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Can Almond Milk Be Called Milk?

      Can almond milk be called milk? Producers of plant-based beverages are being challenged on using the word milk. In December 2016, 32 members of Congress, backed by members of the dairy industry, asked the Food and Drug Administration to demand creators of plant-based beverages to create a new name for their products. This bipartisan group asked manufactures to not use the word “milk” claiming it is misleading for consumers.

      O'Connor, A. Got almond milk? Dairy farms protest milk label on nondairy drinks. Available at: https://www.nytimes.com/2017/02/13/well/eat/got-almond-milk-dairy-farms-protest-milk-label-on-nondairy-drinks.html?_r=0. Accessed February 14, 2017.

      As recently as December 2015, a case alleging Trade Joe's was misleading customers in its packaging of soy milk and violated the standards of identity of milk was dismissed by the judge stating, “No reasonable consumer would confuse soy with dairy milk.” Previous cases have also been dismissed.
      • Watson E.
      Is It Legal to Call Plant-based Beverages From Nuts, Seeds and Legumes “Milk”.
      Although the use of the term milk remains in question, the nutritional content and use of both diary and nondairy beverages in the person with chronic kidney disease (CKD) remain to be judged by the heath care professional. The purpose of this product update is to compare the protein, potassium, and phosphorus of select plant-based beverages to milk, to comment on the use of plant-based products for the person with kidney disease and to contemplate as alleged, that plant-based milk may be misleading to persons on dialysis.
      There is a proliferation of plant-based milk products on the market, such as almond, soy, rice, coconut, flax, and hemp to name a few. The variety keeps expanding as does sales and product growth. Almond milk leads in sales.
      • Watson E.
      Packaged Facts: Almond and Coconut Milk on Fire: Soy Milk on the skids; Skim Milk Losing Share.
      A food navigator report states, consumers are trending away from animal-based products (meat or dairy) over concerns about lactose, fat, and cholesterol. These products are perceived as “healthier” than milk. Lifestyle changes are also accounting for overall decreased milk consumption as millennials are getting away from eating cereal and milk, opting for other choices that are easier to eat on the run.
      The renal diet is a mainstay of treatment for the person with CKD. One purpose of this diet is to avoid unnecessary and potentially dangerous buildup of nutritional elements, such as phosphorus and potassium. Hyperphosphatemia has been found to be associated with increased risk for cardiovascular diseases, secondary hyperparathyroidism, and bone disease. Hyperkalemia run the increased risk for cardiac arrhythmia, cardiac arrest, and mortality in dialysis patients. Patients on dialysis are encouraged to eat a high-protein diet often while juggling their potassium and phosphorus limitations.
      National Kidney Foundation
      K/DOQI Clinical Practice guidelines for nutrition in chronic renal failure.
      This becomes almost contradictory advice as many high-protein foods are also high in potassium and phosphorus. Milk is one of those foods.
      Milk is often restricted in the food plan for the person with kidney disease. One cup of milk contains 233 mg phosphorus, 366 mg of potassium, 8 g protein, see Table 1. And it contributes to the daily fluid intake which is often limited. An example of a printed renal diet, Chronic Kidney Disease Stage 5: Nutrition Guidelines, available from the Academy of Nutrition and Dietetics Diet Manual lists half cup milk as the amount suggested for an exchange in the dairy and high-phosphorus choices.

      Academy of Nutrition and Dietetics. Nutrition Care Manual. Chronic Kidney Disease Stage 5 Nutrition Therapy. Available at: https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=157. Accessed January 10, 2017.

