The Diet for Chronic Kidney Disease (CKD)

The Diet Must Be Individualized and Will Change as CKD Progresses.

U.S. Department of Health and Human Services National Institute of Health

This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD), especially among communities most impacted by the disease, NKDEP works in collaboration with a range of government, nonprofit, and health care organizations to: raise awareness among people at risk for CKD about the need for testing; educate people with CKD about how to manage their disease; provide information, training, and tools to help health care providers better detect and treat CKD; and support changes in the laboratory community that yield more accurate, reliable, and accessible test results. To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from NIDDK, please visit: http://www.niddk.nih.gov.

Meet our Presenters

Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.

Ms. Kuracina is the lead author of the American Dietetic Associations CKD Nutrition Management Training Certificate Program and NKDEPs nutrition resources for managing patients with CKD. Ms. Kuracina has more than 20 years of experience in clinical dietetics with the Indian Health Service (IHS). She is a senior clinical consultant with the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. She also serves as a diabetes dietitian and coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico, a role in which she routinely counsels patients who have chronic kidney disease (CKD).

Meet our Presenters

Andrew S. Narva, M.D., F.A.C.P. Dr. Narva is the director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health (NIH). Prior to joining NIH in 2006, he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Via telemedicine from NIH, he continues to provide care for IHS patients who have chronic kidney disease. A highly recognized nephrologist and public servant, Dr. Narva has served as a member of the Medical Review Board of ESRD Network 15 and as chair of the Minority Outreach Committee of the National Kidney Foundation (NKF). He serves on the NKF Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Diabetes and is a member of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Expert Panel.

Participants will be able to:

1. Compare the different food groupings for normal, diabetes, and kidney diets 2. Describe national trends in intakes of sodium, protein, phosphorus, and potassium 3. Use the U.S. Department of Agriculture (USDA) National Nutrient Database for Standard Reference, Release 23, to compare food items for phosphorus, sodium, and potassium contents

Brief Review
Blood pressure control may slow CKD progression.
Limit sodium to 1,500 milligrams. Target blood pressure goal is individualized. A target blood pressure < 130/80 mm Hg is often recommended but without strong evidence.

Diabetes control early may lower CKD risk later.

Target A1c is individualized, based on age, comorbid conditions, and frequency of hypoglycemia. Spontaneous improvement in glycemic control may indicate CKD progression.

Review
Urine albumin is a marker of kidney damage.
Higher levels are associated with more rapid progression of CKD. Weight loss, sodium restriction, certain blood pressure medications, avoidance of excessive protein intake, and tobacco cessation may reduce urine albumin.

CKD increases risk of cardiovascular disease (CVD).

Nontraditional risk factors for CVD include certain complications seen in CKD.

Complications are complex

Anemia
Iron and erythropoietin

Hypoalbuminemia Hyperkalemia (serum K 5.0 mEq/L) Metabolic acidosis

Maintaining serum CO2 22 mEq/L may be beneficial. Dietary protein may play a role.

Bone disorders
1,25(OH)2 vitamin D, calcium, phosphorus

Topics
Body weight Energy needs Dietary Reference Intakes Food groups Protein, sodium, phosphorus, potassium Food preparation techniques

Assessing body weight in CKD

No standardized norms for CKD. Use clinical judgment.
Actual weight Weight history (recent and long term) Weights over time

No evidence to base adjustment for obesity or edema in CKD.

Reference: http://www.adaevidencelibrary.com

Which weight to use?

Ideal (desirable) body weight Standard body weight Edema-free actual body weight Adjusted edema-free body weight
Used for dialysis patients

Adjusted body weight Hamwi method Body Mass Index (BMI)

Use your clinical judgment

When using current body weight,
May overestimate dietary needs with obesity May underestimate dietary needs with underweight

No adjustment method is better than any other.

Energy needs are not higher in CKD

Individualized Need 2335 kilocalories (kcal)/kg to maintain nutritional status.
Current weight Weight-loss goals Age and gender Physical activity Metabolic stressors

May see spontaneous decrease in intake as CKD progresses.

Reference: Byham-Gray, J Renal Nutr 2006; 16(1):1726.

Comparative Standards used for assessment of intake and needs.

