Hidden phosphorus in popular beverages

[okarol]

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
Lisa Murphy-Gutekunst

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 ...

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 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.

References

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.

Table 1
Nutritional Analysis of Selected Beverages

                                         Sodium  Potassium  Phosphorus
Product                                    mg       mg          mg

Dr Pepper[R]
  Red Fusion 12 oz.                        55       0.4         32
Hawaiian Punch[R]
  Fruit Juicy 12 oz.                      170       45         173
  Green Berry Rush 12 oz.                 170       44         173
Hires[R]
  Root Beer 12 oz.                         70       0.5         20
  Diet Root Beer 12 oz.                   100       0.2         20
Mountain Dew[R]
  Code Red 12 oz.                         105        0          53
  Amp 12 oz.                               70        9          37
Slice[R]
  Cherry Spice 12 oz.                      35        0          34
  Dr. Slice 12 oz.                         35        0          34
Fruitworks[R]
  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
Aquafina Essentials[R]
  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
Nestea[R]
  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[R]
  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         134

http://findarticles.com/p/articles/mi_m0ICF/is_4_32/ai_n17210656

[Wayne]

Well that sucks....there are at least half a dozen of the drinks on the chart I was drinking b/c I was supposed to stay away from the dark colas...isn't that special?   

[Zach]

Unfortunately, this article does not seem to be on the radar of most renal dietitians.  Shame on them.

[monrein]

Even before dialysis, and my transplant, I didn't drink soda drinks or any of these beverages because of the many additives, high sugar content and basically empty calories.  I think we consume far too many "useless" food products in North America and just because we like them doesn't make them good.  If I'm going to take in phosphorus (inevitable for dialysis patients) it's going to be in foods that give me the added benefit of fiber, high quality protein or other nutrients to provide some counterbalance to the downside of phosphorus. 
As kids we rarely drank pop or sweet drinks at home and when we asked Mum to buy them she always said that when we grew up we could be as foolish as we liked but until then we weren't having pop as a regular drink.  Ironically, she herself lived on coffee and cigarettes.  She also died of Melanoma at 46.

My current favorite drink is low-sodium soda water with a squeeze of fresh lime juice.  Cutting back on sodium is also key for me in controlling fluid intake.

Diet and exercise are the two things only we can control.  Oh yeah, and making sure we take our meds religiously.

[Rerun]

I usually drink just water but I love milk and that is good for the normal person.

[monrein]

I usually drink just water but I love milk and that is good for the normal person.

Absolutely.  My 90 year old mother-in-law has loved milk all her life and still drinks over a litre of skim milk a day.  Her bones are in terrific shape and she has only lost about a half an inch of her height. 

[Zach]

As kids we rarely drank pop or sweet drinks at home and when we asked Mum to buy them she always said that when we grew up we could be as foolish as we liked but until then we weren't having pop as a regular drink.

Not even D & G Kola Champagne?

[monrein]

We liked the Grape Soda and ginger beer but we didn't get it often.  We had a dairy farm that sold milk to an ice cream factory however and the freezer always had masses of ice cream and fudgesicles.  Not exactly low in sugar either.  My Mum wasn't always consistent.

We also weren't allowed to read comic books but could read any "real" books we wanted even ones with explicit sexual content or violence. 

[Wayne]

I usually drink just water but I love milk and that is good for the normal person.

I usually try to drink 2 waters to 1 of whatever else.  But I have to agree with you....there is nothing like a nice big cold glass of milk....yum! 

[flip]

I still drink pretty much what I want to. I drink Sprite instead of Coke and I use the Dairy Delicious milk. My phosphorus is usually on the low side and I don't take binders.

[monrein]

I was able to drink pretty much what I wanted for about a year after starting dialysis the first time and my numbers were good.  Then suddenly I had a high potassium scare and had to start being pretty careful, then stopped peeing almost completely.

I envy you for drinking freely.  I'm kinda nostalgic about it but I really hate carrying too much fluid so I'm careful.

[flip]

I've found it much easier to not watch my fluid intake and pull off a kilo or two during dialysis. The fluid all goes to my belly. I sometimes have to take my belt up a notch after dialysis.

[jbeany]

I'm the opposite - being fluid overloaded drives me buggy, so the less I have to take off, the happier I am.

I never did like pop, even as a kid.  I don't drink it at all, but I do miss giant glasses of milk!

