Low phosphate diet for chronic kidney disease

Contents

• What is phosphate?
• How to achieve a low phosphate diet
• Dairy foods
• Meat, fish and protein alternatives
• Bread, rice, potatoes, pasta and other starchy foods
• Fruit and vegetables
• Foods high in fat and/or sugar
• Drinks
• Additional information
• Phosphate binders
• Phosphate intake/ binder distribution

What is phosphate?
Phosphate is a mineral found in a range of different foods. It helps maintain healthy bones.

Why is the amount of phosphate in my blood too high?
Healthy kidneys usually filter and get rid of excess phosphate from the blood.
Phosphate can build up in your blood if your kidneys are not working properly.

The recommended range for your blood phosphate is: __________ mmol/L
Your recent blood phosphate was ________ mmol/L on ____ /____ /____

Why does it matter if my phosphate level is too high?
High blood phosphate levels may initially cause:

• Red eyes and itchy skin.

Prolonged high phosphate levels can lead to:

• Weaker bones and aching joints.
• Hardened blood vessels, increasing your risk of heart disease.

What could I do to control my blood phosphate levels?

• The first step is to follow a low phosphate diet.
• If your phosphate remains high you may then be prescribed a tablet called a phosphate binder to help lower your blood phosphate levels.

Your diet and phosphate binders may change, depending on your appetite and any other medications and treatment for your kidneys.

How to achieve a low phosphate diet
The dietary advice in this booklet has been developed by registered dietitians. Using this guide can help you to choose the foods that you enjoy whilst helping to keep your blood phosphate levels controlled.

A balanced diet consists of having a variety of foods from different food groups as shown in the following pages.

Within each food group, this guide shows which foods are low, medium or high in phosphate. Try to choose mainly from those foods that are low in phosphate. Foods that are medium in phosphate content can be eaten in moderation, but try to limit high phosphate foods to occasional use only.

Your dietitian will give you individualized advice on any changes which will be of benefit to you.

Please remember that any other diets you may be following still apply when you are on a low phosphate diet and your dietitian will support and guide you in order to achieve this. Keeping to a low salt diet is also important in a healthy diet, especially for people with kidney disease.

Processed foods and food additives
Processed foods often have phosphate and salt added to them.

Have a look at the labels on processed foods and try to limit those that contain the words phosphate or phosphoric acid including pyrophosphate, polyphosphate and sodium phosphate. Look out in particular for ham, breaded chicken, cake mixes, instant sauces and dark carbonated drinks as they often contain these. This type of phosphate is easily absorbed from your food, into your body, as they are artificial. spaces

Most of the salt that we eat is from processed foods. This is another good reason to try and reduce the amount of processed foods eaten. Try to choose fresh, unprocessed food as much as possible.

Dairy foods
Dairy foods are a major source of protein, vitamins and minerals. However, they are higher in phosphate than meat and fish.

Each day choose items from the list below that add to a total of 3 points, in order to have enough protein but not too much phosphate.

One point	Two points
100ml (½ cup) cow’s milk (full cream, semi skimmed, skimmed, pasteurized, sterilized or UHT milk) 100ml soya milk (fortified) 200ml rice / oat / soya milk (unfortified) 60g (2oz) of the following: cottage cheese, ricotta 30g (1oz) of the following: brie, feta, mozzarella, stilton 1 pot (100g) fromage frais 1 pot (125g) soya yoghurt 2 scoops (120g) ice cream 1 pot (90g) crème caramel 3tsp (10g) dried milk powder 8 heaped tsp / 4 servings (26g) non-dairy creamer	200ml (1/3pt) cow’s milk or soya milk (fortified) 30g (1oz) of the following hard cheeses: cheddar, edam, wensleydale, red Leicester 15g (½oz) parmesan cheese 150ml (¼ pint) custard 200g (½ tin) milk pudding 1 pot (150g) yoghurt Note: 30g (1oz) cheese is the size of a small matchbox
Three points
300ml (½ pint) cow’s milk or soya milk (fortified)

Low phosphate dairy foods (No dairy points per average portion)

Cream cheese Crème fraîche Cream and soured cream

High phosphate dairy foods (At least 3 dairy points per average portion)
Cheese spread Processed cheese Condensed milk Evaporated Milk Milk based sauces Cheese sauce Coconut milk/ cream Instant pastas and sauces	Readymade meals such as: Macaroni cheese Lasagne Quiche Pizza

Please note, the above lists are not exhaustive. If your food choice is not in the table then please speak to the dietitian to discuss.

