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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 Association’s CKD Nutrition Management Training Certificate Program and NKDEP’s 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).
Narva is the director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health (NIH). A highly recognized nephrologist and public servant. Prior to joining NIH in 2006. F. Detection. Narva. Evaluation. and Treatment of High Blood Pressure 8 Expert Panel.P.C.A.. 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). Via telemedicine from NIH.Meet our Presenters Andrew S. 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.D. M. he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Dr. . he continues to provide care for IHS patients who have chronic kidney disease. Dr.
S. Describe national trends in intakes of sodium. and potassium 3. Use the U. Compare the different food groupings for normal. and potassium contents . sodium. Department of Agriculture (USDA) National Nutrient Database for Standard Reference. phosphorus. protein. diabetes. and kidney “diets” 2. to compare food items for phosphorus. Release 23.Participants will be able to: 1.
Brief Review • Blood pressure control may slow CKD progression. based on age.500 milligrams. − Limit sodium to 1. − Target blood pressure goal is individualized. . − Target A1c is individualized. − Spontaneous improvement in glycemic control may indicate CKD progression. comorbid conditions. − A target blood pressure < 130/80 mm Hg is often recommended but without strong evidence. and frequency of hypoglycemia. • Diabetes control early may lower CKD risk later.
− Weight loss.Review • Urine albumin is a marker of kidney damage. • CKD increases risk of cardiovascular disease (CVD). sodium restriction. . avoidance of excessive protein intake. and tobacco cessation may reduce urine albumin. − Nontraditional risk factors for CVD include certain complications seen in CKD. certain blood pressure medications. − Higher levels are associated with more rapid progression of CKD.
25(OH)2 vitamin D.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. • Bone disorders − 1. phosphorus . calcium. − Dietary protein may play a role.
Topics • • • • • • Body weight Energy needs Dietary Reference Intakes Food groups Protein. sodium. phosphorus. potassium Food preparation techniques .
adaevidencelibrary. Reference: http://www. Use clinical judgment.com .Assessing body weight in CKD • • No standardized norms for CKD. − Actual weight − Weight history (recent and long term) − Weights over time • No evidence to base adjustment for obesity or edema in CKD.
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) .
− May overestimate dietary needs with obesity − May underestimate dietary needs with underweight • No adjustment method is better than any other.Use your clinical judgment • When using current body weight. .
− − − − − Current weight Weight-loss goals Age and gender Physical activity Metabolic stressors • May see spontaneous decrease in intake as CKD progresses. 16(1):17–26.Energy needs are not higher in CKD • • Individualized Need 23–35 kilocalories (kcal)/kg to maintain nutritional status. Reference: Byham-Gray. J Renal Nutr 2006. .
DIETARY REFERENCE INTAKES .Comparative Standards used for assessment of intake and needs.
. • Established to meet the needs of healthy individuals across different life stages (age) and gender. • Provide four nutrient-based reference values for planning and assessing diets.Dietary Reference Intakes (DRIs) • Established by Food and Nutrition Board of the Institute of Medicine (National Academy of Sciences).
DRI definitions • Estimated Average Requirement (EAR) − Requirements for half the healthy individuals • Recommended Dietary Allowance (RDA) − Requirement for 97–98% 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 .
Requirements for CKD are not firmly established.” • • DRIs are for healthy people. Reference: International Dietetics & Nutrition Terminology (3rd edition) .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.
300 580 700 4.500 UL EAR RDA UL AI 2.8 g/kg) 1. condition > 19 years CKD. 2010 .300 580 700 4. HTN.000 4.8 g/kg) 1. African Americans‡ > 19 years DRI EAR RDA RDA Women 38 g 46 g* (0. †Reference man = 70 kg.iom.DRIs for selected nutrients Nutrient Protein (g/ day) Sodium (mg/ day) Age. HTN = hypertension *Reference woman = 57 kg.000 3.500 Men 46 g 56 g† (0.edu) DM = diabetes mellitus.700 Phosphorus (mg/day) > 19–70 years > 70 years Potassium (mg/day) > 19 years Institute of Medicine (http://www.000 4.000 3.700 2. > 50 years old. DM. ‡Dietary Guidelines for Americans.
gov/SP2UserFiles/Place/12355000/pdf/0708/ Table_1_NIN_GEN_07.pdf .What We Eat in America (WWEIA) helps identify nutrient intakes • Dietary intake interview of National Health and Nutrition Examination Survey (NHANES) • • Most recent has 2007–2008 data Based on two 24-hour diet recalls Reference: http://www.usda.ars.
