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Can Pizza Fit in to the Renal Diet? A Review of the Phosphorus, Potassium, and Sodium Content of Selected Frozen and Delivery Options

      Pizza is one of the most widely consumed foods in the United States.
      • Barrett L.
      Pizza Power 2013 State of the Industry Report.
      According to “What We Eat in America,” the dietary interview component of the NHANES 2007 to 2010, approximately 13% of Americans are eating pizza on any given day.
      • Rhodes D.G.
      • Adler M.E.
      • Clemens J.C.
      • LaComb R.P.
      • Moshfegh A.J.
      Consumption of pizza: What We Eat in America, NHANES 2007-2010. Food Surveys Research Group Dietary Data Brief No. 11. February 2014.
      In addition, pizza can account for as much as 25% of the day's energy requirements and is a top contributor to sodium in the typical American diet.
      • Rhodes D.G.
      • Adler M.E.
      • Clemens J.C.
      • LaComb R.P.
      • Moshfegh A.J.
      Consumption of pizza: What We Eat in America, NHANES 2007-2010. Food Surveys Research Group Dietary Data Brief No. 11. February 2014.
      Pizza sales at chain restaurants are growing, but according to industry reports, frozen pizza sales are also up in the United States.
      • Barrett L.
      Pizza Power 2013 State of the Industry Report.
      With these foods trending among the general population, should we as renal dietitians expect that our patients will indulge?
      Although most renal dietitians do not encourage their patients to eat pizza, it is probably realistic to assume that at some point pizza will find its way to the tables of our patients. The wide variety of ingredients found in pizza, including the crust and toppings, can be a significant source of phosphorus, potassium, and sodium in the diets of renal patients. Cheese, tomato-based sauces, and vegetable toppings may contribute to life-threatening hyperkalemia. Cheese and preservatives in meat toppings and dough additives may contribute to high serum phosphorus levels. Elevated serum phosphorus in renal patients may cause long-term renal bone disease and coronary artery calcification.
      • Byham-Gray L.
      • Stover J.
      • Wiesen K.
      A Clinical Guide to Nutrition Care in Kidney Disease.
      In addition, the high sodium content of many pizza ingredients may contribute to increased thirst and interdialytic fluid gains in dialysis patients as well as dangerous increases in blood pressure.
      • Byham-Gray L.
      • Stover J.
      • Wiesen K.
      A Clinical Guide to Nutrition Care in Kidney Disease.
      The role of the renal dietitian is to educate patients regarding the safest and healthiest food options for their medical condition, in other words, recommending the “best” options for their patients. Often the dietitian will recommend a “fresh food” approach or focus on homemade options which may or may not be realistic for many renal patients. Sometimes, however, the dietitian must recommend the “not as bad” option, especially with pizza, to continue to provide realistic counseling for patients navigating the real world of family reunions, date nights, grandkids' birthday parties, and late night pizza cravings.
      Many more motivated patients will read food package labels before purchasing or eating an item, but often these food labels are incomplete and do not include phosphorus or potassium content. Some patients may even determine if there is nutrient information available online before heading out to a restaurant or may use a smart phone app such as the KidneyDiet® application (Pain Free Living, Inc., Whitby, Canada) to look up nutrient information. Some nutrient databases are available that list all data per 100 g of food product, which is probably more helpful to the food and nutrition professional than to the patient or consumer.
      The US Department of Agriculture Food and Nutrition Database is an excellent source of information for both frozen and restaurant pizza products and was used primarily for the purposes of this article. It lists a variety of nutrient contents including the most currently available information on phosphorus, potassium, and sodium content of pizzas. In addition, one can toggle back and forth between various serving sizes including a standard slice, a whole pie, and a 100-g serving, whichever is the most useful. Serving sizes were shown to vary widely. The serving sizes for frozen pizza tended to be bigger than those for restaurant products and even among restaurant pizza; the sizes of the slices varied from the traditional wedge serving to small square slices. Products like thin crust pizza with few or no toppings weighed less overall than a thicker crust pizza with “the works” on it. Information on ingredients of various pizza brands was obtained from the company or manufacturer Web sites.
      Table 1 contains nutrient information for selected frozen brands, including some that are missing data on phosphorus content but which were still included as they are among the top 10 leading frozen pizza brands sold in the United States.

      Statista. Sales of the Leading 10 Frozen Pizza Brands of the United States in 2013. http://www.statista.com/statistics/189650/top-frozen-pizza-brands-in-the-united-states. Accessed December 19, 2014.