DIETARY REFERENCE INTAKES

Dietary Reference Intakes (DRIs)

Established by Food and Nutrition Board of the Institute of Medicine (National Academy of Sciences). Provide four nutrient-based reference values for planning and assessing diets. Established to meet the needs of healthy individuals across different life stages (age) and gender.

DRI definitions
Estimated Average Requirement (EAR)
Requirements for half the healthy individuals

Recommended Dietary Allowance (RDA)

Requirement for 9798% of all healthy individuals

Adequate Intake (AI)

Observed or experimentally determined
Used when RDA is not available

Tolerable Upper Intake Level (UL)

Highest average daily intake unlikely to pose a risk of adverse health effects to most people in the general population Level at which risk of harm begins to increase

DRIs are used in the Nutrition Care Process

Comparative Standards for Assessment
Total estimated ______ needs assumed to be consistent with the DRIs unless otherwise specified.

DRIs are for healthy people. Requirements for CKD are not firmly established.

Reference: International Dietetics & Nutrition Terminology (3rd edition)

DRIs for selected nutrients

Nutrient
Protein (g/ day) Sodium (mg/ day)

Age, condition
> 19 years CKD, HTN, DM, > 50 years old, African Americans > 19 years

DRI
EAR RDA RDA

Women
38 g 46 g* (0.8 g/kg) 1,500

Men
46 g 56 g (0.8 g/kg) 1,500

UL EAR RDA UL AI

2,300 580 700 4,000 3,000 4,700

2,300 580 700 4,000 3,000 4,700

Phosphorus (mg/day)

> 1970 years > 70 years

Potassium (mg/day)

> 19 years

Institute of Medicine (http://www.iom.edu)

DM = diabetes mellitus; HTN = hypertension *Reference woman = 57 kg; Reference man = 70 kg; Dietary Guidelines for Americans, 2010

What We Eat in America (WWEIA) helps identify nutrient intakes

Dietary intake interview of National Health and Nutrition Examination Survey (NHANES)

Most recent has 20072008 data Based on two 24-hour diet recalls

Reference: http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/0708/ Table_1_NIN_GEN_07.pdf

DRIs are used as comparative standards when assessing intake

Protein RDA = 0.8 g/kg Sodium (Na) = 1,500 mg for CKD Phosphorus (P) RDA = 700 mg Potassium (K) AI = 4,700 mg

Reference: Dietary Guidelines for Americans, 2010; IOM, 2006

Foods grouped together because they share similar nutritional properties.

FOOD GROUPS

Food groups for health and chronic disease focus on specific content

USDA Food Pattern (MyPlate)

Dietary Guidelines, 2010 Vegetables sorted by color; animal and vegetable proteins

Diabetes
Carbohydrate content

Chronic kidney disease

Protein, sodium, phosphorus, and potassium content

Food groups get more complicated

USDA Food Pattern
Grains Vegetables: Dark green Red & orange Beans & peas Starchy and other Fruit and juices Milk and milk products Protein foods Seafood Meat, poultry, eggs Nuts, seeds, soy products Meat/meat substitutes

Diabetic Exchange
Carbohydrates: Starch Fruits Milk Other Nonstarchy vegetables

National Renal Diet

Breads, Cereals, Grains High Na High P Vegetables Low, medium, high K Fruit Low, medium, high K Protein (including milk) High Na High P Vegetarian High Na High P Calorie Flavoring

Oils Solid fats and added sugars

Fats Alcohol

USDA Food Pattern* for 2,000 Calories is very similar to DASH diet
Grains Whole (> 3 servings) 6 ounces (oz.) 2 cups (c.)

Vegetables Dark-green, red & orange, beans & peas, other, starchy Fruit and juices Milk and milk products Protein foods Meat, poultry, eggs, fish/seafood, beans & peas; nuts, seeds, and soy products Oils Solid fats and added sugars

2 cups 3 cups 5 oz.

27 grams 258 calories (13% total kcal)

* Previously referred to as MyPyramid

Selected nutrient contents of USDA Food Pattern

Food Group
Grains (1 oz.) Grains (1 oz.) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Fruit and juices (1/2 cup) Milk (1 cup) Meat & beans (1 oz.) Whole Refined Dark-green Red & orange Beans & peas Starchy Other

Pro (g)
2.4 2.2 1.6 0.7 8.0 1.7 0.9 0.7 8.3 6.9

Na (mg)
87 153 30 41 3 5 57 3 103 93

P (mg)
85 33 39 25 119 43 21 17 247 63

K (mg)
91 29 229 214 363 286 162 213 382 91

Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93S107.

