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 14215. Email: lmurphy@davita.com 2005 by the National Kidney Foundation, Inc. 1532-8503/05/1502-0016$30.00/0 doi:10.1016/j.jrn.2004.12.001 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
e2 LISA MURPHY-GUTEKUNST Table 1. Nutrition Analysis of Selected Beverages A&W A&W Cream Soda 45 0.6 0.6 Diet A&W Cream Soda 70 0.4 0.1 A&W Root Beer 45 0.5 0.7 Diet A&W Root Beer 70 0.2 0 Canada Dry Club Soda 90 0.2 0.2 Collins Mixer 28 54 3 Cranberry Ginger Ale 28 0.4 0.5 Ginger Ale 75 0.2 0.1 Diet Cranberry Ginger Ale 40 0.3 0.5 Seltzer 15 0 Tonic Water 25 0.3 0.4 Diet Tonic Water 50 0.1 0 Crush Orange 45 0.5 0.5 Diet Rite Diet Rite Cola 0 17 41 Diet Rite Black Cherry 0 56 0.1 Diet Rite Kiwi Strawberry 0 19 0 Diet Rite Red Raspberry 0 44 0 Diet Rite Tangerine 0 32 0 Diet Rite White Grape 0 17 0 Diet Rite Golden Peach 0 47 0 Dr. Pepper Dr. Pepper 55 0.4 45 Diet Dr. Pepper 55 0.1 44 Caffeine-Free Dr. Pepper 55 0.4 45 Caffeine-Free Diet Dr. Pepper 55 0.1 44 Red Fusion 55 0.4 32 Hawaiian Punch Fruit Juicy 170 45 173 Green Berry Rush 170 44 173 Hire s Root Beer 70 0.5 20 Diet Root Beer 100 0.2 20 RC RC Cola 50 0.4 52 Diet RC Cola 45 45 31 RC Cherry Cola 50 0.6 52 RC Caffeine-Free Cola 45 0.5 52 Schweppes Bitter Lemon (10-oz serving) 55 12 1 Collins Mixer 25 0.2 0 Club Soda 105 0.5 0.4 Ginger Ale 40 0.3 0.3 Diet Ginger Ale 90 0.1 0 7-Up 7-Up 75 0.6 0.6 7-Up Diet 45 77 0.1 Cherry 7-Up 40 30 0.5 Diet Cherry 7-Up 45 44 0 Squirt Squirt 25 5 0.8 Diet Squirt 25 12 1 Ruby Red Squirt 25 7 1 Diet Ruby Red Squirt 30 7 0.7
HIDDEN PHOSPHORUS IN POPULAR BEVERAGES e3 Table 1. Nutrition Analysis of Selected Beverages (Cont d) Sundrop Sundrop 30 7 1 Diet Sundrop 100 51 4 Cherry Sundrop 30 7 0.7 Caffeine-Free Sundrop 30 7 1 Sunkist Orange 45 0.2 0.2 Diet Orange 100 0.1 0 Vernor s Vernor s 25 0.3 0.5 Diet Vernor s 15 0.1 0 Welch s Grape 55 3 0.8 Strawberry 45 0.5 0.6 Fruit Punch 45 0.5 0.6 Country Time Lemonade Country Time Lemonade 105 10 0.4 Pepsi Pepsi 35 0 53 Caffeine-Free Pepsi 35 10 53 Pepsi Blue 35 62 33 Pepsi One 45 30 55 Diet Pepsi 35 30 41 Diet Caffeine-Free Pepsi 35 30 41 Pepsi Twist 40 79 54 Diet Pepsi Twist 40 46 41 Pepsi Vanilla 40 0 43 Diet Pepsi Vanilla 40 0 43 Wild Cherry 35 0 53 Wild Cherry Diet 40 56 53 Mountain Dew Mountain Dew 70 0 0.3 Diet Mountain Dew 35 70 0.3 Diet Caffeine-Free Mountain Dew 70 0 0.3 Code Red 105 0 53 Diet Code Red 40 72 0 Diet Caffeine-Free 35 70 0.3 Live Wire 65 0 0 Amp 70 9 37 Slice Cherry Lime 50 0 0 Cherry Spice 35 0 34 Diet Orange 50 90 0 Dr. Slice 35 0 34 Fruit Punch 55 0 0 Grape 70 0 0 Orange-Bold Taste 50 105 0 Peach 65 50 0 Pineapple 70 0 0 Red 55 0 0 Slice Cola 35 0 51 Slice Cola Diet 35 0 41 Strawberry 55 0 0 Mug Root Beer 65 0 0 Diet Root Beer 70 0 0 Cream Soda 65 0 0 Diet Cream Soda 80 0 0
