Alternative Milk Beverages

Article Outline

• Acknowledgments
• References
• Copyright

THE INCREASED VARIETY and selection of alternative milk beverages have left many nephrology dietitians questioning the appropriateness of these products for patients with chronic kidney disease (CKD) patients. Most nephrology dietitians encourage CKD patients to limit their intake of cow's milk due to the high phosphorus and potassium contents. Eight ounces of cow's milk contains approximately 230 mg phosphorus and 365 mg potassium.¹ It is generally recommended that CKD patients limit milk intake to one half cup per day. In the past, nondairy creamer has been suggested as an alternative to milk. Nondairy creamer contains 154 mg phosphorus and 458 mg potassium per 8-ounce serving.¹ Some dietitians may also recommend soy and/or rice milk as an alternative to cow's milk for those following a prescribed renal diet. Although soy and rice milk have been on the market for many years, they have recently gained popularity and have become more widely available. A wide variety of other alternative milk beverages have also recently emerged in the market, including nut, oat, and hemp milk beverages. This product update discusses the appropriateness of these products for the CKD population. Table 1 provides the nutritional information for alternative milk beverage products found at major grocery retailers across the country (Trader Joe's, Whole Foods, Safeway stores, and Supervalu stores).

Table 1. Alternative Milk Beverages

As early as 1933, scientists were studying the phosphorus content of milk.² It is known that milk contains calcium, magnesium, sodium, potassium, citrate, chloride, and inorganic phosphate.³ Many dialysis patients were raised drinking milk and told it was “good for their bones.” Ironically, once they experience kidney failure, the opposite is true. Between 30% and 60% of the phosphorus content in milk is absorbed in the intestines and is linearly related to the overall phosphorus intake over a wide range of 4 to 30 mg/kg/day.⁴ Phosphate is a well-known uremic toxin, which is known to contribute to hyperparathyroidism, vitamin D metabolism, and hypocalcemia in dialysis patients.⁵ Uncontrolled hyperphosphatemia leads to metabolic disturbances of the bone and altered mineral metabolism. This results in more complications and long-term damage to the parathyroid glands, bones, and cardiovascular system. Serum phosphorus levels greater than 5.0 mg/dl are an independent risk factor for mortality in hemodialysis patients. It has been studied that the relative risk of death with a phosphorus level between 5.0 mg/dl and 6.0 mg/dl is 1.07, and the risk increases to 2.02 with a phosphorus level of greater than 9.0 mg/dl.⁶

Hyperphosphatemia may result for a variety of reasons. Some reasons may include excess dietary phosphorus intake, either by naturally occurring or added sources of phosphorus in food and beverage products, and increased intestinal absorption of phosphorus, sometimes caused by the inappropriate use of vitamin D therapies or the inadequate use of phosphorus binders. Other causes of hyperphosphatemia in dialysis patients include inadequate dialysis removal of phosphorus and the release of phosphorus from the bone and tissue.⁷ Each dialysis treatment removes approximately 250 to 1000 mg of the phosphorus.⁸ In addition to dialysis, the other options for the management of phosphorus in dialysis patients are dietary modification, phosphate binder medications, and vitamin D analogs.

Dietary modification is one of the primary methods used to prevent and treat hyperphosphatemia. The average American diet is high in phosphorus. According to recent data from the U.S. Department of Agriculture, the average daily dietary intake of phosphorus is 1600 mg for adult males and 1148 mg for adult women.⁹ The KDOQI Clinical Guidelines recommend a modification of 800 to 1000 mg of phosphorus per day.¹⁰ The foods that are highest in naturally occurring phosphorus include dairy products, meats, nuts, and beans. The greatest challenge for patients and dietitians alike is phosphate additives, which are being used more frequently in the processing and manufacturing of foods. It is especially challenging since the phosphorus content is not listed on the Nutrition Facts Label because phosphorus labeling is not required and regulated by the Food and Drug Administration.¹¹