Most protein-rich foods are a source of phosphorus (P) and potassium (K)
Amount
Meat Poultry Fish & seafood Beans & peas Egg Egg white* Nuts, seeds Milk 1 ounce 1 ounce 1 ounce c. cooked 1 large 1 large ounce 1 cup

Pro (g)
7.0 8.2 6.5 4.0 6.3 3.6 3.3 8.3

Na (mg)
145 24 51 2 62 55 16 103

P (mg)
62 56 59 60 86 5 70 247

K (mg)
105 70 82 182 63 54 93 382

Soymilk from added 1 cup 6.4 153 250 * Data (with http://www.nal.usda.gov/fnic/foodcomp/cgi-bin/list_nut_edit.pl284 Ca, vitamins A&D)*
Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93S107.

Summary: Basic Food Groups

Whole grains are higher in P and K. Vegetables vary widely in K content.
Dried beans and peas are rich in K.

Most protein-rich foods are a source of P and K.

Egg whites are low in phosphorus.

Diabetic food exchanges are grouped primarily by carbohydrate content

Food Carbohydrate (g) Protein (g) Fat (g) Calories

Starch Fruit Milk Other carbohydrates Nonstarchy vegetables Meat and meat substitutes Fats Alcohol

15 15 12 15 5 Varies

03 8 Varies 2 7 -

01 08 Varies 08+ 5 -

80 60 100160 Varies 25 45100 45 100

Reference: Adapted from http://nutritioncaremanual.org/vault/editor/docs/Choose_Your_Foods_lists_bw_Layout_1.pdf

National renal diet reflects variability within food groups due to processing
Protein Calories (g) High protein High Na High P Vegetarian protein High Na, P, K Breads, starches High Na, P Vegetables Low, medium, high K Fruits Low, medium, high K Calorie Flavor 68 50100 Sodium (mg) 20150 200400 20150 10200 250400 0150 150400 050 Phosphorus (mg) 50100 Potassium (mg) 50150

70150 23 23 50200 10100

100300 80150 200400 1070 100200 1070

60150 250500 10100 20150 150250 250550 20150 150250 250550 0100 0100

01

20100

010

120

01 0

100150 020

0100 250300

0100 020

Food groupings are more complicated with chronic disease

Carbohydrate content (diabetes) Protein content (CKD) Sodium content (CKD and diabetes) Phosphorus content (CKD) Potassium content (CKD)

The RDA for protein is 0.8 g/kg/body weight.

PROTEIN

Most U.S. adults eat more protein than recommended

Reference: http://www.ars.usda.gov (IOM, 2005; FDA, 2009)

Adequate, not excessive, protein for CKD

The RDA for protein is 0.8 g/kg. Reducing excessive protein intake will reduce nitrogenous waste, phosphorus, potassium, and metabolic acids.

A spontaneous decrease in protein intake may occur as estimated glomerular filtration rate (eGFR) declines.

CKD patients may report an aversion to certain animal proteins.

Which type of protein is best in CKD?

Animal or vegetable?

Data is limited in regard to CKD. If kidney function is normal:

In short-term studies, increased animal protein intake may be associated with an increased GFR.

If CKD is present:
In obese rats, soy protein may result in a slower rate of glomerulosclerosis compared to casein. Excessive animal and vegetable protein intake may accelerate progression in humans.

References: Maddox et al. Kidney Int 2002; 61(1):96104; Bernstein et al. J Am Diet Assoc 2007; 107(4):644650.

How much high biological value (HBV) protein is needed in CKD?

Evidence is lacking or limited in CKD. ADA Evidence Library has no recommendation or supporting literature.

Recommendations vary.

References: http://www.adaevidencelibrary.com; http://nutritioncaremanual.org; http:// www.kidney.org/professionals/KDOQI/guidelines_updates/doqi_nut.html; http://www.kidney.org/ professionals/KDOQI/guideline_diabetes/guide5.htm

Adequate protein may seem like a protein restriction (a lot less meat)

The 70-kg reference man needs 0.8 g/kg or 56 grams protein per day.