Tips:

• If you need to use extra milk in a day, try two measures of double cream to one measure of water as a substitute.
• Unfortified rice milk, soya milk and oat milk are lower in phosphate than cow’s milk. However, check the label as fortified varieties often add phosphate.
• When using hard cheese, grate cheese to make it go further. Use mature cheese, as a small amount still adds plenty of flavour or use a small amount of parmesan cheese in cooked dishes.
• Bedtime drinks: make using ½ milk to ½ water with 1-2 tsp of malted milk or drinking chocolate powder as this halves the phosphate content and provides 1 dairy point.

Meat, fish and protein alternatives
These foods are good sources of protein, which is important for building and maintaining muscle and for fighting infection. However, protein food also contain phosphate, although the amount of phosphate they contain varies. Use the following tables to make suitable choices. Check that your serving sizes are similar to the ones described below each table.

Meat and meat products

Low phosphate	Medium phosphate	High phosphate
Bacon Beef Beef burger Chicken Corned beef Duck Gammon Lamb Pork Rabbit Salami Turkey Pork pie Meat pie Veal Venison	Kidneys Sausages Sausage roll	Ham Liver Offal Pâté

Average serving size: Light meal: ▪ 1 – 2 slices cold meat: 30-60g (1-2oz). Main meal: cooked weight 90-120g (3-4oz) ▪ 3 slices roast meat / 1 average sized chop / 1 chicken breast or meat (size of the palm of your hand).

Fish, seafood and shellfish

Low phosphate	Medium phosphate	High phosphate
Crab sticks Salted fish Scallops Tinned crab Tuna fresh* Tuna tinned Tinned salmon* Winkles	Anchovies Catfish Cockles Cod Fish fingers Haddock Herring* Kippers* Lemon sole Mackerel* Plaice Prawns Salmon* Shrimps Squid Skate Trout*	Carp Clams Crab (fresh) Crayfish Fish Paste Fish Roe Monkfish Mussels Oysters Pilchards* Sardines* Scampi Sea bass Taramasalata Whitebait

* Oily fish is good for your heart

Average serving size: Light meal: tinned tuna/ salmon/ mackerel 30-60g (1-2oz) Main meal: 1 fillet of fish (size of the palm of your hand)

Tips:

• Meat and fish are major sources of protein, vitamins and minerals and most have less phosphate than most of the dairy foods, so are excellent food choices.
• Fish bones contain a lot of phosphate, so limit bony fish and remove edible bones before eating.
• Cured, smoked and tinned meats and fish are high in salt. Choose tinned fish in spring water, not brine.

Non-meat sources of protein

Low phosphate	Medium phosphate	High phosphate
Egg white	Black eyed beans Chickpeas Dried soya mince Egg (see allowance) Lentils Mung beans Peanut butter Tofu	Aduki beans Baked beans Hummus Nuts – all types Red kidney beans Pinto beans Seeds – all types Soya beans Quorn

Average serving size: 1-2 eggs 3 tablespoons of cooked beans/ pulses: 90g (30z)

Tips:

• Aim to have no more than 4 eggs/ week. Egg whites can be eaten freely, as the phosphate is found in the egg yolk
• A portion of beans such as chickpeas or lentils can replace a portion of meat or fish as they are good sources of protein without containing too much phosphate.
• If you are vegetarian, continue having beans and lentils as usual.
• Though nuts are high in phosphate, they are also high in protein. If you wish to include these in your diet, please discuss with the dietitian.

Bread, rice, potatoes, pasta, & other starchy foods
Starchy foods provide energy, some vitamins and may contain fibre. Fibre helps to keep your bowels regular. Include something from this group at each meal. Starchy foods are often low in phosphate but phosphate may be added in the manufacturing process (see page 5 for further information).