500 mg for CKD Phosphorus (P) RDA = 700 mg Potassium (K) AI = 4. 2006 .700 mg Reference: Dietary Guidelines for Americans. IOM.8 g/kg Sodium (Na) = 1.DRIs are used as comparative standards when assessing intake • • • • Protein RDA = 0. 2010.
Foods grouped together because they share similar nutritional properties. FOOD GROUPS .
phosphorus. 2010 − Vegetables sorted by color.Food groups for health and chronic disease focus on specific content • USDA Food Pattern (MyPlate) − Dietary Guidelines. and potassium content . sodium. animal and vegetable proteins • Diabetes − Carbohydrate content • Chronic kidney disease − Protein.
Grains High Na High P Vegetables Low. 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 . soy products Meat/meat substitutes Diabetic Exchange Carbohydrates: Starch Fruits Milk Other Nonstarchy vegetables National Renal Diet Breads. Cereals.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. seeds. poultry. medium. eggs Nuts.
red & orange.) 2 ½ cups (c. poultry. 27 grams 258 calories (13% total kcal) * Previously referred to as MyPyramid . fish/seafood. beans & peas. beans & peas.000 Calories is very similar to DASH diet Grains Whole (> 3 servings) 6 ounces (oz.) Vegetables Dark-green. nuts. starchy Fruit and juices Milk and milk products Protein foods Meat. seeds. and soy products Oils Solid fats and added sugars 2 cups 3 cups 5 ½ oz.USDA Food Pattern* for 2. eggs. other.
9 0.) Grains (1 oz.2 1.7 8.4 2.7 8.Selected nutrient contents of USDA Food Pattern Food Group Grains (1 oz.) Whole Refined Dark-green Red & orange Beans & peas Starchy Other Pro (g) 2. J Nutr Educ Behav 2006.) 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.3 6.0 1.6 0. .7 0.9 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. 38(6 suppl): S93–S107.
3 8.2 6.4 153 250 * Data (with http://www.0 6.6 3.gov/fnic/foodcomp/cgi-bin/list_nut_edit.5 4.pl284 Ca.usda.Most protein-rich foods are a source of phosphorus (P) and potassium (K) Amount Meat Poultry Fish & seafood Beans & peas Egg Egg white* Nuts.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. J Nutr Educ Behav 2006. vitamins A&D)* Reference: Marcoe et al. cooked 1 large 1 large ½ ounce 1 cup Pro (g) 7. . 38(6 suppl): S93–S107.3 3.0 8.nal. seeds Milk 1 ounce 1 ounce 1 ounce ¼ c.
− Dried beans and peas are rich in K. Vegetables vary widely in K content. .Summary: Basic Food Groups • • Whole grains are higher in P and 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 0–3 8 Varies 2 7 - 0–1 0–8 Varies 0–8+ 5 - 80 60 100–160 Varies 25 45–100 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. medium. P Vegetables Low. starches High Na. high K Fruits Low. medium. high K Calorie Flavor 6–8 50–100 Sodium (mg) 20–150 200–400 20–150 10–200 250–400 0–150 150–400 0–50 Phosphorus (mg) 50–100 Potassium (mg) 50–150 70–150 2–3 2–3 50–200 10–100 100–300 80–150 200–400 10–70 100–200 10–70 60–150 250–500 10–100 20–150 150–250 250–550 20–150 150–250 250–550 0–100 0–100 0–1 20–100 0–10 1–20 0–1 0 100–150 0–20 0–100 250–300 0–100 0–20 . P. K Breads.
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) .
8 g/kg/body weight.The RDA for protein is 0. PROTEIN .
FDA. 2005.usda.Most U.ars.S. adults eat more protein than recommended Reference: http://www.gov (IOM. 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):96–104; Bernstein et al. J Am Diet Assoc 2007; 107(4):644–650.
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.
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
• If we use 50% HBV to estimate his needs. he needs about 6 ounces.50)(56 grams) = 28 grams] • If we use 75% HBV to estimate his needs. − [(.Adequate protein may seem like a protein restriction (“a lot less meat”) • The 70-kg reference man needs 0.75)(56 grams) = 42 grams] .8 g/kg or 56 grams protein per day. − [(. he needs about 4 ounces.