      Patients who enjoy milk seek alternatives.
      Table 1Comparison of Protein, Potassium, Phosphorus Content of Whole Milk, and Selected Plant-based Milk Beverages
      Type of Beverage (1 Cup)ProteinPotassiumPhosphorusPhosphate Additive
      Cow's milk
       Whole milk, vitamin D added
      https://ndb.nal.usda.gov/.
      8 g368 mg227 mgNo
      Almond
       Almond Breeze Unsweetened Vanilla
      www.almondbreeze.com.
      1 g160 mg20 mg
      Phosphorus information is provided as a percentage of the DV (Daily Value). This has been converted to milligram for ease of comparison, for example, 20% of the 1000 DV = 200 mg.
      No
      Coconut
       So Delicious Dairy Free Unsweetened Coconut Milk
      www.sodeliciousdairyfree.com.
      0 g50 mgN/AYes
      Flax
       Good Karma Unsweetened FlaxMilk
      www.goodkarmafoods.com. Potassium not listed on nutrition facts label; information provided by communication with customer service.
      0 g<1 mg
      www.goodkarmafoods.com. Potassium not listed on nutrition facts label; information provided by communication with customer service.
      150 mg
      Phosphorus information is provided as a percentage of the DV (Daily Value). This has been converted to milligram for ease of comparison, for example, 20% of the 1000 DV = 200 mg.
      Yes
      Hemp
       Pacific Original Unsweetened Hemp Milk
      www.pacificfoods.com.
      3 g110 mg350 mg
      Phosphorus information is provided as a percentage of the DV (Daily Value). This has been converted to milligram for ease of comparison, for example, 20% of the 1000 DV = 200 mg.
      Yes
      Rice
       Rice Dream Rice Drink Original Classic Unenriched
      www.dreamplantbased.com.
      1 gN/AN/ANo
      Seven Grain
       Pacific Original 7 Grain Milk
      www.pacificfoods.com.
      3 g125 mgN/AYes
      Soy
       Silk Unsweetened Soy Milk
      www.silk.com.
      7 g350 mg75 mg
      Phosphorus information is provided as a percentage of the DV (Daily Value). This has been converted to milligram for ease of comparison, for example, 20% of the 1000 DV = 200 mg.
      No
      N/A, not available.
      § www.goodkarmafoods.com. Potassium not listed on nutrition facts label; information provided by communication with customer service.
      || Phosphorus information is provided as a percentage of the DV (Daily Value). This has been converted to milligram for ease of comparison, for example, 20% of the 1000 DV = 200 mg.
      †† www.silk.com.
      Plant-based milks vary significantly in their nutritional profiles. A recently published article in the Journal of Pediatric Gastroenterology and Nutrition details the fortification and enrichment of nondairy milks including the addition of protein, flavorings, sweeteners, and additives.
      • Singhal S.
      • Baker R.D.
      • Baker S.S.
      A comparison of the nutritional value of cow's milk and non-dairy beverages.
      Two previous product updates also provide a comprehensive review of these products. These articles round out the nutrition discussion that is limited by this brief review.
      • Tarantola J.
      • Wujastyk L.
      Alternative milk beverages.
      • Kung C.W.
      Milk alternatives.
      Plant-based foods are slowly gaining acceptance into the kidney diet with the new understanding of phosphorus absorption. This dovetails the current interest in the plant-based diet as a healthful approach to eating. Current research has found inorganic forms of phosphorus in additives to be more readily absorbed than the organic forms of phosphorus found in food items. Phosphate additives, often in processed foods, can be found listed in the ingredient list and often take on a variation of the word phosphate, such as phosphoric acid, sodium aluminum phosphate, or pyrophosphate.
      • Kalantar-Zadeh K.
      • Gutekunst L.
      • Mehrotra R.
      • et al.
      Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease.
      It is unclear how much phosphorus is in a product with phosphate additives; however, the general advice is that the product should be avoided and a similar product without additives would be a better choice.
      Milk is perceived by patients as a food to avoid or limit because of its phosphorus content. However, dialysis patients do not readily identify milk as a high source of potassium. One cup of milk contains 366 mg of potassium. Reported potassium was less than milk with the exception of soy milk which was comparable at 350 mg. Two manufacturers did not have potassium information on the label. Potassium will be included in the new Nutrition Facts label by July 2018.

