Water, Water Everywhere, But What to Drink? An Update on Hidden Phosphorus in Popular Beverages
Article Outline
- Phosphorus Additives in Beverages
- Identifying Phosphate-Containing Beverages and Determining Their Content
- Flavored Waters and Energy Drinks
- References
- Copyright
PRACTITIONERS in the field of chronic kidney disease (CKD) are more aware of the dangers of hidden phosphorus. Articles published in the Journal of Renal Nutrition and other peer-reviewed journals have helped healthcare professionals identify foods containing hidden phosphorus, and provide information on the most common phosphate additives and their uses.1, 2, 3, 4, 5, 6, 7, 8 Awareness of this new and growing danger has stimulated further research into the phosphate-additive content of foods.5, 6, 7, 8, 9 In 2002, the Journal of Renal Nutrition published “Hidden Phosphorus in Popular Beverages,” which focused on the dangers of hidden phosphorus in beverages that were once considered “safe” for CKD patients.1 Since then, more “new and improved” beverages have entered the market, further complicating renal diets and limiting choices for the CKD population. Keeping up with the appropriateness of these beverages for the CKD population is difficult because of the number of new products and the lack of phosphate contents on nutrition labels. This update describes the phosphorus content of popular beverages, and provides information on other popular beverages that contain phosphate additives.
Phosphorus Additives in Beverages
As pointed out in the Journal of Renal Nutrition article of 2002,1 categorizing a line of beverages as “safe” for CKD use is complicated by the fact that formulations change, depending on the packaging of the product. Products packaged in glass usually do not contain phosphate additives. However, the same product packaged in plastic does. In 2002, the reason for this difference was not known.
Further research established that before packaging, some beverages are heated to prevent microbial growth. Glass withstands the heat, but plastic does not. Phosphate additives are used to stabilize beverages and prevent microbial growth.
Moreover, additives are used to keep solids in solution (i.e., beverages containing powders), emulsify products (i.e., nondairy creamers that are a mixture of oil and water), adjust the pH, and enhance flavor.10
Identifying Phosphate-Containing Beverages and Determining Their Content
Healthcare professionals and patients continue to encounter problems identifying phosphorus-containing beverages. Even when one such beverage is identified, determining how much phosphorus is in the beverage can be virtually impossible. Some companies post nutrition information that includes phosphorus content on their websites, whereas others do not. Calling the customer service number listed on the beverage or in the website can lead to a dead end, because many companies do not post the phosphorus information at their call centers. At most, customer service can identify phosphate additives on the ingredient list.
Identifying and contacting parent companies is also cumbersome and, at times, frustrating. During the research this article, the Dr. Pepper/Snapple Company, which manufactures many popular products including Dr. Pepper, Snapple, 7-Up, Canada Dry, Country Time Lemonade, Hawaiian Punch, and many others, did not respond to multiple requests for information, nor could their customer service agents provide much information.
Table 1, Table 2, Table 3 are intended to guide practitioners and patients in tailoring renal diets. Because formulations are known to change, absolute values may also change. Table 1 provides updated values for common beverages. Table 2 include values listed in the 2002 Journal of Renal Nutrition article1 for which no updated values could be found, and Table 3 lists beverages that contain phosphate additives, but for which no absolute values could be found.