[flip]

most liquors don't mix well with milk

[RichardMEL]

My phos levels have always been pretty good.. very much under control - even more so with Renagel but I've recently been going with the "zero" products (like Sprite Zero) which seem a tad better for me.

One thing the article didn't really hit on, perhaps because it's a bit old, is all these energy drinks like Red Bull and the like.. I bet they are loaded with renal nasties.....

[flip]

I drink Red Bull and my dietition said it was okay.

[BigSky]

I drink Red Bull and my dietition said it was okay.

Not a knock against your dietitian but just because she said it was ok doesnt make it so.

One thing dialysis patients need to be careful of is vitamin toxicity.  Red Bull is overloaded with some vitamins.


http://www.aakp.org/aakp-library/Vitamins-&Supplements/

Vitamins and Supplements for ESRD Patients

By Pam Buchholz, RD, CD

Vitamins are important for your body to properly function. Most people can meet their vitamin needs by eating a balanced diet. Unfortunately, many of the best vitamin sources are restricted or limited by renal diets.

Why are my needs different?

There are several reasons your needs are different as a kidney disease patient, in addition to a restricted diet. You may be eating less due to a lack of appetite or you may not feel like making meals. Medications can interfere with the absorption and use of some vitamins. Also, dialysis can lead to a loss of some vitamins and an accumulation of others.

What should I be taking?

Generally, most dialysis patients should be supplemented with water-soluble vitamins, including Vitamins B and C. However, some patients may need more than the recommended amounts. If you could benefit from larger doses or additional vitamins, your doctor and dietitian will work with you. To view recommended amounts of vitamins and supplements, as well as the roles they play, see the table below.

What’s the difference between a multivitamin and a renal vitamin?

A multivitamin often has vitamins and minerals you don’t need, and not enough of the ones you do need. They generally contain Vitamins A, D, E and K, which may cause problems for dialysis patients. Vitamin A is not removed by dialysis and can build up and lead to anemia, hypertriglyceridemia and elevated calcium levels. Multivitamins contain only an inactive form of Vitamin D, which can no longer be activated by your kidneys. If your doctor determines you could benefit from supplementation with Vitamin D, an active form will be provided to you. Vitamin E may be helpful but has the potential to build up to toxic levels. Vitamin K generally does not need to be supplemented unless you have been on long-term antibiotics and are having problems with prothrombin (a protein in the bloodstream that is important in the clotting process) at times. Consult your doctor if you are receiving coumadin or aspirin and taking Vitamin K. Coumadin and aspirin help “thin” your blood while Vitamin K is involved in blood clotting. Multivitamins also include minerals like calcium and phosphorus that do not need to be present for dialysis patients. Your doctor and dietitian will work with you to determine whether you could benefit from supplementation of Vitamins A, D, E or K.

When should I take the vitamins?

Take vitamins after your treatment since dialysis can remove them from your blood. Taking them after the treatment allows your body to absorb and utilize them before the next treatment.                                                     
Recommendations    Role

Thiamine (B1)

1.5 mg/day
   Helps process food; required for proper functioning of the heart, muscles and nervous system; deficiency signs include weakness, fatigue and nerve damage; needs may be increased in continuous ambulatory peritoneal dialysis (CAPD).

Riboflavin (B2)

1.7 mg/day
   Helps the body process food; deficiency signs include sore throat, mouth and/or lip sores, anemia and skin disorders.

Niacin (B3)

20 mg/day
   Involved with the digestive system, skin and nerves; helps the body process food; deficiency signs include inflamed skin, digestive problems and mental impairment; may be prescribed as a treatment for lipid disorders but only under the supervision of a doctor due to potential toxicity.

Pantothenic Acid (B5)

10 mg/day
   Helps process food; essential for production of hormones and cholesterol.

Pyridoxine (B6)

10 mg/day
   Involved in red blood cell development and immune system; helps maintain normal nerve function; required for protein digestion (the higher the protein intake, the higher the need for this vitamin); deficiency signs include mouth and tongue sores, irritability, confusion and depression.

Cobalamin (B12)

6 mcg/day
   Involved in formation of red blood cells; maintenance of the central nervous system; deficiency signs include anemia and neurological symptoms (numbness, tingling, weakness, loss of balance).

