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1 Think about phosphate step 1 Phosphate (PO 4 ) is a mineral that your body needs to make healthy bones and tissues. Your kidneys control the amount of phosphate that is excreted in the urine. When your kidneys are not working properly, they become less efficient at excreting phosphate causing the level of phosphate in your blood to gradually rise. A raised phosphate level, particularly when combined with a high calcium level, is associated with calcium deposits in blood vessels increasing the risk of heart attacks and strokes. A high phosphate levels can affect your bones too, making them ache and become brittle. It is also associated with an increased risk of death. The following guidelines show you how you can reduce your phosphate level by controlling the amount of phosphate you eat. Produced by Renal Dietitians working within University Hospitals of Leicester September 2017

2 Summary of main points - Eat less high phosphate containing foods o Limit the amount of dairy foods you eat o Take care with portion sizes of meat/fish o Avoid high phosphate foods as listed o If you eat high phosphate foods occasionally then consider eating smaller portions - Avoid phosphate containing additives o Check ingredients lists o Where you find phosphate containing additives, look at alternative brands. They may use different ingredients o Choose more fresh / unprocessed food - Take phosphate binder medications if they are prescribed o Phosphate binders should be taken with food (particularly higher phosphate food such as meat/fish/dairy/pulses) as they do not work if taken at other times o Check the instructions on the medicines packaging as different phosphate binders have different instructions o If you struggle to take the medication prescribed for you then please talk to your Health Professional (Doctor, Dietitian, Nurse) as there are alternatives available.

3 THINK ABOUT PHOSPHATE step 1 To help control your phosphate levels, you will need to reduce the amount of phosphate in your diet. Phosphate is found in all foods but some contain more than others. Foods high in protein tend to contain more phosphate meat/fish/pulses/eggs/dairy. It is present in two forms organic (that which is naturally within the food) and inorganic (added phosphate as additives / preservatives). The amount of phosphate that is absorbed from your food varies depending on what the food source is. Organic phosphate (naturally occurring) - Phosphate and protein are found together in food therefore when you eat protein-rich foods you are likely to be eating phosphate-rich foods. For good balance of protein and phosphate, choose more meat / fish and pulses rather than dairy foods such as cheese, milk and yoghurt as these have very much more phosphate in them - Organic phosphate is absorbed more from animal produce such as meat and dairy foods compared to vegetable sources. Inorganic phosphate (added phosphate) - This is found in processed foods - Added phosphate (inorganic) is highly absorbed from food so although the amount in the food may be low it is almost entirely absorbed. Information is available about the naturally occurring phosphate in food so the Dietitians can guide you about which foods to limit however it is more difficult to make specific recommendations about the additives found in processed foods - you will need to read ingredients labels.

4 Eat less high phosphate containing foods Dairy foods such as cheese and milk are particularly high in phosphate so if you limit how often you choose them you can lower your phosphate intake more easily. The table below gives guidelines on suitable portion sizes of protein foods. Protein foods and general guidelines on amounts to eat: Meat/Poultry Fish Milk Yogurt Cheese Eggs Daily/weekly allowance 100g (4oz) main meal and 50g (2oz) snack meal (4-6oz) main meal and 50-75g (2-3oz) snack meal. NB Oily fish tends to have more phosphate than white fish so aim for the smaller portion size of oily fish 1/3 pint (approx. 200ml) per day 2 x 125g pots per week 50g (2oz) hard cheese per week (e.g. Cheddar / Red Leicester) Cream cheese (e.g. Philadelphia) and cottage cheese are lower phosphate choices Avoid cheese spread e.g. Primula/Dairylea Freely NB 95% of the phosphate is in the yolk therefore egg whites alone are low in phosphate Non-dairy milk substitutes Milk substitutes made from other ingredients such as soya, almond, oat, hazelnut and rice are available in the shops. Soya milks tend to be only marginally lower in phosphate than cow s milk. Nut and rice milks are lower in phosphate but often fortified with calcium. Some brands use calcium phosphate as the fortifying ingredient therefore adding phosphate to them. Check labels on individual products to find one that doesn t have added calcium phosphate.

5 In addition try to avoid the following particularly high phosphate foods: MEATS Veal, game, liver, kidney, heart, sweetbreads, paté FISH Tinned fish with bones, e.g. pilchards, sardines. Fish roe, kippers, whitebait. SHELLFISH Crab, scampi, prawns CEREALS All Bran, muesli and cereals containing nuts. Biscuits containing chocolate and nuts. Cakes and biscuits containing baking powder e.g. scones. Puri with added baking powder. Savoury Indian snacks (e.g. chevda, gathia, sev) DRINKS Malted milk drinks, drinking chocolate, cocoa. MISCELLANEOUS Nuts, chocolate, fudge, any Indian sweets containing milk powder or ground nuts. Other nuts (e.g. almonds, peanuts), twiglets, yeast extract (e.g. marmite, Bovril), peanut butter, naan bread, pizza Avoid phosphate containing additives Phosphate - containing additives are used to enhance the flavour of food, extend shelf life and as a raising agent. The types of foods in which these additives are found are processed meat/poultry (packet cold meats / sausages / chicken products), processed cheeses, fast food, drinks, bakery products (cakes/breads) and other processed foods. Food manufacturers do not have to label food showing the phosphate content but by looking at the ingredients lists you will be able to see if any phosphate-containing additives have been used. Different brands of the same foods sometimes use different additives so you may be able to find a brand without added phosphate. It will be indicated by names or E numbers. Some of the names of these are shown below:- phosphate, polyphosphate, diphosphate, triphosphate, phosphoric acid E338, E339, E340, E341, E342, E343, E450, E451, E452, E541, E1410, E1412, E1413, E1414, E1442

6 The easiest way to avoid eating lots of phosphate from additives is to use fresh / unprocessed foods. When you are eating out, many restaurant chains have information regarding ingredients so don t be afraid to ask if this information is available. Additional information is available about home baking as some raising agents contain phosphate. Take phosphate binder medications if they are prescribed In addition to diet changes, you may also be prescribed some tablets known as phosphate binders. There are many different options of tablets available. These tablets should be taken when you eat as they work by binding to phosphate in your food and reducing the amount of phosphate that is absorbed from it. Each tablet has specific instructions about when to take it to maximise the efficiency. Follow the guidance below. Branded name Generic name When / how to take Renacet Calcium acetate Swallow with food Phosex Calcium acetate Swallow with food Calcichew Calcium carbonate Chew mins before food Adcal Calcium carbonate Chew mins before food Osvaren Calcium acetate / Swallow with food magnesium carbonate Renagel Sevelamer Swallow with food hydrochloride Renvela Sevelamer Carbonate Swallow with food Fosrenol Lanthanum carbonate Chew with/after food (NOT before) Velphoro Sucroferric oxyhydroxide Chew with food Developed and produced by Leicestershire Nutrition and Dietetic Services September 2017 LNDS082 Crown Copyright Leicestershire Partnership NHS Trust and University Hospitals of Leicester NHS Trust Access our website on

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