If we use 50% HBV to estimate his needs, he needs about 4 ounces.

[(.50)(56 grams) = 28 grams]

If we use 75% HBV to estimate his needs, he needs about 6 ounces.

[(.75)(56 grams) = 42 grams]

How much protein remains for other food groups?

50% HBV 56 g protein total 28 g HBV protein 28 g other protein

75% HBV 56 g protein total 42 g HBV protein 14 g other protein

How much protein remains for other food groups?

50% HBV 56 g protein total 28 g HBV protein 28 g other protein 75% HBV 56 g protein total 42 g HBV protein 14 g other protein
Lower Protein Pro (g) 2.22.4 0.71.7 0.7 0 0

Answer: Not much

Grains (1 oz.) Vegetables (1/2 cup) Fruits (1/2 cup) Fats and oils Sugars

Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93S107.

Divide the remaining protein between the other food groups

50% HBV Protein remaining 9 grains (2 g)

28 g 18 g 10 g

Protein remaining cup milk (4 g)

6 g 4 g 2 g

Protein remaining

10 g 6g

4 vegetables (1 g) 4 g

Protein remaining 3 fruit (01 g).

2 g 2 g 0g

Work toward smaller portions of protein foods

One serving of meat, poultry, or fish is about the size of a deck of cards.
3 oz. cooked meat, poultry, or fish 21 g protein

Drink a smaller glass of milk.

cup = 4 g protein

Eat a smaller bowl of beans.

cup = 4 g protein

Eat a small amount of nuts or seeds.

1 ounce = 6.6 g protein

Educational resource for dietary protein

National Kidney Disease Education Program Protein Tips for People with CKD

http://nkdep.nih.gov/resources/nkdep-nutritionfactsheetssodium-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf

Protein: Take-home messages

Most people eat more protein than required. Intake should be adequate, not excessive. In early CKD, reduce portions toward one serving per meal. In advanced CKD, a spontaneous reduction in protein intake may occur. In advanced CKD, encourage intake of protein-rich foods that are tolerated and accepted by the patient.

Limit sodium to 1,500 mg a day.

SODIUM

U.S. adults sodium intake exceeds the UL

Reference: http://www.ars.usda.gov (2009), IOM (2006), FDA (2009)

2010 Dietary Guidelines recommend 1,500 mg sodium for CKD patients

Others included in the recommendation are:

African Americans People with hypertension People with diabetes People 51 years and older

Everyone else should aim for 2,300 mg of sodium (UL) per day.

Reference: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ Chapter3.pdf

Sodium intake

sodium excretion

About 90% of total intake is from salt. Most (98%) is absorbed in small intestine. Most is excreted in the urine.

Sodium intake is higher than recommended

Reference:
http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx

INTERMAP: Salt is the leading source of sodium in middleaged Americans

Reference: Adapted from Anderson et al. J Am Diet Assoc 2010; 110(5):736745.

High-sodium foods are not the only source;

frequent consumption of lower sodium foods adds up

Reference: Dietary Guidelines for Americans, 2010

Educational resource for dietary sodium

National Kidney Disease Education Program Sodium Tips for People with CKD

http://nkdep.nih.gov/resources/nkdep-nutritionfactsheetssodium-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.pdf

Possible trend:
Food companies may replace NaCl with KCl in lower sodium products. Read ingredient list for potassium chloride in these types of products.

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.pdf

ACTIVITY
Compare Na and K contents of 100 g of vegetable soup.
http://www.nal.usda.gov/fnic/foodcomp/search/

Look up these specific items Soup, vegetarian vegetable, canned, condensed (06068) Soup, vegetable, canned, low sodium, condensed (06217)

Na -

K -

ACTIVITY
Compare Na and K contents of 100 g of vegetable soup.
http://www.nal.usda.gov/fnic/foodcomp/search/

Look up these specific items

ANSWERS

Na 672 385

K 171 433

Soup, vegetarian vegetable, canned, condensed (06068) Soup, vegetable, canned, low sodium, condensed (06217)

Sodium: Take-home messages

Most people eat more sodium than recommended. Aim for 1,500 mg sodium per day for CKD. Potassium chloride (KCl) may replace salt in lower sodium products; read ingredient list. Salt substitutes (mostly KCl) may not be appropriate for CKD.

