CKD MNT Module 4: The "Diet" for Chronic Kidney Disease
Upcoming SlideShare
Loading in...5
×
 

CKD MNT Module 4: The "Diet" for Chronic Kidney Disease

on

  • 7,770 views

Diet prescriptions in CKD must be individualized; one size does not fit all. This module briefly reviews weight and calorie needs in CKD. Dietary reference intakes; nutrient content of food groups; ...

Diet prescriptions in CKD must be individualized; one size does not fit all. This module briefly reviews weight and calorie needs in CKD. Dietary reference intakes; nutrient content of food groups; and sources of sodium, potassium, phosphorus, and protein are reviewed. Population data is presented showing national trends in nutrient intakes and provides evidence that potassium should be restricted based on serum level, not eGFR.
Several activities take you to the U.S. Department of Agriculture's Nutrient Analysis Library website to identify and compare sources of added sodium, potassium, and phosphorus in certain foods and beverages. The individual nutrient handouts available from NKDEP are highlighted with patient counseling suggestions.

Statistics

Views

Total Views
7,770
Slideshare-icon Views on SlideShare
1,073
Embed Views
6,697

Actions

Likes
1
Downloads
88
Comments
0

10 Embeds 6,697

http://nkdep.nih.gov 6284
http://www.nkdep.nih.gov 334
http://nkdep-nih-gov-new.360distaging.com 67
http://translate.googleusercontent.com 5
http://webcache.googleusercontent.com 2
https://www.google.com.pk 1
http://nkdep.nih.gov.libproxy.lib.unc.edu 1
http://www.google.co.id 1
http://www.google.com.sg 1
http://www.google.com 1
More...

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

CC Attribution-NonCommercial-ShareAlike LicenseCC Attribution-NonCommercial-ShareAlike LicenseCC Attribution-NonCommercial-ShareAlike License