Folic Acid

800-1000 mcg/day
   Helps process and use protein; necessary for production of red blood cells and synthesis of DNA; helps tissue growth and cell function; helps appetite and stimulates formation of digestive acids; doses 5 mg to 30 mg may cause interference of anticonvulsant drugs such as diphenylhydantoin used to treat epilepsy; deficiency signs include tongue inflammation, mouth ulcers, peptic ulcers, diarrhea and anemia.

Biotin

300 mcg/day
   Helps process food; involved in synthesis of hormones and cholesterol; may be an option for treatment of uremic neurological disorders including hiccups and restless leg syndrome.

Vitamin C

60 mg/day
   Antioxidant; needed for growth and repair of tissues, collagen production, wound healing and repair and maintenance of cartilage, bones and teeth; deficiency signs include dry and splitting hair, gingivitis, bleeding gums, dry or scaly skin, slow wound healing, easy bruising, weakened tooth enamel, swollen and painful joints, anemia, and impaired immune system function; larger doses may contribute to oxalate production which can be deposited in soft tissues and bones.

[Zach]

Not a knock against your dietitian but just because she said it was ok doesnt make it so.

One thing dialysis patients need to be careful of is vitamin toxicity.  Red Bull is overloaded with some vitamins.

Excellent point.

[okarol]

Caffeine and Taurine

Energy drinks that promise a short-term boost to energy levels and alertness can contain as much caffeine as 14 cans of pop, which can potentially lead to dangerous health problems such as rapid heart beats, tremors and insomnia, researchers say.

There is also still some concern about the ingredient Taurine and it's benefit. Taurine is a naturally occurring organic acid in the human body; although, it is also present in foods like poultry, fish, and scallops. In addition to being an antioxidant, it is mainly used by the body during physical exertion and stress. In its natural form, taurine is derived from animal tissue, having been first isolated from bull bile, hence the name "Red Bull"; however, the taurine used in the Red Bull drink is produced synthetically.

Drinking one 250 ml can of sugar-free Red Bull increased the “stickiness” of a drinker’s blood, causing a higher risk of blood clots, which can be a precursor to life-threatening strokes, according to a study released last month by the Cardiovascular Research Centre at the Royal Adelaide Hospital in Australia.

In response to the study, the drink’s manufacturer issued a statement, stating that “the study does not show effects which would go beyond that of drinking a cup of coffee. Therefore the reported results were to be expected and lie within the normal physiological range.”

From: http://www.nephinc.com/nutrition-faq.asp

Can I still drink pop? Energy drinks? Alcoholic beverages?

Certain types of pop/soda can be high in phosphorus. All cola (both diet and regular) contains phosphorus and should be limited (1 can per day recommended) and/or avoided. Dr. Pepper/Mr. Pibb and some bottled iced tea also contain some phosphorus and should be treated just like colas. Citrus and other flavored sodas contain very little or no phosphorus and are fine to drink (ie. Root beer, Lemon-lime, Orange, Grape, etc...). Limit wine and/or mixed drinks to no more than one small glass per day. Beer contains phosphorus and should be limited (1 can per day recommended) like colas. All energy drinks (ie. Redbull) and/or sports drinks (ie. Gatorade) should be avoided at all costs due to their added vitamins, minerals, and herbs that dialysis does not remove and will build up in your blood.

[flip]

Red Bull has less caffeine than a cup of coffee. It's also high in sugar, B6, niacin and B12. All I know is that it gives me lots of energy and has raised my hemoglobin to the point that I don't need the epo shots anymore. My dietition studied the ingredients and, based on my situation, said a can per day was perfectly okay. I actually prefer feeling good with good labs.

[kitkatz]

My dietician say stay way from energy drinks at all times.

[monrein]

Mine too.

[flip]

Different strokes for different folks. I know what works for me.

[RichardMEL]

Flip - I don't think anyone is telling you off or anything for doing what you do If it works for you that's great! As I said in another post recently everyone's medical situation is unique and what's valid for one may not be valid for the next person. The thing is that you're monitoring your labs and your own body and everything's going along OK. Personally I am very envious of you that you seem to do OK with virtually no fluid restrictions and still only need to take off a litre or two - I wish I could do that !

The main thing is that you're being monitored by a dietician. Things may change but it seems to be working OK for you and that's the main thing in my book.

I am glad though I brought up the issue of these energy drinks....

[monrein]

It all depends on a person's labs and of course those change over time so the restrictions change over time too.  Residual kidney function makes the difference.