      The first column indicates the pizza brand and style and includes the serving size of the slice expressed as a fraction of the entire pizza as well as in grams. Column 2 indicates phosphorus content per slice in milligrams, column 3 indicates potassium content per slice in milligrams, column 4 indicates sodium content per slice in milligrams, and column 5 indicates whether the product has added phosphates. Where an “N/A” appears, it indicates that data were not available for that product. Table 2 gives the same information as Table 1 for restaurant pizza brands.
      Table 1Pizza Comparison Chart: Frozen
      Brand, Type of Pizza, Size of SlicePhosphorus (mg Per Slice)Potassium (mg Per Slice)Sodium (mg Per Slice)Added Phosphate
      DiGiorno, cheese rising crust, 1/4 of pizza = 183 g
      Pizza slices are shown as both a fraction and by weight in grams for comparison purposes.
      4413591274Yes
      DiGiorno cheese thin crust, 1/4 of pizza = 161 g380375815No
      DiGiorno pepperoni rising crust, 1/4 of pizza = 207 g4664391538Yes
      DiGiorno pepperoni stuffed crust, 1/4 of pizza = 179 g4833201348Yes
      DiGiorno pepperoni thin crust, 1/4 of pizza = 145 g309389961No
      DiGiorno supreme rising crust, 1/4 of pizza = 227 g4794771616Yes
      DiGiorno supreme thin crust, 1/4 of pizza = 155 g290431860Yes
      Freschetta Brick Oven 3 meat medley, 1/5 of pizza = 131 gN/A250960Yes
      Freschetta Brick Oven 5 Italian cheese, 1/4 of pizza = 144 gN/A200930Yes
      Freschetta Brick Oven chicken club, 1/4 of pizza = 155 gN/A230830Yes
      Freschetta Brick Oven mushroom/spinach, 1/5 of pizza = 128 gN/A260610Yes
      Freschetta Brick Oven pepperoni/Italian cheese, 1/5 of pizza = 129 gN/A220930Yes
      Freschetta Brick Oven zesty Italian supreme, 1/5 of pizza = 132gN/A210780Yes
      Freschetta Naturally Rising 4 cheese medley, 1/5 of pizza = 148 gN/A260900No
      Freschetta Naturally Rising Canadian bacon/pineapple, 1/6 of pizza = 130 gN/A220760Yes
      Freschetta Naturally Rising classic supreme, 1/6 of pizza = 146 gN/A270910No
      Freschetta Naturally Rising Margherita, 1/6 of pizza = 129 gN/A240710No
      Freschetta Naturally Rising meat medley, 1/6 of pizza = 136 gN/A270930Yes
      Freschetta Naturally Rising sausage/pepperoni, 1/6 of pizza = 139 gN/A290920No
      Freschetta Naturally Rising signature pepperoni, 1/6 of pizza = 129gN/A250870No
      Kashi mushroom trio/spinach, 1/3 of pizza = 113 g132210663No
      Kashi roasted vegetable, 1/3 of pizza = 116 g132210633No
      Kashi, Margherita, 1/3 of pizza = 113 g139231633No
      Kashi, Mediterranean, 1/3 of pizza = 120 g193202637No
      Newman's Own BBQ chicken, thin crust, 1/3 of pizza = 133 gN/AN/A750No
      Newman's Own 4 cheese medium crust, 1/4 of pizza = 135 gN/AN/A700No
      Newman's Own Buffalo chicken, thin crust, 1/3 of pizza = 132 gN/AN/A580No
      Newman's Own supreme medium crust, 1/4 of pizza = 145 gN/AN/A790No
      Newman's Own uncured pepperoni medium crust, 1/4 of pizza = 134gN/AN/A860No
      Red Baron, 4 cheese, classic Crust, 1/4 of pizza = 149 gN/A180780No
      Red Baron, 4 meat, classic crust, 1/4 of pizza = 154 gN/A240890Yes
      Red Baron, 5 cheese, thin crust, 1/3 of pizza = 139 gN/A230840No
      Red Baron, pepperoni, classic crust, 1/4 of pizza = 146 gN/A210860No
      Red Baron, pepperoni, thin crust, 1/3 of pizza = 149 gN/A2701020No
      Red Baron, Singles, 4 cheese deep dish, 1 pizza = 159 gN/A320840No
      Red Baron, Singles, cheese, deep dish, 1 pizza = 159 gN/A340830No
      Red Baron, Singles, meat trio, deep dish, 1 pizza = 159 gN/A330920No
      Red Baron, Singles, pepperoni deep dish, 1 pizza = 159 gN/A300970No