Bread, flour, and alternatives

Low phosphate	Medium phosphate	High phosphate
Corn flour Cream crackers Croissant English muffins Pita bread Water biscuits White bread Plain flour	Bagel Chapatti Granary bread Oat cakes Rice cakes Rye bread Rye crispbread Wheat crispbread Wholemeal bread Wholemeal flour	Baking powder Crumpets Naan Rye flour Self-raising flour Soya flour

Rice, potatoes, pasta, and grains

Low phosphate	Medium phosphate	High phosphate
Cassava (boiled) Potatoes (boiled, baked, mashed, roast) Rice noodles Sweet potato (boiled) White rice Yam (boiled)	Couscous Pearl barley Instant mashed potatoes Noodles (plain or egg) Potato croquettes Yorkshire pudding Thick cut chips White pasta	Brown rice Dumplings Macaroni cheese Frozen / oven chips Thin cut chips Potato waffles Pot noodle Quinoa Wholemeal pasta

Breakfast cereals

Low phosphate	Medium phosphate	High phosphate
Cornflakes Rice Krispies Special K Sugar Puffs	Fruit & Fibre Grapenuts Porridge oats Puffed wheat Shredded Wheat Shreddies Weetabix	All-Bran Branflakes Muesli Readybreak

Tips

• Use a small amount of milk with breakfast cereals.
• Plain flour contains very little phosphate. Baking powder and self-raising flour contain more. Use these in moderation.

Fibre
Very little of the phosphate found in high fibre foods is absorbed by the body. Hence most of these foods can be eaten as part of a healthy diet.

Examples of high fibre foods

• Wholemeal bread
• Wholegrain cereals e.g. Weetabix, Shredded Wheat
• Oats
• Lentils
• Beans
• Nuts
• Fruit and vegetables

Fruit and vegetables
Fruit and vegetables are naturally low in phosphate but also contain some potassium, so please check with your dietitian if you are currently on a low potassium diet.

Fruit and vegetables are an important source of vitamins, minerals and fibre and help to keep your bowel healthy. It is recommended to have five 80g portions per day. Try to have a variety of fruit and vegetables.

An 80g (3oz) portion of fruit is about a handful of small fruit(strawberries, raspberries, grapes etc.) or a portion of fruit about the size of a small apple, peach or tangerine

An 80g portion of vegetables is about 3 heaped tablespoons or a small bowl of salad. 80g portions are quite small. If you have a large apple for instance, it may weigh about 160g (6oz) so this is 2 portions of fruit.

If you enjoy eating plenty of fruits and vegetables the above guidelines will help you to continue to enjoy variety in your diet and meet your “5 a day”.

As fruit and vegetables (except beans and pulses) are low in phosphate, they don’t need limiting, apart from those listed below:

• Star fruit may cause dangerous side effects for those with kidney problems; it is therefore recommended that you avoid this.
• You may be advised not to have grapefruit if you are taking certain medications.

Foods high in fat and/or sugar
These foods can affect your weight and heart, and some are high in phosphate. Many baked goods contain some phosphate; the main sources being baking powder, self-raising flour, eggs, and milk.

Aim to use these foods sparingly, unless you have a poor appetite or have lost weight recently. Ask to speak to the Dietitian for further advice on these foods.

Fats and oils
Most fats/oils are low in phosphate. Those marked ♥ are better for your heart.

Monounsaturated fats ♥	Olive oil, rapeseed oil, olive oil based spreads
Polyunsaturated fats ♥	Sunflower, soya, corn oils and margarines made from these oils
Saturated fats	Butter, cream, lard and visible fat on meat, coconut oil, palm oil, ghee

Savoury Snacks

Low phosphate	Medium phosphate	High phosphate
Breadsticks Corn snacks (Wotsits, Skips) Cream crackers Crisps (potato, taro) Popcorn Prawn crackers	Pretzels Tortilla chips	Bombay mix Nuts Seeds Twiglets

Sugar and confectionary

Low phosphate	Medium phosphate	High phosphate
Sugar Jam, marmalade Honey, lemon curd Sweet, jellies Fruit gums, mints Marshmallows Turkish delight	Kitkat, Bounty Mars bars, Twix Snickers Cream egg Toffees Liquorice allsorts	Plain, white or milk chocolate. Sweet containing nuts. Fudge

Biscuits and cakes

Low phosphate	Medium phosphate	High phosphate
Cream cakes Doughnuts Jaffa cakes Jam tarts Shortcake Cream/ jam biscuits Ginger biscuits Rich tea/ Nice Digestive biscuits	Battenburg Blueberry muffins Chocolate biscuits Danish pastry Flapjack (plain) Fruit cake Oat based biscuits Sponge cake Swiss roll Tea cakes	Cake mixes Cereal bars Coconut cake Chocolate cake Chocolate muffins Oatcakes Rock cakes Scones Scotch pancakes Waffles