e4 LISA MURPHY-GUTEKUNST Table 1. Nutrition Analysis of Selected Beverages (Cont d) Fruitworks Apple Raspberry 110 35 100 Fruit Punch 80 60 123 Guava Berry 80 56 117 Passion Orange 110 60 123 Peach Papaya 110 60 123 Pink Lemonade 80 80 53 Strawberry Melon 110 110 120 Tangerine Citrus 80 35 90 Tropical Berry 80 60 140 Sierra Mist Sierra Mist 35 48 0 Diet Sierra Mist 35 99 0 Aquafina Essentials Citrus Blend 50 0 0 Tangerine Pineapple 20 0 49 Watermelon 20 0 0 Wild Berry 40 0 0 Tropicana Fruit Drinks Fruit Punch 50 90 93 Lemonade 60 40 38 Pink Lemonade 60 39 37 Peach Papaya 50 41 93 Strawberry Melon 50 76 93 Coca-Cola Coca-Cola Classic 50 0 62 Caffeine-Free Classic 50 0 62 Diet Coke 42 18 27 Caffein-Free Diet Coke 42 18 27 Diet Coke with Lime 42 29 27 Diet Coke with Lemon 42 29 27 Cherry Coke 42 0 56 Diet Cherry Coke 42 18 35 Vanilla Coke 38 0 56 Diet Vanilla Coke 42 29 27 TAB 42 18 45 Citra 60 3 trace Fresca 36 84 trace Inca Kola 47 0 0 Diet Inca Kola 51 11 0 Manzana Mia 62 5 trace Mr. Pibb Pibb Xtra 42 21 44 Diet Mr. Pibb 39 30 44 Red Flash 32 18 0 Sprite Sprite 71 0 0 Sprite ReMix 54 0 0 Diet Sprite 36 110 0 Surge 41 53 trace Barq s Root Beer 66 trace 0 Floatz 66 3 0 Diet Root Beer 72 14 0 Red Crème 65 0 0 Diet Red Crème 65 0 0 French Vanilla Crème 66 0 0 Diet French Vanilla Crème 66 trace 0
HIDDEN PHOSPHORUS IN POPULAR BEVERAGES e5 Table 1. Nutrition Analysis of Selected Beverages (Cont d) Fanta Apple 59 0 0 Berry 33 51 0.2 Grape 45 0 0 Lemon 45 trace 0 Orange 53 0 11 Pineapple 53 0 0 Pink Grapefruit 45 trace 0 Strawberry 45 0 0 Minute Maid Black Cherry 53 0 0 Blueberry 50 0 0 Fruit Punch 51 20 0 Grape 68 78 0 Grape Medley Fruit Soda 32 63 2 Mixed Berry Fruit Soda 32 59 trace Peach 50 0 0 Pineapple 47 0 0 Strawberry 50 0 0 Valencia Orange Fruit Soda 33 71 2 Light Valencia Orange Soda 36 89 2 Mello Yello Mello Yello 50 30 trace Diet Mello Yello 38 77 trace Mello Yello Cherry 45 30 trace Mello Yello Melon 45 30 trace Coca-Cola Ginger Ale Northern Neck Ginger Ale 33 23 0 Diet Northern Neck Ginger Ale 36 20 0 Carver s Ginger Ale 33 23 0 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-
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 10:741-747, 2001 2. Calvo MS: Dietary considerations to prevent loss of bone and renal function. Nutrition 16:564-566, 2000 3. Bell RR, Draper HH, Tzeng DYM, et al: Physiological responses of human adult to foods containing phosphate additives. J Nutr 107:45-50, 1977 4. Uribarri J, Calvo MS: Hidden sources of phosphorus in the typical American diet: Does it matter in nephrology? Semin Dial 16:186-188, 2003