Inorganic phosphorus is absorbed more readily than organic phosphorus.

PHOSPHORUS

Review: Control of serum phosphorus

The reference range is 2.74.6 mg/dL. Serum levels may be within range until CKD is advanced due to increased renal excretion via Parathyroid Hormone (PTH) and Fibroblastic Growth Factor-23 (FGF-23). Intestinal absorption is increased by 1,25(OH)2D. Phosphorus binders may be prescribed. Phosphorus restriction may be beneficial.

References: Liu & Quarles, J Am Soc Nephrol 2007; 18(6):16371647; Fadem & Moe, Adv Chronic Kidney Dis 2007; 14(1):4453.

Phosphorus absorption

excretion

Absorption is both passive and active. Only 4060% of phosphorus is absorbed from whole foods (organic sources).

About 90% is absorbed from inorganic sources such phosphorus food additives.

90% of the phosphorus is filtered by glomeruli and most is reabsorbed within the tubules.

The kidneys play a major role in regulation.

Reference: IOM, 1997; Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519530.

Most U.S. adults exceed the RDA for phosphorus

Reference: http://www.ars.usda.gov (2009), FDA (2009), IOM (1997)

Phosphorus absorption varies by source: organic < inorganic

Organic phosphorus 4060% absorbed Phytates absorption Dairy products Meat, poultry, fish Soy (soy milk, tofu) Nuts and seeds Dried beans and peas Whole grains

Reference: Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519530.

Phosphorus content by food group (organic sources)

Food Group
Grains (1 oz.) Grains (1 oz.) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Vegetables (1/2 cup) Fruit and juices (1/2 cup) Milk (1 cup) Meat & beans (1 oz.) Oils (1 tsp.) Whole Refined Dark-green Red & orange Beans & peas Starchy Other

P (mg) 85 33 39 25 119 43 21 17 247 63

Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93S107.

Whole grains > refined grains

Phytates reduce absorption

Protein-rich foods have phosphorus

Most protein-rich foods are a source of phosphorus

Food Meat Poultry Fish Beans & peas Egg Egg white* Nuts/seeds Milk Soymilk (fortified)* Amount 1 ounce 1 ounce 1 ounce c. cooked 1 large 1 large ounce 1 cup 1 cup P (mg) 62 56 59 60 86 5 70 247 250
More typical intake 6 ounces steak 372 mg phosphorus

1 cup beans 240 mg phosphorus Still high potassium Phytates reduce absorption

2 egg whites 10 mg phosphorus

*http://www.nal.usda.gov/fnic/ foodcomp/cgi-bin/ list_nut_edit.pl Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93S107.

Many products may have added phosphate

Baked goods Self-rising flour, cake mix, waffle mix, Monocalcium phosphate pancake mix, muffin mix, Dicalcium phosphate reduced sodium mixes Calcium acid phosphate Dry mixes, fruit juices, soymilk Cooked cereals, extruded dry cereals Grated cheese, instant puddings Canned fruits and vegetables Baked potato chips Vitamin and mineral supplements, enteral products, prescription and over-the-counter tablets Tricalcium phosphate Tricalcium phosphate Monocalcium phosphate Monocalcium phosphate Monocalcium phosphate Tricalcium phosphate Dicalcium phosphate

Beverages Cereals Dairy Fruit & vegetables Potatoes Pharmaceuticals

Reference: Adapted from http://www.foodadditives.org/phosphates/phosphates_used_in_food.html

Educational resources for dietary phosphorus

National Kidney Disease Education Program Phosphorus: Tips for People with Chronic Kidney Disease (CKD) http://www.nkdep.nih.gov/resources/nkdepnutritionfactsheets-phosphorus-508.pdf

Website for phosphorus in fast foods http://www.case.edu/med/ccrhd/phosfoods/

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf

Inorganic phosphorus

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf

Phosphorus-to-protein ratio is a new way to look at phosphorus in foods

Ratio is based on phosphorus (mg)/protein (g). Ratio helps identify foods to avoid (high ratio). The ratio is not easy to identify from Nutrition Facts labels.

Reference: Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519530.