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 .
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.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. 38(6 suppl): S93–S107.2–2. .4 0.7–1.7 0. J Nutr Educ Behav 2006.
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 ½ 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 (0–1 g)…. 2 g −2 g 0g .
− 3 oz. poultry. poultry. − ½ cup = 4 g protein • Eat a smaller bowl of beans.Work toward smaller portions of protein foods • One serving of meat. or fish is about the size of a deck of cards. or fish 21 g protein • Drink a smaller glass of milk. − ½ cup = 4 g protein • Eat a small amount of nuts or seeds.6 g protein . cooked meat. − 1 ounce = 6.
nih.pdf .gov/resources/nkdep-nutritionfactsheetssodium-508.Educational resource for dietary protein • National Kidney Disease Education Program Protein Tips for People with CKD http://nkdep.
nkdep.pdf .gov/resources/nkdep-nutritionfactsheets-protein-508.Reference: http://www.nih.
Reference: http://www.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.nkdep.pdf .
encourage intake of protein-rich foods that are tolerated and accepted by the patient.Protein: Take-home messages • • • Most people eat more protein than required. • In advanced CKD. • In advanced CKD. reduce portions toward one serving per meal. a spontaneous reduction in protein intake may occur. not excessive. In early CKD. . Intake should be adequate.
SODIUM .Limit sodium to 1.500 mg a day.
usda. adults’ sodium intake exceeds the UL Reference: http://www.S.gov (2009).U. FDA (2009) . IOM (2006).ars.
Reference: http://www.300 mg of sodium (UL) per day.2010 Dietary Guidelines recommend 1.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ Chapter3.usda.pdf .cnpp.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.
.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.
edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx .Sodium intake is higher than recommended Reference: http://www.iom.
110(5):736–745. J Am Diet Assoc 2010. .INTERMAP: Salt is the leading source of sodium in middleaged Americans Reference: Adapted from Anderson et al.
frequent consumption of lower sodium foods adds up Reference: Dietary Guidelines for Americans. 2010 .High-sodium foods are not the only source.
nih.Educational resource for dietary sodium • National Kidney Disease Education Program Sodium Tips for People with CKD http://nkdep.gov/resources/nkdep-nutritionfactsheetssodium-508.pdf .
nih.pdf .gov/resources/nkdep-nutritionfactsheets-sodium-508.nkdep.Reference: http://www.
nkdep.pdf .Reference: http://www.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.
− Read ingredient list for potassium chloride in these types of products.pdf .nih.• Possible trend: − Food companies may replace NaCl with KCl in lower sodium products. Reference: http://www.nkdep.gov/resources/nkdep-nutritionfactsheets-sodium-508.
condensed (06217) Na - K - . vegetable. canned. low sodium. canned.usda.nal.ACTIVITY • Compare Na and K contents of 100 g of vegetable soup. condensed (06068) Soup. vegetarian vegetable.gov/fnic/foodcomp/search/ Look up these specific items Soup. http://www.
nal.usda. condensed (06217) . condensed (06068) Soup.ACTIVITY • Compare Na and K contents of 100 g of vegetable soup. vegetarian vegetable.gov/fnic/foodcomp/search/ Look up these specific items ANSWERS Na 672 385 K 171 433 Soup. canned. http://www. vegetable. canned. low sodium.
Potassium chloride (KCl) may replace salt in lower sodium products. .Sodium: Take-home messages • • • Most people eat more sodium than recommended.500 mg sodium per day for CKD. Aim for 1. • Salt substitutes (mostly KCl) may not be appropriate for CKD. read ingredient list.
PHOSPHORUS .Inorganic phosphorus is absorbed more readily than organic phosphorus.
Phosphorus restriction may be beneficial. • • • Intestinal absorption is increased by 1. References: Liu & Quarles. Adv Chronic Kidney Dis 2007.7–4.25(OH)2D. Fadem & Moe. J Am Soc Nephrol 2007. Phosphorus binders may be prescribed. 14(1):44–53.Review: Control of serum phosphorus • • The reference range is 2. .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). 18(6):1637–1647.