Table 1. Updated Information: Nutritional Analysis of Selected Beverages (All Values Are for 12 Ounces)
| Product | Phosphorus (mg) |
|---|---|
| AMP Energy | |
 AMP Energy | 60 |
| AMP Energy Elevate | 30 |
| AMP Energy Lightning | 30 |
| AMP Energy Overdrive | 30 |
| AMP Energy Relaunch | 30 |
| AMP Energy Sugar Free | 60 |
| AMP Energy Traction | 30 |
| AMP Energy Trading Paint | 30 |
| AMP Energy With Black Tea | 207 |
| AMP Energy With Green Tea | 83 |
| Aquafina Flavorsplash | |
| Grape | 128 |
| Lemon | 101 |
| Peach Mango | 123 |
| Raspberry | 93 |
| Strawberry Kiwi | 93 |
| Wild Berry | 93 |
| Barq's | |
| All flavors | 0 |
| Coca-Cola | |
| Coca-Cola Classic | 62 |
| Caffeine Free Classic | 62 |
| Coca-Cola Zero | 54 |
| Diet Coke | 27 |
| Caffein Free Diet Coke | 27 |
| Diet Coke With Splenda | 50 |
| Diet Coke With Lime | 27 |
| Cherry Coke | 56 |
| Diet Cherry Coke | 35 |
| Cherry Coke Zero | 56 |
| Vanilla Coke | 56 |
| Vanilla Coke Zero | 56 |
| Tab | 45 |
| Dansani waters | |
| All flavors | 0 |
| Fanta | |
| Most flavors | 0 |
| Orange | 11 |
| Red Tangerine | 11 |
| Fresca | |
| All flavors | Trace |
| Gatorade & G2 | |
| All flavors | 36 |
| Lipton Brisk Tea | |
| Green | 98 |
| Lemon | 98 |
| Raspberry | 141 |
| Sweet Tea | 189 |
| No Calorie Lemon | 53 |
| Lipton Iced Tea (plastic bottle) | |
| Diet Green Tea With Citrus | 104 |
| Diet Green Tea With Mixed Berry | 98 |
| Diet Iced Tea With Lemon | 104 |
| Diet White Tea With Peach Papaya | 104 |
| Diet White Tea With Raspberry | 104 |
| Green Tea With Citrus | 108 |
| Green Tea With Mixed Berry | 114 |
| Iced Tea With Lemon | 114 |
| White Tea With Raspberry | 114 |
| Lipton Pure Leaf | |
| All flavors | 0 |
| Lipton Sparkling | |
| Berry | 104 |
| Diet Strawberry Kiwi | 98 |
| Strawberry Kiwi | 104 |
| Mello Yello | |
| All flavors | Trace |
| Mountain Dew | |
| Most flavors | 0 |
| Code Red | 53 |
| Mr. Pibb | |
| Pibb Xtra | 44 |
| Pibb Zero | 44 |
| Mug | |
| All flavors | 0 |
| Nestea | |
| Diet Lemon | 54 |
| Green Tea Citrus | 71 |
| Diet Green Tea Citrus | 71 |
| Lemon Sweet | Trace |
| Red Tea Pomegranate Passion | 51 |
| Raspberry | 47 |
| Pepsi | |
| Regular Pepsi | 54 |
| Caffeine Free Pepsi | 54 |
| Pepsi Max | 54 |
| Pepsi Natural | 0 |
| Pepsi One | 65 |
| Pepsi Throwback | 60 |
| Wild Cherry | 54 |
| Diet Pepsi | 41 |
| Diet Caffeine Free Pepsi | 41 |
| Diet Pepsi Lemon | 68 |
| Diet Pepsi Lime | 57 |
| Diet Pepsi Vanilla | 57 |
| Diet Pepsi Wild Cherry | 54 |
| Jazz Black Cherry | 44 |
| Jazz French Vanilla | 44 |
| Jazz Caramel Cream | 44 |
| Propel water | |
| All flavors | 89 |
| Sierra Mist | |
| All flavors | 0 |
| Slice | |
| All flavors | 0 |
| SoBe Lifewater | |
| All flavors | 0 |
| Sprite | |
| All flavors | 0 |
| Tropicana fruit drinks | |
| Fruit Punch | 140 |
| Grape | 63 |
| Lemonade | 53 |
| Orangeade | 65 |
| Pink Lemonade | 53 |
| Strawberry Melon | 140 |
| Light Berry | 107 |
| Light Lemonade | 53 |
| Light Orangeade | 96 |
| Tropicana Twister | |
| All flavors | 0 |
| Vault | |
| All flavors | Trace |
Table 2. Nutritional Analysis of Selected Beverages (All Values Are for 12 Ounces)
| Product | Phosphorus (mg) |
|---|---|
| A&W | |
| A&W Cream Soda | 0.9 |
| Diet A&W Cream Soda | 0.2 |
| A&W Root Beer | 1 |
| Diet A&W Root Beer | 0 |
| Canada Dry | |
| Club Soda | 0.3 |
| Collins Mixer | 4.5 |
| Cranberry Ginger Ale | 0.75 |
| Ginger Ale | 0.15 |