      Red Baron, Singles, supreme deep dish, 1 pizza = 163 gN/A320900No
      Red Baron, special deluxe, classic crust, 1/5 of pizza = 130 gN/A220690No
      Red Baron, supreme, classic crust, 1/5 of pizza = 133 gN/A190720No
      Red Baron, supreme, thin crust, 1/4 of pizza = 124 gN/A230790No
      Tony's cheese, 1/3 of pizza = 137 gN/A210600Yes
      Tony's meat-trio, 1/3 of pizza = 146 gN/A250750Yes
      Tony's pepperoni, 1/3 of pizza = 134 gN/A220650Yes
      Tony's sausage, 1/3 of pizza = 142 gN/A240700Yes
      Tony's sausage/pepperoni, 1/3 of pizza = 140gN/A240710Yes
      Tony's supreme, 1/3 of pizza = 149 gN/A250710Yes
      Pizza slices are shown as both a fraction and by weight in grams for comparison purposes.
      Table 2Pizza Comparison Chart: Delivery and Eating Out
      Brand, Type of Pizza, Size of SlicePhosphorus (mg Per Slice)Potassium (mg Per Slice)Sodium (mg Per Slice)Added Phosphate
      Domino's 14″ cheese, hand tossed crust, 1/8 of pizza = 108 g
      Pizza slices are shown as both a fraction and by weight in grams for comparison purposes.
      220174565No
      Domino's 14″ cheese, thin crust, 1/8 of pizza = 70 g204141440Yes
      Domino's 14″ extravaganza, hand-tossed, 1/8 of pizza = 151 g278263689N/A
      Domino's 14″ pepperoni, hand tossed crust, 1/8 of pizza = 113 g216207690N/A
      Domino's 14″ pepperoni, thin crust, 1/8 of pizza = 79 g208177619Yes
      Domino's 14″ sausage, hand tossed crust, 1/8 of pizza = 114 g223209677Yes
      Domino's 14″ sausage, Thin Crust, 1/8 of pizza = 78 g211180566Yes
      Little Caesar's 14″ cheese, round, regular crust, 1/8 of pizza = 89g206151404N/A
      Little Caesar's 14″ cheese, large deep dish, 1/9 of pizza = 102 g225163441N/A
      Little Caesar's 14″ cheese, thin crust, 1/12 of pizza = 48 g14385218N/A
      Little Caesar's 14″ meat/veggie, regular crust, 1/9 of pizza = 115 g238224665N/A
      Little Caesar's 14″ pepperoni, large, deep dish, 1/9 of pizza = 104 g224180512N/A
      Little Caesar's 14″ pepperoni, round regular crust, 1/9 of pizza = 90g202160466N/A
      Papa John's 14″ cheese, original crust, 1/8 of pizza = 117 g238161676N/A
      Papa John's 14″ cheese, thin crust, 1/8 of pizza = 87 g213139459N/A
      Papa John's 14″ pepperoni, original crust, 1/8 of pizza = 123 g241184825N/A
      Papa John's 14″ the works, original crust, 1/7 of pizza = 153 g245245872N/A
      Pizza Hut 12″ cheese, hand tossed crust, 1/8 of pizza = 96 g239166658No
      Pizza Hut 12″ cheese, pan crust, 1/8 of pizza = 100 g241168624No
      Pizza Hut 12″ cheese, thin crust, 1/8 of pizza = 69 g219132541No
      Pizza Hut 12″ pepperoni, hand tossed, 1/8 of pizza = 96 g209199769No
      Pizza Hut 12″ pepperoni, pan crust, 1/8 of pizza = 96 g197191664No
      Pizza Hut 12″ super supreme, hand tossed, 1/8 of pizza = 127 g254296875Yes
      Pizza Hut 14″ cheese, hand tossed crust, 1/8 of pizza = 105 g239192708No
      Pizza Hut 14″ cheese, pan crust, 1/8 of pizza = 112 g242190650No
      Pizza Hut 14″ cheese, thin crust, 1/8 of pizza = 79 g235156677No
      Pizza Hut 14″ pepperoni pan crust, 1/8 of pizza = 133 g218211764No
      Pizza Hut 14″ pepperoni, hand tossed, 1/8 of pizza = 110 g227228835No
      Pizza Hut 14″ pepperoni, thin/crispy, 1/8 of pizza = 80 g195178774No
      Pizza Hut 14″ super supreme, hand tossed, 1/8 of pizza = 123 g225256809Yes
      Pizza slices are shown as both a fraction and by weight in grams for comparison purposes.
      As a typical nutrient prescription for a hemodialysis patient is 2000 mg of sodium, 2000 mg of potassium and <1000 mg of phosphorus, it is easy to see how a few slices of some brands of pizza could push a patient over the limit of some or all of these nutrients for the entire day.