P-to-Protein Ratio < 5

Egg white, large Orange roughy, 3 oz. Lamb, 3 oz. Tuna, water packed, 3 oz. Chicken drumstick Beef, 3 oz. Ground beef, 3 oz. Chicken breast, 3 oz. Turkey, 3 oz. Pork sausage, 2 links Taco, fast food

1.4

P-to-Protein Ratio 10 < 15

Egg substitute, c. Salmon-sockeye, 3 oz. Bagel, 4 Cheeseburger, fast food Bologna, 2 slices Cottage cheese, c. Tuna, oil packed, 3 oz. Tempeh, c. Tofu raw, c. Peanut butter, 1 T.

10.1 10.1 10.2 10.5 10.7 10.7 10.7 10.8 12.0 13.1

P-to-Protein Ratio 5 < 10

4.5 6.3 6.4 6.5 7.0 7.5 7.5 7.5 8.6 9.8

Whole egg, large from Kalantar-Zadeh 13.3 2010 Reference: Adapted et al.,

P-to-Protein Ratio 15 < 25 Peanuts, 1 oz. Baked beans/franks, c. Edamame, c. Black beans, c. Ricotta cheese, c. Pinto beans, c. Cream cheese, 1 T. Soymilk, c. Mozzarella, 1 oz. Cheddar, 1 oz. American cheese, 1 oz. 15.1 15.5

P-to-Protein Ratio > 25

Egg/sausage biscuit, fast food Milk 2%, 1 c. 15.6 15.8 16.1 16.2 16.7 17.4 20.1 20.4 Pecans, 20 halves Half and half, 1T. Cashews, 1 oz. Tahini, 2 T. Sunflower seeds, 3 T. Nondairy creamer, liquid, 1 oz.

28.1

28.3 30.4 31.8 32.3 43.1 59.7 63.3

Reference: Adapted from Kalantar-Zadeh et al., 2010

22.8

The amount of phosphorus in foods is not easy to discern

Nutrient data bases and food lists include total amounts and no information about organic and inorganic phosphorus.

The phosphorus-to-protein ratio is not easily determined or obtained.

PHOS on ingredient list will help identify food with phosphorus food additives.

Use ingredient list to find phosphorus additives, look for PHOS

Phosphorus is not required on Nutrition Facts labels. Nutrition Facts labels may list phosphorus, and the % Daily Value used is 1,000 mg.

Read ingredients for PHOS additives. Choose a different food if PHOS is listed.

References: http://www.nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf; http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/ FoodLabelingNutrition/FoodLabelingGuide/ucm064928.htm

Reference: http://www.nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf

ACTIVITY Nutrient analysis: Beverages

Compare any 12 oz. cola carbonated beverage with 12 oz. of any other carbonated beverage for P, K, and Na content in mg.

Check tea (ready-to-drink, with lemon flavor) and compare 12 oz. of three different brands for P, K, and Na content in mg.

Reference: http://www.nal.usda.gov/fnic/foodcomp/search/

Nutrient analysis: Beverages

Beverage Carbonated beverage, cola, contains caffeine Carbonated beverage, low calorie, cola or pepper type, with aspartame, contains caffeine Carbonated beverage, lemon-lime, without caffeine Volume P (mg) K (mg) Na (mg) 12 oz. 12 oz.

12 oz.

Tea, ready-to-drink, (Brand A) iced tea, with 12 oz. lemon flavor Tea, ready-to-drink, (Brand B) iced tea, with lemon flavor 12 oz.

Tea, ready-to-drink, (Brand C) iced tea, with 12 oz. lemon flavor

Nutrient analysis: Beverages

Beverage Carbonated beverage, cola, contains caffeine Carbonated beverage, low calorie, cola or pepper type, with aspartame, contains caffeine Carbonated beverage, lemon-lime, without caffeine Volume P (mg) K (mg) Na (mg) 12 oz. 12 oz. 37 32 7 28 15 28

12 oz.

0 4 95 132

4 37 70 70

33 15 77 77

Tea, ready-to-drink, (Brand A) iced tea, with 12 oz. lemon flavor Tea, ready-to-drink, (Brand B) iced tea, with lemon flavor 12 oz.

Tea, ready-to-drink, (Brand C) iced tea, with 12 oz. lemon flavor

Phosphorus: Take-home messages

The RDA for phosphorus is 700 mg/day. Most people eat more than the recommended amount. Serum level may be normal until CKD is advanced. Absorption increases with 1,25(OH)2 vitamin D. Phosphorus binders may be prescribed; take with meals. Inorganic phosphorus in food additives is absorbed more readily. Read ingredient list for PHOS to find added phosphorus.

