This article is from 2005 but I had never read it so hopefully the info is still accurate.Hidden phosphorus in popular beverages
Nephrology Nursing Journal, July-August, 2005
The renal health care team has been struggling to control serum phosphorus in patients with chronic kidney disease (CKD) since the potential harmful effects of hyperphosphatemia became apparent. Through a National Institutes of Health MedLine literature search, articles linking elevated serum phosphorus levels and secondary parathyroidism appear as early as 1966, and links between "persistently high (over 60) calcium phosphorus product" and cardiac calcification as early as 1975 (Arora, Lacy, Schacht, Martin & Gutch, 1975, p. 4). By 1975, there was enough evidence between phosphorus levels and renal osteodystrophy for the American Dietetic Association to issue its recommendation of restricting phosphorus intake in this population in hopes that "the bone lesions of secondary hyperparathyroidism and osteomalacia may be minimized and even prevented" (Schoolwerth & Engle 1975, abstract). Today, there is further evidence (Block, 2004, Kestenbaum et al. 2004) to link altered mineral metabolism with cardiac calcification and death.
In 2003, the National Kidney Foundation released the K/DOOI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. The guidelines established targets for optimal calcium, phosphorus, calcium phosphorus product, and intact parathyroid levels. They also emphasized the need to meet these goals in order to minimize the CKD's risk of morbidity and mortality.
Medications such as sevelamer HCl and cinacalet HCl have helped patients reach calcium and PTH target however, hyperphosphatemia continues to be an ongoing problem.
To maintain dialysis normal serum phosphorus levels, patient education has emphasized adherence with phosphate binder prescription and maintenance of a low phosphorus diet. In addition to the standard advice to avoid dairy products and legumes, education also focused on lower phosphorus protein foods. Nurses and dietitians continued to encourage patients to avoid colas and "pepper" style beverages and rallied behind root beer, iced teas, and other "clear" beverages. They were considered safe. That is, until now ...
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 American's have come to expect. In a recent article, Uribarri & Calvo (2003) report 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.
Furthermore, Calvo (2000) states that in 1990, phosphorus additives contributed to an estimated 470 mg/day to the American diet, and with the insurgence of the new foods, additives could now contribute up to 1000 rag/day depending upon an individual's food choices.
What Makes This Problem Unique to the Renal Community?
What makes this problem unique to the renal community is that 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 (Bell, Draper, Tzeng, Shin, & Schmidt 1977). Diets higher in these inorganic salts will result in higher phosphorus absorption.
Trying to identify these new, higher phosphorus foods can be challenging. Manufacturers are no longer required to list the phosphorus content on the food label. As a result, if the company does analyze the product for phosphorus, it is sometimes classified as "proprietary" information or buried so deep and so far away that customer service representatives have to turn the request for information over to one or two different departments. Even 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[R] is considered a Kraft[R]-brand food, but some Country Time Lemonade[R] products are manufactured and distributed through Dr. Pepper/7-Up[R]. Finally, each company formulates its products differently, and within each product, the individual delivery packages may be formulated differently. For example, the ingredients in a bottled iced tea may be different than that of the same brand of canned iced tea.
Table 1 presents the phosphorus content of some commonly consumed beverages. You may be surprised to see that Hire's[R] root beer contains phosphorus, that Diet Coke[R] has less phosphorus than any other diet cola, and that a 12-ounce can of Nestea Cool[R] iced tea has more phosphorus than 4 ounces of milk!
As this table indicates, it is important that we continue to educate patients on dialysis on the importance of reading labels and sharing the "safe" brands they find, and to notify us of "unsafe" brands.
The Issues in Renal Nutrition in Nephrology Nursing department is designed to focus on nutritional issues for nephrology patients. Address correspondence to: Deborah Brommage, Department Editor, Nephrology Nursing Journal; East Holly Avenue/Box 56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.
Arora, K.K., & Lacy, J.P.(1975). Calcific cardiomyopathy in advanced renal disease. Archives of Internal Medicine, 135, 603-605.
