possible association between secreted α-clotho levels and phosphate in young, low-income children [18, 19]. Children aged 24 months who reported drinking SSBs showed significantly higher α-clotho levels (2029.78 ± 999.45 pg / ml) than those who did not (1402.78 ± 496.28 pg / ml), even when the weight Z-value at birth, leptin, values after two years, insulin at birth, gender of the children, maternal upbringing, and household income were controlled. Our results suggest that food sources of phosphate as a food additive can influence this relationship . Phosphate is commonly used as an additive in sugary beverages sold to children and especially cola , commonly consumed by young children, especially in low-income, higher-risk communities. Fifty-nine percent of our cohort were already consuming SSBs by the age of two.
Phosphorus additives on food labels can be difficult to read, and the amount of phosphorus in sugar-sweetened beverages can range from <1 mg to 175 mg per serving . Even if parents in our study avoided giving their kids carbonated sodas, the drinks they thought were better alternatives contain high amounts of phosphorus per serving: Hawaiian Punch (175 mg), Fruit Works ( 63 mg-140), Aquafina Flavor (62 mg - 85 mg), Tropicana Fruit Punch (93 mg) . Even amounts of around 60 mg per serving serve as significant sources of dietary phosphates. The organic absorption rate of phosphates from meat, dairy products, cereals and beans is 40-60%  while the absorption rate of inorganic phosphates in SSBs, processed meats and cheeses  can be up to 100% .
The physiological regulation of phosphate is controlled by the FGF-23 / α-Klotho mechanism in such a way that an increase in phosphate levels is associated with an increase in both FGF-23s 24 and α-clotho levels [1, 6]. An increase in the phosphate level signals the FGF-23 complex to trigger a cascade that reduces the number of sodium-dependent phosphate (NaPi) cotransporters type 2a (NaPi-2a) on the brush border membrane of the proximal tubules and thereby promotes phosphate excretion in the kidneys . α-Klotho is required for FGF-23 to induce a negative phosphate balance in this mechanism. This has been shown in previous studies where recombinant FGF-23 protein failed to lower serum phosphate levels in Klotho-deficient mice . While α-Klotho is a necessary co-receptor for phosphate regulation α-Klotho also shows effects independent of FGF-23 and parathyroid hormone (PTH), which regulate calcium ion homeostasis in the kidneys . While previous evidence shows that high levels of α-Klotho have beneficial physiological effects  and benefits for knowledge The increase in α-Klotho levels through activation of the FGF-23 phosphate regulatory pathway raises concerns about possible long-term damage.
As significant sources of inorganic phosphates that are easily absorbed, SSBs create an artificial surge in FGF-23. Elevated FGF-23 has been linked to negative health consequences including inflammation  and is an early marker of chronic kidney disease . It is not clear whether the positive effects of increased α-Klotho levels would compensate for the possible harm of chronically increased FGF-23 levels. Our previous study found that insulin at birth was inversely correlated with cord blood α-Klotho levels  There can be a confusing relationship between α-clotho, SSBs, and insulin. The control of insulin in our study strengthened the relationship between α-Klotho and SSBs. Future studies should evaluate FGF-23 in addition to the α-Klotho mirrors.
Any use of SSBs in children may be positively associated with α-clotho levels, confirming previous studies that diets high in phosphate are related to FGF-23 / α-clotho mechanisms [9, 18]. The initial spike in α-Klotho can be an immediate short-term response to controlling phosphate levels  but could have lasting negative effects. High levels of FGF-23 are linked to cardiovascular damage and inflammation . Ingestion in early childhood could be particularly harmful as high dietary phosphates have been shown to be more harmful during critical growth periods .
Eating habits are known to be established early in life, and previous evidence shows that nutritional quality tracks and decreases from early childhood through adolescence . SSB use in early childhood could extend into puberty  especially with increased exposure to advertising  This leads to a lifelong increase in consumption .
Future studies should include additional metabolic and micronutrient serum indicators. We did not rate serum phosphate, FGF-23, or vitamin D levels in our participants. These serum markers would have provided a more complete understanding of the relationship between dietary phosphate intake, including inorganic phosphate from SSBs, α-clotho, and metabolic profile, including vitamin D status . In addition, future studies should consider all dietary sources of phosphate, including those from other foods high in phosphate (e.g. beans, lentils, pasta, and rice), as well as the intake of other sources of inorganic phosphate from fast foods, other processed foods, and canned foods.