Hidden phosphorus in popular beverages: Part 1

Article Outline

• Phosphorus additives
• What makes this problem unique to the renal community?
• Postscript
• References

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 low-phosphorus protein foods. We continue to encourage our 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…

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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

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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 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 consumed 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!

Table 1. Nutrition Analysis of Selected Beverages

Product	Sodium (mg)	Potassium (mg)	Phosphorus (mg)
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
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
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
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

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.

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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.

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References 

1. Block GS . Control of serum phosphorus (Implication for coronary artery calcification and calcific uremic arteriolopathy (calciphylaxis)) . Curr Opin Nephrol Hypertens . 2001;10:741–747
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2. Calvo MS . Dietary considerations to prevent loss of bone and renal function . Nutrition . 2000;16:564–566
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3. Bell RR , Draper HH , Tzeng DYM , et al.   Physiological responses of human adult to foods containing phosphate additives . J Nutr . 1977;107:45–50
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4. Uribarri J , Calvo MS . Hidden sources of phosphorus in the typical American diet (Does it matter in nephrology?) . Semin Dial . 2003;16:186–188
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