Restrict dietary potassium when serum levels are elevated.

POTASSIUM

U.S. adults do not meet the AI for potassium intake

Reference: http://www.ars.usda.gov (2009), FDA (2009), IOM (2006)

Review: Control of serum potassium

The reference range is 3.55.0 milliequivalents (mEq)/liter(L). The renin-angiotensin-aldosterone system (RAAS) is involved in potassium balance. Medications that affect RAAS increase risk of hyperkalemia. Transcellular shifts may increase serum potassium in CKD.

e.g., inadequate insulin, metabolic acidosis

Dietary Guidelines 2010 includes foods rich in potassium for general population

Key Recommendations:
Increase vegetable and fruit intake. Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans and peas. Consume at least one-half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains.

Reference: Dietary Guidelines for Americans, 2010

Key Recommendations (continued)

Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages. Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds.

Reference: Dietary Guidelines for Americans, 2010

Need to restrict dietary potassium when serum level is elevated

Specific level of eGFR does not determine need for potassium restriction.

Restrict potassium to help achieve and maintain safe level.

The level of restriction should be individualized.

Numerous sources contribute to potassium levels in CKD

Potassium-rich foods Salt substitutes
Low-sodium products may have added KCl.

Medications:
K supplements
KCl, K citrate

Impair excretion
ACEi ARBs K+-sparing diuretics Nonsteroidal antiinflammatory drugs

Herbs and dietary supplement (examples)

Noni juice (56 mmol/L) Alfalfa Dandelion Horsetail Nettle

Potassium food additives

References: Palmer, N Eng J Med 2004;351(6):58592; Hollander-Rodriguez & Calvert, Am Fam Physician. 2006;73(2):28390.

Educational resource for dietary potassium

National Kidney Disease Education Program Potassium Tips for People with CKD
http://nkdep.nih.gov/resources/nkdep-nutritionfactsheetspotassium-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf

Potassium: Take-home messages

Most U.S. adults do not get adequate potassium from their diets. An adequate intake (4,700 mg) of potassium may help lower BP in the general population. Restrict dietary K when serum levels are high. Products with KCl should be avoided. Some low-sodium products may use KCl in place of NaCl; read ingredient list to identify these products.

Boiling foods may reduce levels of oxidants and potassium.

FOOD PREPARATION TECHNIQUES

Food preparation techniques may play a role in CKD

Certain cooking techniques may reduce Advanced Glycation End Products (AGEs) formation in food.

Leaching potatoes and other tubers prior to boiling may not be necessary to lower potassium content.

References: Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11, Burrowes & Ramer, J Renal Nutr 2006; 16(4):304311.

Bethke & Jansky, J Food Sci 2008; 73(5):H80H85;

Dietary protein and fat may play a role in AGE formation

AGEs are formed during cooking. About 10% of dietary AGEs are absorbed. Frying, grilling, or broiling with fat result in higher levels of AGEs compared to steaming or stewing.

Reference: Uribarri & Tuttle, Clin J Am Soc Nephrol 2006; 1(6):12931299.

Dry heat or added fat may increase AGE formation during cooking

Reference: Adapted from Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11

Tips to lower AGE formation

Use water-based techniques such as steaming, poaching, boiling, and stewing. Marinate in lemon juice, tomatoes, or vinegar for 1 hour or more before cooking. Include more low-AGE proteins such as low-fat and non-fat dairy, soy, legumes, rice, corn, and eggs in meals.

References: Uribarri & Tuttle, Clin J Am Soc Nephrol 2006; 1(6):12931299; Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11

Boiling alone removes enough potassium from tubers

Immediately boiling shredded potatoes lowers potassium content more than an overnight soak in large amounts of water (leaching). Double cooking (boiling) lowers the potassium content of many Caribbean tuberous root vegetables.

References: Bethke & Jansky, J Food Sci 2008; 73(5):H80H85; Burrowes & Ramer, J Renal Nutr 2006; 16(4):304311.

Over 2,300 food additives are currently in use.