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • The diet must be individualized and will change as chronic kidney disease (CKD) progresses. We will discuss dietary reference intakes, food groups and national trends in intakes of sodium, protein, phosphorus and potassium. You will look at the U.S. Department of Agriculture National Nutrient Database for Standard Reference, Release 23, to compare food items for phosphorus, sodium and potassium contents.
  • After we complete this module you should be able to compare different food groupings for diets for healthy people and for people with diabetes and with CKD; be able to describe national trends in intakes of sodium, protein, phosphorus and potassium; and use the USDA national nutrient database for standard reference to compare food items for phosphorus, sodium, and potassium content.
  • To begin, we will review some of the salient points from previous modules. First, blood pressure control slows CKD progression and may be the most effective means for decreasing the burden of chronic kidney disease. Dietary interventions include limiting sodium intake to 1500 milligrams per day. The target blood pressure for treatment must be individualized. The goal of less than 130/80 for all patients with CKD, while widely recommended, is not supported by evidence. For people with diabetes, glycemic control early in the course of diabetes may lower CKD risk. However, target hemoglobin A1C must be individualized and based on age, comorbid conditions, and the frequency of hypoglycemia. It’s important to be aware that spontaneous improvement in glycemic control, an improvement in blood sugars in the absence of changing therapy, may indicate CKD progression and may warrant reevaluation of the patient.
  • We want to emphasize again that urine albumin is a marker for kidney damage. Higher levels are associated with more rapid progression. Weight loss, sodium restriction, blood pressure medications, especially ACE inhibitors and ARBs, avoidance of excessive protein intake and tobacco cessation may reduce urine albumin excretion. Do not forget that CKD increases the risk of cardiovascular disease. Traditional risk factors for cardiovascular disease are prevalent in people with CKD. In addition, some of the complications of CKD are non-traditional risk factors for cardiovascular disease.
  • This is a good time to reinforce that chronic kidney disease causes systemic complications including anemia, hypoalbuminemia, hyperkalemia, metabolic acidosis and bone disorders. Dietary interventions may play a key role in the management of all these complications.
  • Next, we will discuss body weight, energy needs, dietary reference intakes, food groups, protein, sodium, phosphorus, and potassium in foods, as well as food preparation techniques.
  • Use clinical judgment when determining which weight to use to estimate nutrient needs. Actual weight or weight history may be a place to start. There is no strong evidence that weight should be adjusted for obesity or edema in chronic kidney disease.
  • There are no standardized norms for weight in CKD. The ideal or desirable body weight for adults is based on life insurance data. Standard body weight is based on median weights of National Health and Nutrition Examination Surveys I and II participants from the 1970s. Standard body weight was used in the Modification of Diet in Renal Disease, or MDRD, study to calculate the urinary nitrogen appearance to assess protein intake. Edema-free actual weight and adjusted edema-free body weight are used more commonly in dialysis patients. The Hamwi method is the quick calculation based on height and gender. For women, start with 100 pounds for the first 60 inches, and add five pounds for each inch over 60 inches. For men, start with 106 pounds for the first 60 inches and add an additional six pounds for every inch over 60 inches. Body Mass Index or BMI is used to categorize weight. The best weight to use in CKD is unknown.
  • Use of current body weight for someone who is underweight may underestimate nutrient needs. Use of current body weight for someone who is very overweight may overestimate nutrient needs. Use your clinical judgment.
  • Energy needs are not higher in CKD. Caloric needs range between 23 and 35 calories per kilogram of body weight. The lower end of the range may be appropriate for weight loss. Caloric needs are based on age, gender, level of physical activity, metabolic stressors, and co-morbidities. People may experience a spontaneous decrease in intake as CKD progresses. The person with early kidney disease may need to lose weight. Someone approaching kidney failure may need to increase protein and caloric intake.
  • We will briefly discuss Dietary Reference Intakes which are the comparative standards used for assessing nutrient needs.
  • Dietary Reference Intakes or DRIs are established by the Food and Nutrition Board of the Institute of Medicine. They provide four nutrient-based reference values for planning and assessing diets for healthy people across different life stages and genders.
  • The estimated average requirement, or EAR, meets the requirements of fifty percent of healthy individuals. The recommended dietary allowance or RDA meets the requirements of 97 to 98 percent of healthy individuals. An adequate intake, or AI, is observed or experimentally determined and used when an RDA is not available. The tolerable upper intake level, or UL, is the highest average daily intake likely to pose no risk of adverse health effects in almost all individuals in the general population.