Clin J Am Soc Nephrol 2010. • About 90% is absorbed from inorganic sources such phosphorus food additives. 1997.Phosphorus absorption • • excretion Absorption is both passive and active. • The kidneys play a major role in regulation. Only 40–60% of phosphorus is absorbed from whole foods (organic sources). 5(3):519–530. . • 90% of the phosphorus is filtered by glomeruli and most is reabsorbed within the tubules. Kalantar-Zadeh et al. Reference: IOM.
gov (2009).usda. FDA (2009). IOM (1997) .Most U. adults exceed the RDA for phosphorus Reference: http://www.ars.S.
Clin J Am Soc Nephrol 2010. tofu) •Nuts and seeds •Dried beans and peas •Whole grains Reference: Kalantar-Zadeh et al. 5(3):519–530. .Phosphorus absorption varies by source: organic < inorganic Organic phosphorus 40–60% absorbed Phytates ↓ absorption •Dairy products •Meat. fish •Soy (soy milk. poultry.
) Grains (1 oz.) 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.Phosphorus content by food group (organic sources) Food Group Grains (1 oz. 38(6 suppl): S93–S107. J Nutr Educ Behav 2006. Whole grains > refined grains • Phytates reduce absorption Protein-rich foods have phosphorus 0 .) 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.
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 ¼ c. cooked 1 large 1 large ½ 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): S93–S107.
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.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf .nkdep.
nkdep.pdf .gov/resources/nkdep-nutritionfactsheets-phosphorus-508.Inorganic phosphorus Reference: http://www.nih.
Phosphorus-to-protein ratio is a new way to look at phosphorus in foods • • • Ratio is based on phosphorus (mg)/protein (g). Clin J Am Soc Nephrol 2010. . Ratio helps identify foods to avoid (high ratio). The ratio is not easy to identify from Nutrition Facts labels. 5(3):519–530. Reference: Kalantar-Zadeh et al.
2 10. 1 T.8 Whole egg.P-to-Protein Ratio < 5 Egg white.5 6..5 8.0 7. fast food Bologna. 10.7 10. 2 links Taco. Tempeh. Chicken breast. 3 oz. Tofu raw. water packed. ½ c. 3 oz.6 9. large from Kalantar-Zadeh 13. 4” Cheeseburger. . ½ c.4 6. Lamb. Tuna. 3 oz. Pork sausage. Tuna.1 P-to-Protein Ratio 5 < 10 - 4.8 12. Peanut butter. large Orange roughy. Chicken drumstick Beef. oil packed. 3 oz.0 13.3 2010 Reference: Adapted et al.7 10. 3 oz. Bagel. 3 oz. Turkey.1 10.5 10. Salmon-sockeye. 3 oz. ¼ c. 3 oz.5 7. ½ c. fast food 1. Ground beef.7 10.5 7. 2 slices Cottage cheese.4 P-to-Protein Ratio 10 < 15 Egg substitute.1 10.5 7. 3 oz.3 6.
20 halves Half and half. 1 oz. 1 oz.3 Reference: Adapted from Kalantar-Zadeh et al. ½ c. Cream cheese. Baked beans/franks.3 43. 1 oz. ½ c.1 16.1 28. Pinto beans. 1 c.4 Pecans. fast food Milk 2%. 2 T.7 63. Ricotta cheese. 2010 22.P-to-Protein Ratio 15 < 25 Peanuts. liquid. 1T. ½ c. 1 oz. 28.4 31.4 20.2 16. Nondairy creamer.7 17.8 32. 1 oz. ½ c. Tahini.3 30. Cashews. Mozzarella.5 P-to-Protein Ratio > 25 Egg/sausage biscuit.1 59. ½ c. American cheese.8 .. 1 oz.1 15. ½ c. 15. Cheddar.1 20. 1 T. Soymilk. Sunflower seeds. Edamame. Black beans.6 15. 3 T.8 16. 15.
• PHOS on ingredient list will help identify food with phosphorus food additives.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.
pdf.htm .nkdep.fda. and the % Daily Value used is 1.Use ingredient list to find phosphorus additives. look for PHOS • • Phosphorus is not required on Nutrition Facts labels.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/ FoodLabelingNutrition/FoodLabelingGuide/ucm064928.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508. http://www. Nutrition Facts labels may list phosphorus. References: http://www.nih. Choose a different food if PHOS is listed.000 mg. • • Read ingredients for “PHOS” additives.
Reference: http://www.nkdep.pdf .nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.