      • Byham-Gray L.
      • Stover J.
      • Wiesen K.
      A Clinical Guide to Nutrition Care in Kidney Disease.
      Table 3, Table 4 show the top 7 picks for “renal-friendlier” pizza for both frozen and restaurant pizza brands based on all 4 nutrition criteria listed in Table 1, Table 2 Although these top picks are certainly not ideal foods for the renal patient, they represent some options that are available. Figure 1 includes suggestions for counseling patients when selecting pizza brands so that if they do choose to indulge in one of America's favorite foods, they can make an informed choice regarding brands and portion sizes.
      Table 3The Most “Renal Friendly” Frozen Pizza—and the Top 7 Picks Are …
      Brand, Type of Pizza, Size of SlicePhosphorus (mg Per Slice)Potassium (mg Per Slice)Sodium (mg Per Slice)Added Phosphate
      Freschetta Naturally Rising Margherita, 1/6 of pizza = 129 gN/A
      These values are not available; however, all pizzas contain some phosphorus.
      240710No
      Kashi mushroom trio/spinach, 1/3 of pizza = 113 g132210663No
      Kashi roasted vegetable, 1/3 of pizza = 116 g132210633No
      Kashi, Margherita, 1/3 of pizza = 113 g139231633No
      Kashi, Mediterranean, 1/3 of pizza = 120 g193202637No
      Newman's Own Buffalo chicken, thin crust, 1/3 of pizza = 132 gN/A
      These values are not available; however, all pizzas contain some phosphorus.
      N/A
      These values are not available; however, all pizzas contain some phosphorus.
      580No
      Red Baron, special deluxe, classic crust, 1/5 of pizza = 130 gN/A
      These values are not available; however, all pizzas contain some phosphorus.
      220690No
      These values are not available; however, all pizzas contain some phosphorus.
      Table 4The Most “Renal Friendly” Delivery or Carry-Out Pizza—and the Top 7 Picks Are …
      Brand, Type of Pizza, Size of SlicePhosphorus (mg Per Slice)Potassium (mg Per Slice)Sodium (mg Per Slice)Added Phosphate
      Little Caesar's 14″ cheese, round, regular crust, 1/8 of pizza = 89g206151404N/A
      This information is not available.
      Little Caesar's 14″ cheese, large deep dish, 1/9 of pizza = 102 g225163441N/A
      Little Caesar's 14″ cheese, thin crust, 1/12 of pizza = 48 g14385218N/A
      Little Caesar's 14″ pepperoni, large, deep dish, 1/9 of pizza = 104 g224180512N/A
      Little Caesar's 14″ pepperoni, round regular crust, 1/9 of pizza = 90g202160466N/A
      Papa John's 14″ cheese, thin crust, 1/8 of pizza = 87 g213139459N/A
      Pizza Hut 12″ cheese, thin crust, 1/8 of pizza = 69 g219132541No
      This information is not available.
      Figure thumbnail gr1
      Figure 1General guidelines for selecting pizza.

      Nutrient Information Sources

      US Department of Agriculture National Nutrition Database: http://ndb.nal.usda.gov/nbd

      References

        • Barrett L.
        Pizza Power 2013 State of the Industry Report.
        PMQ Pizza Magazine, Oxford, MS2012 (Accessed December 13, 2014)
        • Rhodes D.G.
        • Adler M.E.
        • Clemens J.C.
        • LaComb R.P.
        • Moshfegh A.J.
        Consumption of pizza: What We Eat in America, NHANES 2007-2010. Food Surveys Research Group Dietary Data Brief No. 11. February 2014.
        Adv Nutr. 2014; 5: 456
        • Byham-Gray L.
        • Stover J.
        • Wiesen K.
        A Clinical Guide to Nutrition Care in Kidney Disease.
        2nd ed. Academy of Nutrition and Dietetics, Chicago, IL2013
      1. Statista. Sales of the Leading 10 Frozen Pizza Brands of the United States in 2013. http://www.statista.com/statistics/189650/top-frozen-pizza-brands-in-the-united-states. Accessed December 19, 2014.