| Diet Cranberry Ginger Ale | 0.75 |
| Seltzer | 0 |
| Tonic Water | 0.6 |
| Diet Tonic Water | 0 |
| Country Time Lemonade | |
| Country Time Lemonade | 0.6 |
| Crush | |
| Orange | 0.75 |
| Diet Rite | |
| Diet Rite Cola | 62 |
| Diet Rite Black Cherry | 0.2 |
| Diet Rite Kiwi Strawberry | 0 |
| Diet Rite Red Raspberry | 0 |
| Diet Rite Tangerine | 0 |
| Diet Rite White Grape | 0 |
| Diet Rite Golden Peach | 0 |
| Dr Pepper | |
| Dr Pepper | 68 |
| Diet Dr Pepper | 66 |
| Caffeine Free Dr. Pepper | 68 |
| Caffeine Free Diet Dr. Pepper | 66 |
| Red Fusion | 48 |
| Hawaiian Punch | |
| Fruit Juicy | 260 |
| Green Berry Rush | 260 |
| Hires | |
| Root Beer | 30 |
| Diet Root Beer | 30 |
| Minute Maid | |
| Most flavors | 0 |
| Grape Medley Fruit Soda | 3 |
| Mixed Berry Fruit Soda | Trace |
| Valencia Orange Fruit Soda | 3 |
| Light Valencia Orange Soda | 3 |
| RC | |
| RC Cola | 52 |
| Diet RC Cola | 31 |
| RC Cherry Cola | 52 |
| RC Caffeine Free Cola | 52 |
| Schweppes | |
| Bitter Lemon (10-ounce serving) | 1 |
| Collins Mixer | 0 |
| Club Soda | 0.4 |
| Ginger Ale | 0.3 |
| Diet Ginger Ale | 0 |
| 7 Up | |
| 7 Up Regular | 0.6 |
| 7 Up Diet | 0.1 |
| Cherry 7 Up | 0.5 |
| Diet Cherry 7 Up | 0 |
| Squirt | |
| Squirt Regular | 0.8 |
| Diet Squirt | 1 |
| Ruby Red Squirt | 1 |
| Diet Ruby Red Squirt | 0.7 |
| Sundrop | |
| Sundrop | 1 |
| Diet Sundrop | 4 |
| Cherry Sundrop | 0.7 |
| Caffeine Free Sundrop | 1 |
| Sunkist | |
| Orange | 0.2 |
| Diet Orange | 0 |
| Vernor's | |
| Vernor's | 0.5 |
| Diet Vernor's | 0 |
| Welch's | |
| Grape | 0.8 |
| Strawberry | 0.6 |
| Fruit Punch | 0.6 |
| Fruitworks | |
| Apple Raspberry | 150 |
| Fruit Punch | 185 |
| Guava Berry | 176 |
| Passion Orange | 185 |
| Peach Papaya | 185 |
| Pink Lemonade | 80 |
| Strawberry Melon | 180 |
| Tangerine Citrus | 135 |
| Tropical Berry | 210 |
Table 3. Beverages Containing Phosphate Salts
| Company | Flavor | Packaging |
|---|---|---|
| Minute Maid | Orangeade | 12 fluid-ounce can |
| 16 fluid-ounce bottle | ||
| 16.9 fluid-ounce bottle | ||
| 20 fluid-ounce bottle | ||
| 2-L bottle | ||
| Light Orangeade | 12 fluid-ounce can | |
| 16.9 fluid-ounce bottle | ||
| Fruit Punch | 10 fluid-ounce bottle | |
| 12 fluid-ounce can | ||
| 16 fluid-ounce bottle | ||
| 20 fluid-ounce bottle | ||
| 2-L bottle | ||
| Kids+ Orange Juice | 200-mL carton | |
| 64 fluid-ounce carton | ||
| 128 fluid-ounce jug | ||
| Orange Tangerine | Frozen can | |
| Original + Calcium | 8 fluid-ounce bottle | |
| Frozen can | ||
| 64 fluid-ounce carton | ||
| 96 fluid-ounce jug | ||
| 128 fluid-ounce jug | ||
| Light Orange Juice Beverage | 64 fluid-ounce carton | |
| Snapple | Diet Peach Green Tea | 20 fluid-ounce bottle (plastic) |
| Pineapple Peach Mango Oolong Tea | 20 fluid-ounce bottle (plastic) | |
| Pomegranate Raspberry Red Tea | 20 fluid-ounce bottle (plastic) | |
| Peach Green Tea | 20 fluid-ounce bottle (plastic) | |
| Rice Dreams | Original Enriched | 64-ounce refrigerated |
| Enriched Vanilla | 64-ounce refrigerated | |
| Enriched Chocolate | 32-ounce shelf-stable | |
| Enriched Original | 32-ounce shelf-stable | |
| Enriched Vanilla | 32-ounce shelf-stable | |
| Heartwise Original | 32-ounce shelf-stable | |
| Heartwise Vanilla | 32-ounce shelf-stable | |
| Supreme Chocolate Chai | 32-ounce shelf-stable | |
| Hazelnut Vanilla | 32-ounce shelf-stable | |
| Soy Dreams | Original Enriched | 64-ounce refrigerated |
