RENAL DIETITIANS have been raging a

Transcription

1 PRODUCT UPDATE Column Editor: Maria Karalis, MBA, RD, LD Hidden Phosphorus in Popular Beverages: Part 1 Lisa Murphy-Gutekunst, MSEd, RD, CSR RENAL DIETITIANS have been raging a war on phosphorus since the nephrology community discovered its harmful effects. Historically, we hoped to protect the patients from renal osteodystrophy associated with chronic hyperphosphatemia. Now, we try to protect them from the systemic effects, such as cardiac calcification, associated with elevated serum phosphorus levels. 1 With the introduction of the National Kidney Foundation s Kidney Disease Outcomes and Quality Initiative Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease, there has been an increased focus on achieving serum calcium, phosphorus, CaxP product, and parathyroid hormone goals. Medications such as sevelamer hydrochloride and calcimimetic agents have helped us to reach our calcium and parathyroid hormone goals, however, hyperphosphatemia continues to be an ongoing problem. To combat the problem of hyperphosphatemia, dietitians have emphasized adherence to phosphate binder prescriptions and maintenance of a low-phosphorus diet. In addition to the standard advice to avoid dairy products and legumes, we also advised patients regarding lowphosphorus protein foods. We continue to encourage our patients to avoid colas and pepper - style beverages and rallied behind root beer, iced From DaVita, Inc, Cleve-Hill Dialysis, Buffalo, NY. Address reprint requests to Lisa Murphy-Gutekunst, MSEd, RD, CSR, DaVita, Inc, Cleve-Hill Dialysis, 1461 Kensington Ave, Buffalo, NY lmurphy@davita.com 2005 by the National Kidney Foundation, Inc /05/ $30.00/0 doi: /j.jrn teas, and other clear beverages. They were considered safe. That is, until now... Phosphorus Additives As Americans continue to demand high-quality convenience food, food-processing practices have stepped up the use of phosphorus additives to ensure the quality and flavor that Americans have come to expect. The most notable products using phosphorus additives are restructured meats (chicken nuggets and hotdogs), processed and spreadable cheeses, instant products (puddings and sauces), refrigerated bakery products, and beverages. 2 In 1990, phosphorus additives contributed an estimated 470 mg of phosphorus per day to the American diet. 2 With the surge in the popularity of these new foods, additives could now contribute up to 1,000 mg of phosphorus per day depending on an individual s food choices. 3 What Makes This Problem Unique to the Renal Community? These phosphorus additives are highly absorbable. In a typical mixed diet of grains, meat, and dairy, only 60% of the dietary phosphorus is absorbed, whereas phosphoric acid and various polyphosphates and pyrophosphates are almost 100% absorbed. 4 Diets higher in these inorganic salts will result in higher phosphorus absorption. Identifying these new higher-phosphorus foods can be challenging. Manufacturers are no longer required to list the phosphorus content on the food label. If the manufacturer does analyze Journal of Renal Nutrition, Vol 15, No 2 (April), 2005: pp e1-e6 e1

2 e2 LISA MURPHY-GUTEKUNST Table 1. Nutrition Analysis of Selected Beverages A&W A&W Cream Soda Diet A&W Cream Soda A&W Root Beer Diet A&W Root Beer Canada Dry Club Soda Collins Mixer Cranberry Ginger Ale Ginger Ale Diet Cranberry Ginger Ale Seltzer 15 0 Tonic Water Diet Tonic Water Crush Orange Diet Rite Diet Rite Cola Diet Rite Black Cherry Diet Rite Kiwi Strawberry Diet Rite Red Raspberry Diet Rite Tangerine Diet Rite White Grape Diet Rite Golden Peach Dr. Pepper Dr. Pepper Diet Dr. Pepper Caffeine-Free Dr. Pepper Caffeine-Free Diet Dr. Pepper Red Fusion Hawaiian Punch Fruit Juicy Green Berry Rush Hire s Root Beer Diet Root Beer RC RC Cola Diet RC Cola RC Cherry Cola RC Caffeine-Free Cola Schweppes Bitter Lemon (10-oz serving) Collins Mixer Club Soda Ginger Ale Diet Ginger Ale Up 7-Up Up Diet Cherry 7-Up Diet Cherry 7-Up Squirt Squirt Diet Squirt Ruby Red Squirt Diet Ruby Red Squirt

3 HIDDEN PHOSPHORUS IN POPULAR BEVERAGES e3 Table 1. Nutrition Analysis of Selected Beverages (Cont d) Sundrop Sundrop Diet Sundrop Cherry Sundrop Caffeine-Free Sundrop Sunkist Orange Diet Orange Vernor s Vernor s Diet Vernor s Welch s Grape Strawberry Fruit Punch Country Time Lemonade Country Time Lemonade Pepsi Pepsi Caffeine-Free Pepsi Pepsi Blue Pepsi One Diet Pepsi Diet Caffeine-Free Pepsi Pepsi Twist Diet Pepsi Twist Pepsi Vanilla Diet Pepsi Vanilla Wild Cherry Wild Cherry Diet Mountain Dew Mountain Dew Diet Mountain Dew Diet Caffeine-Free Mountain Dew Code Red Diet Code Red Diet Caffeine-Free Live Wire Amp Slice Cherry Lime Cherry Spice Diet Orange Dr. Slice Fruit Punch Grape Orange-Bold Taste Peach Pineapple Red Slice Cola Slice Cola Diet Strawberry Mug Root Beer Diet Root Beer Cream Soda Diet Cream Soda