  • We use the DRIs in the nutrition care process as the comparative standard. The DRIs are based on healthy people, not people with CKD.
  • This table summarizes the DRIs for selected nutrients of concern in CKD. Protein is in grams per day and needs are based on body weight. The RDA for protein is 0.8 grams per kilogram. The 57 kilogram reference woman needs 46 grams of protein and the 70 kilogram reference man only needs 56 grams of protein. The 2010 dietary guidelines recommend limiting sodium to 1500 milligrams per day for people with kidney disease. The tolerable upper intake level for sodium is 2,300 milligrams. The RDA for phosphorus for adults is 700 milligrams. The adequate intake, or AI, for potassium is 4,700 milligrams per day for adult women and men. The AI does not apply for those who take medications that impair potassium excretion.
  • One of our objectives is to describe national trends in intakes of sodium, protein, phosphorus, and potassium. “What We Eat in America” data summarizes two 24-hour dietary recalls from the National Health and Nutrition Examination Survey population. The most recent data is from 2007 and 2008. You will see summary slides for sodium, protein, phosphorus and potassium later in this module.
  • The DRIs are the comparative standards used to assess intake in healthy individuals.
  • We will now discuss food groups. Foods are grouped together because they share similar nutritional properties.
  • The USDA Food Pattern or “MyPlate,” previously known as the food pyramid, is based on the 2010 dietary guidelines. Carbohydrates count in diabetes. Protein, sodium, phosphorus, and potassium matter in kidney disease.
  • This table shows food groupings used in the USDA Food Pattern, diabetic exchanges, and the National Renal Diet. In the left column, the USDA Food Pattern includes grains, vegetables, fruit, milk, protein foods, oils, and solid fats and added sugars. Diabetic exchanges are primarily based on carbohydrate content. Meats and meat substitutes are also categorized by fat content. The far right column shows the National Renal Diet food groupings. Foods are grouped by protein, sodium, phosphorus, and potassium. Milk is part of the protein group.
  • The 2011 USDA Food Pattern is very similar to the Dietary Approaches to Stop Hypertension or DASH diet discussed in module 2. A 2,000 calorie diet pattern is shown here. Total daily amounts are listed as well.
  • This table shows nutrient contents of the food groups. Whole grains have a little more protein, less sodium, more phosphorus, and more potassium than refined grains. Refined grains, such as a slice of white bread, may have about 150 milligrams of sodium in a serving. Vegetables vary in color and carbohydrate content. Protein ranges from 0.7 grams in a serving of red and orange vegetables to 8 grams in a half-cup of beans and peas. Vegetables are not a source of sodium unless salt is added during preparation or processing. Phosphorus ranges from 25 milligrams in red and orange vegetables to 119 milligrams in beans and peas. Fruits and vegetables vary widely in potassium content. Beans and peas are rich in protein and phosphorus and are very rich in potassium. Fruit is low in protein, sodium, and phosphorus. Potassium content varies. Not all fruit contains 211 milligrams of potassium as shown in this table. Milk is a source of protein, sodium, phosphorus, and potassium and limiting intake limits those nutrients. Protein-rich foods generally contain sodium, phosphorus, and potassium. We will discuss protein foods shortly. Oil is not a source of protein, sodium, phosphorus, or potassium. Discretionary calories, or added sugars and solid fats, are not rich in protein, phosphorus or potassium. Salted butter and salted margarine contain sodium.
  • This table shows the average nutrient contents of protein-rich foods. Most contain phosphorus and potassium. Beans and peas are potassium-rich. Compared to the other protein-rich foods, egg whites are low in phosphorus. Milk and soymilk have the most sodium, phosphorus, and potassium of the foods shown.
  • To summarize this section, refined grains may be better than whole grains as they are lower in phosphorus and potassium. Vegetables vary widely in potassium content. Beans and peas are very rich in potassium. Most protein-rich foods are a source of phosphorus and potassium. Egg whites are the exception; they are low in phosphorus.
  • Diabetic food exchanges are grouped primarily by carbohydrate content. A serving of starch, fruit, milk, and other carbohydrate choices has 15 grams of carbohydrates. Non-starchy vegetables have about five grams of carbohydrates. Meat, meat substitutes, and fats do not contain carbohydrates.
  • The National Renal Diet food groupings reflect processing. Processed foods may have more sodium, phosphorus, or potassium. Sodium, phosphorus, and potassium contents range widely within the food groups shown.
  • To summarize, the food groupings are more complicated with chronic disease. Carbohydrate counting may help people with diabetes. When the kidneys are involved, protein, sodium, phosphorus, and potassium become important.
  • We will now discuss protein. The RDA for protein is based on body weight, and 0.8 grams per kilogram body weight is considered adequate.