K. of any other carbonated beverage for P. K. with lemon flavor) and compare 12 oz. cola carbonated beverage with 12 oz. Reference: http://www.nal.usda. and Na content in mg. and Na content in mg. • Check tea (ready-to-drink.gov/fnic/foodcomp/search/ . of three different brands for P.ACTIVITY Nutrient analysis: Beverages • Compare any 12 oz.
with 12 oz. - - - Tea. (Brand B) iced tea. 12 oz. cola. (Brand C) iced tea.Nutrient analysis: Beverages Beverage Carbonated beverage. ready-to-drink. ready-to-drink. (Brand A) iced tea. lemon-lime. with 12 oz. contains caffeine Carbonated beverage. without caffeine Volume P (mg) K (mg) Na (mg) 12 oz. with aspartame. Tea. lemon flavor Tea. lemon flavor . cola or pepper type. - - - 12 oz. ready-to-drink. with lemon flavor 12 oz. low calorie. contains caffeine Carbonated beverage.
Nutrient analysis: Beverages Beverage Carbonated beverage. with 12 oz. contains caffeine Carbonated beverage. contains caffeine Carbonated beverage. 37 32 7 28 15 28 12 oz. lemon flavor . cola. lemon-lime. Tea. lemon flavor Tea. with aspartame. 12 oz. (Brand A) iced tea. ready-to-drink. low calorie. with lemon flavor 12 oz. with 12 oz. ready-to-drink. without caffeine Volume P (mg) K (mg) Na (mg) 12 oz. (Brand C) iced tea. 0 4 95 132 4 37 70 70 33 15 77 77 Tea. ready-to-drink. cola or pepper type. (Brand B) iced tea.
Serum level may be normal until CKD is advanced. take with meals. Absorption increases with 1.Phosphorus: Take-home messages • • • • • The RDA for phosphorus is 700 mg/day. . • Inorganic phosphorus in food additives is absorbed more readily.25(OH)2 vitamin D. • Read ingredient list for PHOS to find added phosphorus. Most people eat more than the recommended amount. Phosphorus binders may be prescribed.
Restrict dietary potassium when serum levels are elevated. POTASSIUM .
FDA (2009).usda.gov (2009). IOM (2006) .ars. adults do not meet the AI for potassium intake Reference: http://www.S.U.
Review: Control of serum potassium • The reference range is 3. metabolic acidosis . • The renin-angiotensin-aldosterone system (RAAS) is involved in potassium balance. − e.0 milliequivalents (mEq)/liter(L). inadequate insulin.g. • Transcellular shifts may increase serum potassium in CKD..5–5. • Medications that affect RAAS increase risk of hyperkalemia.
•Eat a variety of vegetables. especially dark-green and red and orange vegetables and beans and peas.Dietary Guidelines 2010 includes foods rich in potassium for general population Key Recommendations: •Increase vegetable and fruit intake. •Consume at least one-half of all grains as whole grains. 2010 . Increase whole-grain intake by replacing refined grains with whole grains. Reference: Dietary Guidelines for Americans.
• Choose a variety of protein foods. beans and peas. cheese. or fortified soy beverages. eggs. yogurt. and unsalted nuts and seeds. Reference: Dietary Guidelines for Americans.Key Recommendations (continued) • Increase intake of fat-free or low-fat milk and milk products. such as milk. which include seafood. lean meat and poultry. 2010 . soy products.
• Restrict potassium to help achieve and maintain safe level. .Need to restrict dietary potassium when serum level is elevated • Specific level of eGFR does not determine need for potassium restriction. • 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. 2006.351(6):585–92.73(2):283–90. N Eng J Med 2004. Am Fam Physician. Hollander-Rodriguez & Calvert. 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. • Medications: − K supplements • KCl.
gov/resources/nkdep-nutritionfactsheetspotassium-508.Educational resource for dietary potassium • National Kidney Disease Education Program Potassium Tips for People with CKD http://nkdep.pdf .nih.
nkdep.gov/resources/nkdep-nutritionfactsheets-potassium-508.nih.pdf .Reference: http://www.
Reference: http://www.pdf .nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.
read ingredient list to identify these products. Some low-sodium products may use KCl in place of NaCl. . • An adequate intake (4.S. Products with KCl should be avoided.700 mg) of potassium may help lower BP in the general population. • • • Restrict dietary K when serum levels are high.Potassium: Take-home messages • Most U. adults do not get adequate potassium from their diets.