      US Food and Drug Administration. Changes to the Nutrition Facts Label. Available at: https://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/labelingnutrition/ucm385663.htm. Accessed February 25, 2017

      Table 1 is a brief comparison of plant-based milk alternatives. The unsweetened variety of each plant source was selected.
      Plant-based milk beverages have expanded from soy milk, the varieties sampled are almond, rice, coconut, flax, hemp, and 7-grain plant milks. Each item is identified as a satisfying alternative for consumers who desire a milk-like consistency for cereal or other food combinations. Each plant-based drink is marketed to promote a different health benefit. For patients with CKD, soy milk offers close to the same amount of protein as cow's milk, 7 g per 1 cup serving while providing less phosphorus than cow's milk, see Table 1. Conversely, almond, coconut, flax, and rice milk each have 0 to 1 g of protein per 1 cup serving but also contain minimal amounts of potassium and phosphorus. Flax and hemp milk provide a small amount of protein 3 g per 1 cup serving as well as minimal potassium and phosphorus. The 7-grain plant milk is derived from 7 different whole grains to produce a beverage that is creamy and nutty and provides 3-g protein per 1 cup serving. To this end, professionals should appreciate the lack of highly biologically available proteins in common plant milks. Finally, plant-based milks may complement the renal diet because of their low concentrations of potassium and phosphorus. However coconut, flax, and hemp milk contained phosphate additives.
      Milk alternatives are a new food category for both the dietitian and patient to consider when planning the renal diet. A presumed benefit of these drinks is that they do not contain phosphorus or potassium as milk does making them a friendlier option for the dialysis patient. However, with the exception of soy milk, the protein content is in question. Their use is tricky as nutritional content varies widely among products in this broad-based category. The informed professional and patient will go to the nutrition facts label to seek out the nutrition information of the product being considered. A skilled professional working with an individual patient will know which product is best for the individual patient situation.

      References

      1. O'Connor, A. Got almond milk? Dairy farms protest milk label on nondairy drinks. Available at: https://www.nytimes.com/2017/02/13/well/eat/got-almond-milk-dairy-farms-protest-milk-label-on-nondairy-drinks.html?_r=0. Accessed February 14, 2017.

        • Watson E.
        Is It Legal to Call Plant-based Beverages From Nuts, Seeds and Legumes “Milk”.
        (Food navigator-USA.com) William Reed Business Media, Crawley, England2016
        • Watson E.
        Packaged Facts: Almond and Coconut Milk on Fire: Soy Milk on the skids; Skim Milk Losing Share.
        (Food navigator-USA.com) William Reed Business Media, Crawley, England2016
        • National Kidney Foundation
        K/DOQI Clinical Practice guidelines for nutrition in chronic renal failure.
        Am J Kidney Dis. 2000; 35: S40-S43
      2. Academy of Nutrition and Dietetics. Nutrition Care Manual. Chronic Kidney Disease Stage 5 Nutrition Therapy. Available at: https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=157. Accessed January 10, 2017.

        • Singhal S.
        • Baker R.D.
        • Baker S.S.
        A comparison of the nutritional value of cow's milk and non-dairy beverages.
        J Pediatr Gastroenterol Nutr. 2016; (Epub ahead of print)
        • Tarantola J.
        • Wujastyk L.
        Alternative milk beverages.
        J Ren Nutr. 2009; 19: e1-e10
        • Kung C.W.
        Milk alternatives.
        J Ren Nutr. 2010; : e7-e15
        • Kalantar-Zadeh K.
        • Gutekunst L.
        • Mehrotra R.
        • et al.
        Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease.
        Clin J Am Soc Nephrol. 2010; 5: 519-530
      3. US Food and Drug Administration. Changes to the Nutrition Facts Label. Available at: https://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/labelingnutrition/ucm385663.htm. Accessed February 25, 2017