  • Most adults eat more protein than recommended. The RDA is shown on the left. The food label is based on 50 grams of protein. As you look along the x-axis, at all ages listed, both women and men exceeded the RDA for protein. The average protein intake was about 67 grams of protein for women and about 98 grams of protein per day for men. Remember, the reference woman needed 46 grams of protein and the reference man needed 56 grams of protein per day.
  • People with chronic kidney disease need adequate, not excessive, protein intake. Protein foods are a source of nitrogen, phosphorus, potassium, and metabolic acid. In early kidney disease, people may need to eat less protein. As CKD advances, the challenge may shift to maintaining adequate protein intake. The patient may report aversions to certain meats. You may have to work to find protein foods that still taste good and incorporate them into meal plans.
  • The total amount of protein may make a bigger difference than the type of protein. In short term studies, animal protein intake may transiently increase GFR in people with normal kidney function. In obese rats, soy protein may slow the rate of glomerulosclerosis. Excessive protein intake, regardless of source, may accelerate progression of kidney disease in humans.
  • How much high biologic value protein is needed? We do not know, but recommendations vary from 50 percent and 50 to 75 percent.
  • Whether we use 50 percent, 60 percent or 75 percent high biologic value protein, this amount may seem like a protein restriction. Let’s look at our 70 kilogram reference man. He needs 56 grams of protein per day. Fifty percent of 56 grams is 28 grams of protein. Divide 28 grams of protein by seven grams per ounce for a total of four ounces per day. At 75 percent high biologic value protein, he needs about six ounces of meat. Seventy-five percent of 56 grams is 42 grams of protein or about six ounces.
  • How is the remaining protein divided? The remaining protein is divided between the other food groups. The 70 kilogram reference man needs 28 grams of high biologic value protein. At 50 percent high biologic value protein, only 28 grams of protein remains for all the other food groups. Even less remains if we use 75 percent high biologic value protein.
  • For example, let’s use 50 percent high biologic value as the recommended amount. Twenty-eight grams of protein remain for sources other than high biologic value sources. This could be divided into nine servings of grains, four servings of vegetables, one half cup of milk, and three fruits. Milk also counts as high biologic value protein.
  • Smaller servings of protein-rich foods will decrease phosphorus and potassium intake, as well as reduce nitrogenous waste and acid load. Three ounces of cooked meat looks like the size of a deck of cards. A 10-ounce steak has about 70 grams of protein, or about three servings. The patient may not be able to get down to three ounces right away. A 6-ounce steak would be better than a 10-ounce steak.
  • The National Kidney Disease Education Program has a few tools to use when counseling patients including “Protein Tips for People with CKD.”
  • This is the front of the protein handout. You see brief information about the nutrient, and its importance in CKD. It explains, “When your body uses protein, it produces waste. This waste is removed by the kidneys. Too much protein can make the kidneys work harder, so people with CKD may need to eat less protein.”
  • The back side lists some tips about portions. The deck of playing cards graphic can be used to remind people about serving sizes. A half of glass of milk is shown instead of a full glass of milk.
  • The take-home messages for this section include: most people eat more protein than needed, and people should focus on reducing intake from excessive to adequate intake. For people with early kidney disease, reducing portions towards one serving per meal helps. People with very low eGFRs may need to be encouraged to eat protein that is acceptable to them.
  • We will now discuss sodium.
  • Most adults consume sodium in excess of the tolerable upper intake level. On the far left side of this graph, you see 1,500 milligrams recommended for CKD. The UL is 2,300 milligrams. As with protein intake, all age groups and both genders consume more sodium than recommended. This graph shows sodium intake tends to decrease with age, but intake of people over age 51 exceeded the recommended 1,500 milligrams.
  • You have heard these recommendations before. Many of us should be aiming for 1,500 milligrams of sodium per day.
  • We discussed sodium absorption and excretion in module 2. You may recall urinary sodium excretion was about equal to the intake in both DASH studies. CKD means fewer functioning nephrons may be available to excrete sodium.
  • This graph shows U.S. adults consumed less sodium in the early 1970s. Sodium intake has increased since then. Where does the extra sodium come from?
  • Almost 30 percent of sodium comes from salt from restaurants, fast foods, and home. The INTERMAP is as an international cross-sectional epidemiological study that included the United States, United Kingdom, two separate regions of the People's Republic of China, and Japan. Food sources and preparation vary widely across these regions.
  • Added salt is not the only source of sodium. Data from NHANES 2005-2006 which includes children ages two and older shows that yeast bread provides over seven percent of dietary sodium.
