Water, Water Everywhere, But What to Drink? An Update on Hidden Phosphorus in Popular Beverages

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.