Bell R.R., Draper H.H., Tzeng D.Y.M., Shin H.K., & Schmidt G.R. (1977). Physiological responses of human adult to foods containing phosphate additives. Journal of Nutrition, 107, 45-50.
Block, G.S. (2004). Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. Journal of the American Society of Nephrology, 15, 2208-2218.
Calvo M.S. (2000). Dietary considerations to prevent loss of bone and renal function. Nutrition, 16, 564-566.
Kestenbaum, B., et a1.(2004) Serum phosphate level and mortality risk among people with chronic kidney disease. Journal of the American Society of Nephrology, 16, 520-528.
National Kidney Foundation. (2003). NKF K/DOQI: Clinical practice guidelines for bone metabolism and disease in chronic kidney disease. American Journal of Kidney Diseases, 42, Supplement 3.
Parfitt, A.M. (1969). Soft-tissue calcification in uremia. Archives of Internal Medicine, 124, 544-556.
Schoolwerth A.C., & Engle, J.E.(1975) Calcium and phosphorus in diet therapy of uremia. Journal of the American Dietetic Association, 66, 460-464.
Stanbury, S.W., & Lumb G.A. (1966). Parathyroid function in chronic renal failure. A statistical survey of the plasma biochemistry in azotaemic renal osteodystrophy. Quarterly Journal of Medicine, 35, 1-23.
Uribarri J., & Calvo M.S. (2003) Hidden sources of phosphorus in the typical American diet: Does it matter in nephrology? Seminars in Dialysis, 16, 186-188.
Nutritional Analysis of Selected Beverages
Sodium Potassium Phosphorus
Product mg mg mg
Red Fusion 12 oz. 55 0.4 32
Fruit Juicy 12 oz. 170 45 173
Green Berry Rush 12 oz. 170 44 173
Root Beer 12 oz. 70 0.5 20
Diet Root Beer 12 oz. 100 0.2 20
Code Red 12 oz. 105 0 53
Amp 12 oz. 70 9 37
Cherry Spice 12 oz. 35 0 34
Dr. Slice 12 oz. 35 0 34
Apple Raspberry 12 oz. 110 35 100
Fruit Punch 12 oz. 80 60 123
Guava Berry 12 oz. 80 56 117
Passion Orange 12 oz. 110 60 123
Peach Papaya 12 oz. 110 60 123
Pink Lemonade 12 oz. 80 80 53
Strawberry Melon 12 oz. 110 110 120
Tangerine Citrus 12 oz. 80 35 90
Tropical Berry 12 oz. 80 60 140
Tangerine Pineapple 12 oz. 20 0 49
Tropicana Fruit Drinks[R]
Fruit Punch 12 oz. 50 90 93
Lemonade 12 oz. 60 40 38
Pink Lemonade 12 oz. 60 39 37
Peach Papaya 12 oz. 50 41 93
Strawberry Melon 12 oz. 50 76 93
Mello Yello Melon 12 oz. 45 30 trace
Coca-Cola Ginger Ale[R]
Northern Neck Ginger Ale 12 oz. 33 23 0
Diet Northern Neck Ginger Ale 12 oz. 36 20 0
Carver's Ginger Ale 12 oz. 33 23 0
Diet Lemon 12 oz. 36 na 0
Honey Lemon Green Tea 12 oz. 35 na 0
Lemon Sweet 12 oz. 35 na 0
Raspberry 12 oz. 38 na 0
Sweetened 12 oz. 38 na 32
Decaffeinated Sweetened 12 oz. 36 na 32
Unsweetened 12 oz. 38 na 32
COOL 12 oz. 102 na 134
Diet COOL 12 oz. 107 na 159
Lemonade Tea 12 oz. 102 na 68
Peach Frrreezer 12 oz. 102 na 134
Raspberry Cooler 12 oz. 101 na 134http://findarticles.com/p/articles/mi_m0ICF/is_4_32/ai_n17210656