  • You can consider using the National Kidney Disease Education Program’s “Sodium Tips for People with CKD.”
  • The handout follows a similar format as found in the protein tip sheet.
  • The back of the sodium handout has a few tips about food preparation and shows a sample nutrition facts label. Always start at the top to find the serving size. One cup of this product has 660 milligrams of sodium or 28 percent of the daily value. Not everyone uses the percent daily values. A percent daily value of 5 percent or less is considered low. A percent daily value of 20 percent or more is high. Would this product fit into the 1,500 milligram sodium budget for the day? It could. A patient could eat a smaller portion or they could eat the one cup serving and make sure the other meals are very low in sodium.
  • Of particular concern for CKD patients, lower sodium products may have potassium chloride in place of sodium chloride. Not only do people have to use Nutrition Facts to identify foods lower in sodium, they may need to check the ingredient list for added potassium chloride.
  • You are now going to compare sodium and potassium contents in specific vegetable soups. The language listed here is specific to the products you need to check. Please look up the sodium and potassium contents of 100 grams of vegetarian vegetable canned, condensed soup and compare this with vegetable, canned, low sodium, condensed soup.
  • You found 100 grams of regular vegetable soup has 672 milligrams sodium and 171 milligrams potassium. You found the low sodium version has 385 milligrams sodium and 433 milligrams potassium. Although we have no ingredient lists to identify ingredients, the low sodium product may have added potassium chloride.
  • The take-home messages for this section include: most Americans eat more sodium than is recommended, and many people should aim for 1,500 milligrams of sodium per day. Potassium chloride may replace sodium chloride in lower sodium products. Read the ingredient lists. Using salt substitutes in place of table salt is not recommended for people with CKD.
  • We will now discuss phosphorus. In module 3, you learned phosphorus found in food additives is absorbed more readily.
  • A brief review about serum phosphorus may help refresh your memory. The reference range for serum phosphorus is 2.7 to 4.6 milligrams per deciliter. Serum levels may be within normal range until the eGFR is low due to the actions of parathyroid hormone and fibroblastic growth factor-23. Vitamin D supplements may be prescribed and increase the risk of hyperphosphatemia. Phosphorus-binding medications and phosphorus restriction may help control serum phosphorus. The exact level needed has not been determined for CKD. The RDA is 700 milligrams per day.
  • Phosphorus is absorbed both passively and actively. Phosphorus absorption varies by food source. The kidneys play a major role in the regulation of serum levels.
  • National trends in intake show most U.S. adults exceed the RDA for phosphorus. The RDA is shown on the far left. The percent daily value found on food labels is based on 1,000 milligrams. You may wonder about discrepancy between the RDA and percent daily values. Percent daily values used on food labels are based on 1968 dietary reference recommendations for adolescent males. Women consume about 1,100 milligrams per day on average. Men consume over 1,550 milligrams per day on average.
  • The source of phosphorus makes a difference when we consider intestinal absorption. Naturally occurring phosphorus is 40-60% absorbed. Inorganic phosphorus added to food is greater than 90% absorbed. Added phosphorus may be found in dietary supplements and certain calcium fortified products. module 4 as of 4-15
  • We discussed phosphorus in the food groups. Not all of the phosphorus in whole grains and protein-rich foods will be absorbed.
  • Most people do not follow recommended serving sizes. A more typical portion of meat may be six ounces of steak which has 372 milligrams phosphorus. One cup of beans has 240 milligrams phosphorus. Egg whites are very low in phosphorus. Two egg whites have 10 milligrams.
  • Many products have phosphorus additives. The column on the left shows examples of product categories. Multivitamins may contain added phosphorus.
  • Once again, the National Kidney Disease Education Program has tips about phosphorus.
  • The phosphorus handout has the bone graphic to help patients remember why this mineral is important in CKD.
  • The back of the handout lists tips to lower phosphorus in the diet. You know protein-rich foods have phosphorus, and the same deck of cards is used to show servings of protein-rich foods. Look for PHOS on the ingredient list to identify added phosphorus.
  • Phosphorus is still a concern for the dialysis population and protein needs are higher in dialysis. Increased protein intake means increased phosphorus intake. The phosphorus-to-protein ratio is another way of looking at phosphorus in foods, and is based on the milligrams of phosphorus per gram of protein. A high ratio means the phosphorus content is high in relation to protein content. Those foods should be avoided. The ratio is not easy to obtain or identify from food labels. The phosphorus-to-protein ratio may become important in CKD as well.