Puddings

Low phosphate	Medium phosphate	High phosphate
Fruit crumble/ pie Fresh fruit salad Tinned fruit Meringue/ pavlova Jelly Sorbet Lemon meringue pie Treacle tart	Trifle Mousse Cheesecake Ice cream* Fromage frais* Crème caramel* *Refer to dairy section	Bread & butter pudding Pancakes Sponge pudding Yoghurt* Custard* Rice pudding* *Refer to dairy section

Tips

• Extra snacks between meals and puddings may be useful for those with a poor appetite who are only managing small meals.
• Puddings are often served with custard or ice cream.
• Cream or Crème fraîche are lower phosphate alternatives.

Drinks
Most drinks are fairly low in phosphate. However there are some drinks that are much higher.

Some dark fizzy drinks contain significant amounts of phosphate (phosphoric acid) that are easily absorbed by the body. Keep these to a minimum and choose light coloured fizzy drinks instead.

If you need to watch your fluid intake, ensure that you count all these drinks as part of your daily fluid allowance.

Speak to your Dietitian if you are taking supplement drinks such as Complan or Build Up.

Alcohol
Please discuss with your Doctor or Renal Consultant.
The NHS guidance recommends that men and women drink no more than 14 units of alcohol per week, with some alcohol free days.

Low phosphate	Medium phosphate	High phosphate
Coffee (little milk) Fruit Juice Light coloured fizzy drinks (e.g. lemonade, Fanta, Tizer) Red Bull Oxo Squash/ Cordial Tea Water (incl. flavoured/tonic)		Bovril Dark fizzy drinks such as Coca Cola/Pepsi/Dr Pepper Malted milk drinks such as Horlicks, Ovaltine Hot chocolate Milky Coffee Milkshake Supplement drinks (e.g. Build up, Complan, Nurishment)
Cider Sherry Spirits Wine	Ale Bitter	Lager Stout

Miscellaneous
Spices, garlic, herbs, pepper and condiments such as mustard, tomato ketchup, brown sauce, salad cream, mayonnaise, and vinegar are low in phosphate.

Most soups are low in phosphate and protein but high in salt; discuss with the dietitian if you wish to have soup often.

Sauces such as white sauce and cheese sauce contain a lot of phosphate.

Bovril and marmite are high in both phosphate and salt and are best used sparingly.

Phosphate binders

Why might I need phosphate binders?
In addition to a low phosphate diet, phosphate binders may be prescribed (see next page). Binders combine with some of the phosphate in your food, allowing it to pass out of your body with your stool.

It is essential for phosphate binders to be taken with meals and snacks that contain phosphate, as prescribed.

You may find that the dose and type of your binders may change depending on your blood levels of calcium and phosphate.

Remember to take your binders with you if you are eating out.

It is important to be aware that phosphate binders can impact the absorption of other medications, examples include levothyroxine, iron supplements and antibiotics. To ensure that the phosphate binders do not interact with your other medication it is advisable to discuss this with your doctor or pharmacist.

Types of Phosphate Binders

Name of the binder	When to take	How to take
Calcichew (calcium carbonate)	Just before meals, during or just after each meal.	Chew
Renacet (calcium acetate)	With meals	Swallow Whole
Renvela Powder (Sevelamer Carbonate)	With meals	Dissolve in 60ml water Use within 30 minutes
Renagel (sevelamer hydrochloride)	With meals	Swallow Whole
Renvela (sevelamer carbonate)	With meals	Swallow Whole
Fosrenol (lanthanum carbonate)	During or just after meals.	Chew (also available as powder)
Velphoro (sucroferric oxyhydroxide)	With meals	Chewed or crushed. (Not swallowed whole).

Where is the phosphate in my diet?
Meal:

Estimated phosphate (mg):

Total phosphate in my diet:

To reduce phosphate I need to:

Binder distribution:
Meal ________________ take ________________ binders
Snack ________________ take ________________ binders
Meal ________________ take ________________ binders
Snack ________________ take ________________ binders

Worcestershire Acute Hospitals NHS Trust
Covering the Alexandra Hospital, Redditch, Worcestershire Royal Hospital and Kidderminster Hospital

Tel: 01905 760 136
Email: [email protected]

Given out by Registered Dietitian:
Name: …………………………………………….…………

Produced by:
The Nutrition & Dietetic Department
Worcestershire Acute Hospitals NHS Trust

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

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