FOOD PREPARATION TECHNIQUES .Boiling foods may reduce levels of oxidants and potassium.
. J Food Sci 2008. Kidney Int 2009. 16(4):304–311. • Leaching potatoes and other tubers prior to boiling may not be necessary to lower potassium content. 73(5):H80–H85.Food preparation techniques may play a role in CKD • Certain cooking techniques may reduce Advanced Glycation End Products (AGEs) formation in food. J Renal Nutr 2006. 76 (suppl 114): S3-S11. Burrowes & Ramer. References: Vlassara. Bethke & Jansky.
Clin J Am Soc Nephrol 2006. grilling. or broiling with fat result in higher levels of AGEs compared to steaming or stewing. Frying. About 10% of dietary AGEs are absorbed. Reference: Uribarri & Tuttle. 1(6):1293–1299. .Dietary protein and fat may play a role in AGE formation • • • AGEs are formed during cooking.
Kidney Int 2009.Dry heat or added fat may increase AGE formation during cooking Reference: Adapted from Vlassara. 76 (suppl 114): S3-S11 .
poaching. rice. Kidney Int 2009. boiling. 76 (suppl 114): S3-S11 . 1(6):1293–1299. tomatoes. Vlassara. corn. • Include more low-AGE proteins such as low-fat and non-fat dairy. and stewing. legumes. soy.Tips to lower AGE formation • Use water-based techniques such as steaming. References: Uribarri & Tuttle. and eggs in meals. • Marinate in lemon juice. Clin J Am Soc Nephrol 2006. or vinegar for 1 hour or more before cooking.
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). 73(5):H80–H85. J Food Sci 2008. . 16(4):304–311. Burrowes & Ramer. • Double cooking (boiling) lowers the potassium content of many Caribbean tuberous root vegetables. References: Bethke & Jansky. J Renal Nutr 2006.
Over 2. FOOD ADDITIVES .300 food additives are currently in use.
foodadditives.org/pdf/Food_Additives_Booklet.pdf .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.
gov/Food/FoodIngredientsPackaging/ FoodAdditives/ucm191033.The FDA approves the use of food additives in any food • Listing of Food Additive Status at FDA: http://www.fda.htm .
frozen eggs. sodium. frozen desserts − Sodium trimetaphosphate • Food starch modifier . artificially sweetened fruit jellies. and tribasic) • Cheese.Some food additives contain phosphorus. di-. potassium • Some examples: − Potassium glycerophosphate • Dietary supplement − Potassium phosphate (monobasic) • Frozen eggs as a color preservative − Sodium phosphate (mono-.
plain. white. prepared Egg.nal. potassium. raw. - - - Reference: http://www. and/or sodium content Breakfast Pancake. prepared from recipe Pancake.gov/fnic/foodcomp/search/ . liquid or frozen. plain. prepared Pancake. fresh Egg. incomplete. whole-wheat. dry mix. dry mix.usda. fresh Egg substitute. raw. complete. fat-free Amount P(mg) K (mg) 4” 4” 4” Na (mg) - 1 large 1 large ¼ c. yolk.ACTIVITY: Food additives may increase phosphorus.
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 ½ cup ½ 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 ¼ c.
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 ½ 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, ½ c. fortified with calcium (* read footnote)
* Phosphorus content varies among brands, depending upon calcium compound used (calcium phosphate, calcium citrate, etc.).
pdf .nkdep.gov/resources/nkdep-factsheet-overallpatient-508.Reference: http://www.nih.
Reference: http://www.gov/resources/nkdep-factsheet-overallpatient-508.nkdep.pdf .nih.
nih.pdf .Reference: http://www.nkdep.gov/resources/nkdep-factsheet-overallpatient-508.
nkdep.pdf .nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.Reference: http://www.
DRIs are for healthy people and are used to compare intake. Food additives add to Na. and K intakes. not excessive protein (0. Individualize recommendations for CKD.500 mg for CKD – RDA for phosphorus = 700 mg. – Adequate. . individualize • • Boiling is better than frying.700 mg.Summary • • • Use clinical judgment for body weight.8g/kg) – Sodium = 1. individualize – AI for potassium = 4. P.
and phosphorus. sodium. • Most Americans do not get adequate dietary potassium. • The diet must be individualized in CKD and will change as CKD progresses.Summary (continued) • Many Americans exceed recommended intakes of protein. .
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