FOOD ADDITIVES

Food additives have a purpose

Food additives may:
Provide nutrition Help maintain quality and freshness Aid in processing and preparation Increase food appeal

Reference: http://www.foodadditives.org/pdf/Food_Additives_Booklet.pdf

The FDA approves the use of food additives in any food

Listing of Food Additive Status at FDA:

http://www.fda.gov/Food/FoodIngredientsPackaging/ FoodAdditives/ucm191033.htm

Some food additives contain phosphorus, sodium, potassium

Some examples:
Potassium glycerophosphate
Dietary supplement

Potassium phosphate (monobasic)

Frozen eggs as a color preservative

Sodium phosphate (mono-, di-, and tribasic)

Cheese, artificially sweetened fruit jellies, frozen eggs, frozen desserts

Sodium trimetaphosphate
Food starch modifier

ACTIVITY: Food additives may increase phosphorus, potassium, and/or sodium content
Breakfast Pancake, plain, prepared from recipe Pancake, plain, dry mix, complete, prepared Pancake, whole-wheat, dry mix, incomplete, prepared Egg, white, raw, fresh Egg, yolk, raw, fresh Egg substitute, liquid or frozen, fat-free Amount P(mg) K (mg) 4 4 4 Na (mg) -

1 large 1 large c.

Reference: http://www.nal.usda.gov/fnic/foodcomp/search/

ACTIVITY: Enhanced and fortified foods may have more P, K, or Na

Amount Pork, fresh; loin, tenderloin, separable lean only; cooked, roasted Pork, fresh, enhanced; loin, tenderloin, separable lean only; cooked, roasted Soymilk, original and vanilla, unfortified Soymilk (all flavors), lowfat, with added calcium, vitamins A and D Soymilk, chocolate, unfortified Orange juice, raw Orange juice, includes from concentrate, fortified with calcium (* read footnote) 100 g (3 oz.) 100 g 1 cup 1 cup 1 cup cup cup P(mg) K (mg) Na (mg) -

* Phosphorus content varies among brands, depending upon calcium compound used (calcium phosphate, calcium citrate, etc.).

ACTIVITY: Food additives may increase phosphorus, potassium, and/or sodium content
Breakfast Pancake, plain, prepared from recipe Pancake, plain, dry mix, complete, prepared Pancake, whole-wheat, dry mix, incomplete, prepared Egg, white, raw, fresh Egg, yolk, raw, fresh Amount 4 4 4 P(mg) K (mg) 60 127 164 50 66 123 Na (mg) 167 239 252

1 large 1 large

5 66 43

54 19 128

55 8 119

Egg substitute, liquid or frozen, fat-free c.

Reference: http://www.nal.usda.gov/fnic/foodcomp/search/

ACTIVITY: Enhanced and fortified foods may have more P, K, or Na

Amount Pork, fresh; loin, tenderloin, separable lean only; cooked, roasted Pork, enhanced; loin, tenderloin, separable lean only; cooked, roasted Soymilk, original and vanilla, unfortified Soymilk (all flavors), lowfat, with added calcium, vitamins A and D Soymilk, chocolate, unfortified Orange juice, raw 100 g (3 oz.) 100 g 1 cup 1 cup 1 cup c. P (mg) K (mg) 267 227 316 126 151 124 21 59 * 421 358 567 287 156 347 248 222 Na (mg) 57 48 231 124 90 129 1 2

Orange juice, includes from concentrate, c. fortified with calcium (* read footnote)

* Phosphorus content varies among brands, depending upon calcium compound used (calcium phosphate, calcium citrate, etc.).

Reference: http://www.nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf

Reference: http://www.nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf

Reference: http://www.nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf

Summary
Use clinical judgment for body weight. Individualize recommendations for CKD. DRIs are for healthy people and are used to compare intake.
Adequate, not excessive protein (0.8g/kg) Sodium = 1,500 mg for CKD RDA for phosphorus = 700 mg, individualize AI for potassium = 4,700 mg, individualize

Boiling is better than frying. Food additives add to Na, P, and K intakes.

Summary (continued)
Many Americans exceed recommended intakes of protein, sodium, and phosphorus. Most Americans do not get adequate dietary potassium. The diet must be individualized in CKD and will change as CKD progresses.

References
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Byham-Gray, LD. Weighing the evidence: energy determinations across the spectrum of kidney disease. Journal of Renal Nutrition. 2006;16(1):1726.

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