| Enriched Vanilla | 64-ounce refrigerated | |
| Almond Dream | Original Enriched | 64-ounce refrigerated |
| Unsweetened Enriched | 64-ounce refrigerated | |
| Oat Dream | Maple Brown Sugar Enriched | 32-ounce shelf-stable |
| Original | 32-ounce shelf-stable | |
| Hemp Dream | Original | 32-ounce shelf-stable |
| Vanilla | 32-ounce shelf-stable | |
| Kidz Dream | Berry Blast Smoothie | 8-ounce shelf-stable |
| Orange Cream Smoothie | 8-ounce shelf-stable | |
| International Delight | All flavors | All packages |
| Coffee Mate | All flavors | Liquid preparations |
| Powder contains <2% by weight of phosphate additive (<0.02 g) | ||
Flavored Waters and Energy Drinks
The fastest growing market in the beverage industry is that of flavored waters and energy drinks. Promising everything from increased energy levels and immunity, to focus (or improved concentration), to weight loss, these beverages are nothing more than water, B-vitamins, caffeine (in some cases), and a mix of the trendiest herbal remedies. Surprisingly, most do not contain phosphate additives. Those that do usually comprise the flavored bottled waters that promise nothing except flavored rehydration.
As we move into the second decade of the 21st century, we should continue to demand that food manufacturers provide us with detailed information so that we can better educate our patients. With their knowledge of food, chemicals, and marketing, the patient's adventure in shopping will continue. For our CKD population, this may be a blessing or a curse. As those who care for the CKD population, we must remain vigilant to the ongoing threat to food choices and phosphate control.
Manufacturer Contact Information
Coca-Cola Company
(Brands: A&W, Barq's, Coca-Cola, Dansani, Fanta, Fresca, Mellow Yellow, Minute Maid, Mr. Pibb, Sprite, and Vault)
Atlanta, GA 30301
Coffee-Mate
Nestle Corportation
Glendale, CA 91205
Dream Products
Hain Celestial Group, Inc.
Boulder, CO 80301
Gatorade Company
Chicago, IL 60604
International Delight
White Wave Foods
Broomfield, CO 80021
Pepsi-Co
(Brands: Aquafina, Lipton, Mountain Dew, Mug, Propel, Sierra Mist, Slice, SoBe, and Tropicana)
Purchase, NY 10577
Snapple
Dr. Pepper/Snapple Group, Inc.
Plano, TX 75024
References
- . Hidden phosphorus in popular beverages. J Ren Nutr. 2005;15(2):e1–e6
- . Hidden phosphorus at breakfast—Part 2. J Ren Nutr. 2005;15(3):e1–e4
- . Hidden phosphorus: Enhanced meat—Part 3. J Ren Nutr. 2005;15(4):e1–e4
- . Hidden phosphorus—Where do we go from here?. J Ren Nutr. 2007;17(4):e31–e36
- . Phosphorus-containing food additives and the accuracy of nutrient databases: Implications for renal patients. J Ren Nutr. 2007;17:350–354
- . Fast food, phosphorus-containing additives and the renal diet. J Ren Nutr. 2008;18:466–470
- . Dietary phosphorus restriction in dialysis patients: Potential impact of processed meat, poultry, and fish products as protein sources. Am J Kidney Dis. 2009;54:18–23
- Effect of food additives on hyperphosphatemia among patients with end-stage renal disease. JAMA. 2009;301:629–635
- . Phosphorus and potassium content of enhanced meat and poultry products: Implications for patients who receive dialysis. Clin J Am Soc Nephrol. 2009;4:1370–1373
- ICL Performance Products, LP: www.icl-perfproductslp.com. Accessed July 2009.
PII: S1051-2276(09)00292-1
doi:10.1053/j.jrn.2009.11.001
© 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved.