  • Here are examples of foods with low phosphorus-to-protein ratios. Egg whites have a very low phosphorus-to-protein ratio. We may not recommend some of these foods even though the phosphorus-to-protein ratio is relatively low. However, people may eat many of these foods routinely.
  • This is the final slide showing examples of foods with higher phosphorus-to-protein ratios. Of some interest, liquid non-dairy creamer has a very high ratio. I remember when we used to offer liquid non-dairy creamer in place of milk on dialysis patients’ breakfast trays.
  • The nutrient databases do not have information about sources of phosphorus; they list total amount of phosphorus per specific serving. People with chronic kidney disease can look for “PHOS” on the ingredient list to help them identify foods with added phosphorus.
  • We have discussed this before: counsel people about added phosphorus.
  • The National Kidney Disease Education Program’s “How to Read a Food Label” can be used when counseling patients about ingredient lists and added phosphorus.
  • The time has come for another activity. This time, you will compare phosphorus, potassium, and sodium in certain beverages. Compare any 12-ounce cola, carbonated beverage and 12 ounces of any other non-cola carbonated beverage. Check ready-to-drink tea with lemon flavor. You should find three different brands within the database.
  • At this time please pause…
  • Here are the answers. Colas and certain teas have added phosphorus. Frequently, people with diabetes tell me diet cola has more sodium than regular cola. The low-calorie cola has 28 milligrams sodium compared to 15 milligrams in regular cola. Sodium is not the issue for colas in CKD. The different brands of tea shown here as brand A, B and C vary in phosphorus, potassium, and sodium. Phosphorus ranges from 4 to 132 milligrams in 12 ounces. If ninety percent of added phosphorus is absorbed, the tea with 132 milligrams of added phosphorus provides 119 milligrams in 12 ounces.
  • The take-home messages for this section are: the RDA for phosphorus is 700 milligrams per day, and most of us eat more. Serum phosphorus may be normal until the eGFR is low due to the actions of parathyroid hormone and fibroblastic growth factor-23. Hyperphosphatemia may be seen with supplemental vitamin D. Dietary restriction, phosphorus-binding medication, and sources of added phosphorus are important in CKD.
  • We will now discuss potassium.
  • Most people do not consume an adequate amount of potassium. The AI is 4,700 milligrams, and is shown on the far left. The percent daily value, if found on a nutrition facts label, is based on 3,500 milligrams of potassium. The average intake for a woman is about 2,300 milligrams per day, and the average intake for a man is about 3,000 milligrams per day. If a potassium restriction is needed, start with current intake and decrease from there.
  • A brief review of serum potassium may be helpful. The reference range is 3.5 to 5.0 milliequivalents per liter. We previously discussed the role of the renin-angiotensin-aldosterone system, medications that affect that system and how transcellular shifts may alter serum potassium. The serum level is not solely dependent on potassium intake.
  • As I said earlier, most of us do not consume adequate amounts of potassium. The 2010 dietary guidelines recommend increasing potassium-rich foods. Why talk about this? Inadequate potassium intake may be associated with high blood pressure. These are the food groups with potassium. The next slide lists the other food groups rich in potassium.
  • We have discussed the potassium in these food groups before. Avoiding or eating smaller portions will help limit intake in people with CKD.
  • Potassium restriction is individualized, and one should restrict when the serum level is elevated. Since most of us do not consume adequate potassium to begin with, we cannot define one specific milligram restriction that would be appropriate for every individual. Decrease intake from current level of intake.
  • Potassium-rich food, salt substitutes, herbs and dietary supplements, food additives, and medications all contribute to serum potassium levels. module 4 as of 4-15
  • The National Kidney Disease Education Program has a potassium tip sheet for use with patients.
  • This handout has information about serum potassium levels. It states, “The level of potassium in your blood should be between 3.5 and 5.0.” The box at the bottom lists a few foods to eat and a few others to avoid.
  • This handout focuses on the food groups we usually promote, not limit –fruits and vegetables. If patients are following the steps described in the “Eating Right for Kidney Health” handout, they are eating smaller amounts of meat, poultry, fish, nuts and seeds, and milk products, and reducing potassium intake. Potassium restriction may require limiting fruits and vegetables high in potassium. Some fruits and vegetables with less than 200 milligrams per serving are in the upper box. A low potassium food can easily become a high potassium food if a large quantity is eaten. A high potassium food can be included as long as the portion is small. As you can see, not every fruit and vegetable is listed.
  • The take-home messages include: most U.S. adults do not get adequate potassium from their diets, and adequate intake for the general population is 4,700 milligrams per day. Restrict intake when the serum level is elevated. Products with potassium chloride should be avoided. Read the ingredient lists and choose products that do not have added potassium.