4 e4 LISA MURPHY-GUTEKUNST Table 1. Nutrition Analysis of Selected Beverages (Cont d) Fruitworks Apple Raspberry Fruit Punch Guava Berry Passion Orange Peach Papaya Pink Lemonade Strawberry Melon Tangerine Citrus Tropical Berry Sierra Mist Sierra Mist Diet Sierra Mist Aquafina Essentials Citrus Blend Tangerine Pineapple Watermelon Wild Berry Tropicana Fruit Drinks Fruit Punch Lemonade Pink Lemonade Peach Papaya Strawberry Melon Coca-Cola Coca-Cola Classic Caffeine-Free Classic Diet Coke Caffein-Free Diet Coke Diet Coke with Lime Diet Coke with Lemon Cherry Coke Diet Cherry Coke Vanilla Coke Diet Vanilla Coke TAB Citra 60 3 trace Fresca trace Inca Kola Diet Inca Kola Manzana Mia 62 5 trace Mr. Pibb Pibb Xtra Diet Mr. Pibb Red Flash Sprite Sprite Sprite ReMix Diet Sprite Surge trace Barq s Root Beer 66 trace 0 Floatz Diet Root Beer Red Crème Diet Red Crème French Vanilla Crème Diet French Vanilla Crème 66 trace 0

5 HIDDEN PHOSPHORUS IN POPULAR BEVERAGES e5 Table 1. Nutrition Analysis of Selected Beverages (Cont d) Fanta Apple Berry Grape Lemon 45 trace 0 Orange Pineapple Pink Grapefruit 45 trace 0 Strawberry Minute Maid Black Cherry Blueberry Fruit Punch Grape Grape Medley Fruit Soda Mixed Berry Fruit Soda trace Peach Pineapple Strawberry Valencia Orange Fruit Soda Light Valencia Orange Soda Mello Yello Mello Yello trace Diet Mello Yello trace Mello Yello Cherry trace Mello Yello Melon trace Coca-Cola Ginger Ale Northern Neck Ginger Ale Diet Northern Neck Ginger Ale Carver s Ginger Ale Nestea Diet Lemon 36 na 0 Honey Lemon Green Tea 35 na 0 Lemon Sweet 35 na 0 Raspberry 38 na 0 Sweetened 38 na 32 Decaffeinated Sweetened 36 na 32 Unsweetened 38 na 32 COOL COOL 102 na 134 Diet COOL 107 na 159 Lemonade Tea 102 na 68 Peach Frrreezer 102 na 134 Raspberry Cooler 101 na 134 the product for phosphorus, it is sometimes classified as proprietary information. Often the analysis is not readily accessible to customer service representatives, who must submit the request for information to one or two different departments. Then there is no guarantee that the company can locate the information. Another challenge is the practice of products being affiliated with one company and manufactured, packaged, and distributed by another company. For example, Country Time Lemonade is considered a Kraft-brand food, but some Country Time Lemonade products are manufactured and distributed through Dr. Pepper/7-Up. Finally, each company formulates its products differently, and within each product, the individual delivery packages may be formulated differently. For instance, the ingredients in a bottled iced tea may be different than the same brand of canned iced tea. Table 1 presents the sodium, potassium, and phosphorus content of most commonly con-

6 e6 LISA MURPHY-GUTEKUNST sumed beverages. You may be surprised to see that Hire s root beer contains phosphorus, Diet Coke has less phosphorus than any other diet cola, and a 12-oz can of Nestea Cool iced tea has more phosphorus than 4 oz of milk! As this table indicates, it is important that renal dietitians stay informed and continue to educate CKD patients on the importance of reading labels. In our efforts to keep dietitians informed, the next Product Update (Part 2) will focus on hidden phosphorus in commonly consumed breakfast foods. Postscript More than 10 companies were contacted and asked to provide the nutrition analysis for their beverages. Many were unable to provide such information, and at the time of printing, Campbell s, the parent company of V-8 Splash and Invigorate, was still processing the request. Snapple brand was unable to provide a written nutrition analysis of all of their products. However, they were able to assure us that Snapple products are made from 100% natural products without the addition of phosphorus salts. References 1. Block GS: Control of serum phosphorus: Implication for coronary artery calcification and calcific uremic arteriolopathy (calciphylaxis). Curr Opin Nephrol Hypertens 10: , Calvo MS: Dietary considerations to prevent loss of bone and renal function. Nutrition 16: , Bell RR, Draper HH, Tzeng DYM, et al: Physiological responses of human adult to foods containing phosphate additives. J Nutr 107:45-50, Uribarri J, Calvo MS: Hidden sources of phosphorus in the typical American diet: Does it matter in nephrology? Semin Dial 16: , 2003