In the past, alternative milk beverages were most commonly found in health food stores; they are now more readily available in supermarkets across the country. The products analyzed in this product update are most likely available in both urban and rural areas. The one exception would be the Dairy Delicious 2% Milk Beverage, which is only available for purchase directly from the manufacturer. It should be noted, however, that individuals in lower socioeconomic groups may have limited access to these products due to the typically higher cost for alternative milk beverages compared with cow's milk. Additionally, while these products may be available at major grocery store chains, they are typically not available from neighborhood convenience stores.⁷

Some of the companies we contacted were unable to provide us with the nutrition information we requested. Either the information was not available for their products or it was unavailable on the company website. Dietitians and CKD patients should continue to request phosphorus and potassium information from food manufacturers to encourage these companies to review and expand their food labeling practices.

Although there are more choices now available, many of the alternative milk beverages analyzed for this article may not be appropriate for CKD patients. Many of these products are fortified and enriched, often making them higher in phosphorus, potassium, sodium, and calcium compared to cow's milk. Like other foods and beverages, the mineral content varied widely from brand to brand. For example, 365 Organic Soymilk Original contains 560 mg of potassium and 80 mg of phosphorus, while Vitasoy Lite Plus Plain Soy Beverage contains 180 mg of potassium and 185 mg of phosphorus. We found nominal, if any, differences between the shelf-stable and refrigerated versions of products within each brand.

Based on the information currently available, it appears that Blue Diamond's Almond Breeze beverages may be the best alternative to cow's milk for CKD patients trying to limit phosphorus, potassium, sodium, and calcium intake. The unsweetened varieties do not contain sugar, which may also make them a good choice for diabetic patients. It must again be emphasized that nephrology dietitians need to provide very specific information (i.e., brand, flavor, exact name of product) for those patients interested in using these products as a substitute for cow's milk, since the nutrient content of alternative milk beverages varies widely from brand to brand. CKD patients may be able to take advantage of this emerging market if they work closely with their nephrology dietitian to select appropriate beverages based on their individual and prescribed nutrition needs.

Back to Article Outline

Acknowledgments 

The authors would like to gratefully acknowledge additional assistance provided for this product update from Aimee Zajc, RD, LDN.

Back to Article Outline

References 

1. U.S. Department of Agriculture: What's In The Foods You Eat Search Tool, 3.0. Nov 1, 2008; http://www.ars.usda.gov/Services/docs.htm?docid=17032
   • View In Article
2. Lampitt LH, Bushill JH. The dialysis of milk. Biochem J. 1933;27(3):711–722
   • View In Article
   • MEDLINE
3. Gaucheron F. The minerals of milk. Reprod Nutr Dev. 2005;45(4):473–483
   • View In Article
   • CrossRef
4. Urbarri J, Calvo MS. Hidden sources of phosphorus in the typical American diet: does it matter in nephrology?. Semin Dialy. 2003;16(3):186–188
   • View In Article
5. Burke SK. Phosphate is a uremic toxin. J Ren Nutr. 2008;18(1):27–32
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (115 KB)
   • CrossRef
6. Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 2004;15(8):2208–2218
   • View In Article
   • MEDLINE
   • CrossRef
7. Sehgal AR, Sullivan C, Leon JB, Bialostosky K. Public health approach to addressing hyperphosphatemia among dialysis patients. J Ren Nutr. 2008;18(3):256–261
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (122 KB)
   • CrossRef
8. DeSoi C, Umanans JG. Does the dialysis prescription influence phosphate removal?. Semin Dial. 2003;8(4):201–203
   • View In Article
   • CrossRef
9. U.S. Department of Agriculture, Agricultural Research Service: Nutrient intakes from food: mean amounts consumed per individual, one day, 2005-2006. Accessed Nov 1, 2008; www.ars.usda.gov/ba/bhnrc/fsrg
   • View In Article
10. National Kidney Foundation . K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease with kidney failure. Am J Kidney Dis. 2003;42(Suppl 3):S13–S93
    • View In Article
11. Murphy-Gutekunst L. Hidden phosphorus in popular beverages. Nephrol Nurs J. 2005;32(4):443–445
    • View In Article
    • MEDLINE