  • This section is about food preparation techniques. Boiling may help reduce oxidant and potassium levels in food.
  • Food preparation methods matter in CKD and other chronic diseases. We tell cardiac patients and people with diabetes to prepare foods without added fat and salt. Advanced glycation end-products were discussed previously in module 2. You may recall that sugars cross-link to the surface of proteins, lipids, and nucleic acids, and this may change the protein shape and function. Certain cooking techniques may reduce the formation of AGEs in food. Another concern is potassium content. In the past we instructed patients to peel, slice, and soak potatoes in water to help remove potassium. Leaching potatoes and other tubers prior to boiling may not be necessary, as you will see.
  • Dietary protein and fat may play a role in AGE formation. When we cook meat or potatoes on a hot metal surface, such as a frying pan or grill, the surface changes. It turns brown, and may become crisp and may produce AGEs. Steaming and stewing produce fewer AGEs compared to frying, grilling, or broiling. The information about grilling and broiling may come as a surprise, as many of us recommend these techniques in place of frying in fat.
  • These graphs show the differences in AGE formation based on cooking methods. Dry heat or frying in fat appears to increase the formation of AGEs compared to water-based cooking techniques.
  • Use water-based cooking techniques such as steaming, poaching, boiling, and stewing. Marinating in lemon juice, tomatoes, or vinegar prior to cooking reduces AGE formation. Certain foods may be considered low AGE proteins. module 4 as of 4-15
  • Two recent studies have shown peeling, slicing, and soaking potatoes and tubers prior to boiling may not be necessary. Washing, peeling, shredding, and immediately boiling potatoes was more effective in lowering potassium than leaching. Double cooking, meaning boiling twice, was found to lower potassium in many Caribbean tuberous root vegetables. Leaching is no longer required.
  • We will now discuss food additives.
  • We have discussed food additives throughout this program. Food additives have a purpose. They may provide nutrition, such as iodine added to salt, or Vitamin D added to milk. They help maintain quality and freshness. We won’t buy baked goods that are moldy. Food additives may aid in food processing or preparation. For example, emulsifiers keep products in solution; humectants help retain moisture. They may be added to keep foods appealing and, in the case of probiotics, to promote health.
  • The Food and Drug Administration is the federal agency that approves the use of any food additives in the food supply.
  • It is no surprise to you now that food additives may contain phosphorus, sodium, and potassium. You can see a few examples listed on this slide. module 4 as of 4-15
  • The final activity for this session is more nutrient analyses, comparing fresh foods with convenience, processed, enhanced, or fortified foods. You will be comparing phosphorus, potassium, and sodium contents of homemade pancakes and a couple of pancake mixes, fresh egg white and yolk with egg substitute, fresh and enhanced pork tenderloin, unfortified and fortified soymilk, and fresh orange juice with calcium-fortified orange juice.
  • Whole wheat pancakes have more phosphorus and potassium compared to the white flour recipe and plain pancake mix. Egg white is lower in phosphorus but higher in potassium and sodium compared to the yolk. The egg substitute has more phosphorus, potassium, and sodium compared to egg white.
  • Fresh pork tenderloin has less phosphorus, potassium, and sodium compared to the enhanced pork tenderloin. You did not have many soymilk choices to check within the database. There are many brands out there. You see nutrient content varies with fortification and flavors. By the way, any type of chocolate is a source of potassium. Calcium-fortified orange juice may be a source of phosphorus, depending on the calcium salt used to fortify. Some are fortified with calcium citrate or calcium carbonate instead of calcium phosphate. Read the ingredient list.
  • This module has a lot of information. Where do you start? Consider starting with the steps found in “Eating Right for Kidney Health.” Start with sodium, protein, and heart-healthy fats.
  • The second page has a few more tips for people to consider.
  • This shows the next steps to eating right. Limit phosphorus and potassium when indicated.
  • Here is NKDEP’s “How to Read a Food Label” handout. The front has the nutrition facts label and sodium. The back has the information about the ingredient list, including both P-H-O-S food additives and potassium chloride.
  • We have covered a lot of ground. To summarize, use clinical judgment when considering which weight to use to estimate nutrient needs and individualize recommendations. The DRIs are based on healthy people and are used to compare intake in the nutrition care process. Work towards adequate, not excessive, protein intake. This will reduce nitrogenous waste, phosphorus, potassium, and acid load. Boiling is better than frying, grilling or broiling. You know food additives are a concern in CKD.
  • We discussed nutrient intakes. Most of us exceed recommended amounts of protein, sodium, and phosphorus. Most of us do not get adequate dietary potassium. The diet is always individualized.
  • module 4 as of 4-15

CKD MNT Module 4: The "Diet" for Chronic Kidney Disease CKD MNT Module 4: The "Diet" for Chronic Kidney Disease Presentation Transcript

  • Module 4: The “Diet” for Chronic Kidney Disease (CKD) The Diet Must Be Individualized and Will Change as CKD Progresses.
  • 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 Participants will be able to:
  •  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. Brief 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. Review
  •  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 Complications are complex
  •  Body weight  Energy needs  Dietary Reference Intakes  Food groups  Protein, sodium, phosphorus, potassium  Food preparation techniques Topics
  •  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. Assessing body weight in CKD Reference: http://www.adaevidencelibrary.com
  •  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) Which weight to use?
  •  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. Use your clinical judgment
  •  Individualized  Need 23–35 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. Energy needs are not higher in CKD Reference: Byham-Gray, J Renal Nutr 2006; 16(1):17–26.
  • DIETARY REFERENCE INTAKES Comparative Standards used for assessment of intake and needs.
  •  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. Dietary Reference Intakes (DRIs)
  •  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 DRI definitions
  •  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. DRIs are used in the Nutrition Care Process Reference: International Dietetics & Nutrition Terminology (3rd edition)
  • DRIs for selected nutrients 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 Nutrient Age, condition DRI Women Men Protein (g/day) > 19 years EAR RDA 38 g 46 g* (0.8 g/kg) 46 g 56 g† (0.8 g/kg) Sodium (mg/day) CKD, HTN, DM, > 50 years old, African Americans‡ RDA UL 1,500 2,300 1,500 2,300 Phosphorus (mg/day) > 19 years > 19–70 years > 70 years EAR RDA UL 580 700 4,000 3,000 580 700 4,000 3,000 Potassium (mg/day) > 19 years AI 4,700 4,700
  •  Dietary intake interview of National Health and Nutrition Examination Survey (NHANES)  Most recent has 2007–2008 data  Based on two 24-hour diet recalls What We Eat in America (WWEIA) helps identify nutrient intakes Reference: http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/0708/Table_1_NIN_GEN_07.pdf
  •  Protein RDA = 0.8 g/kg  Sodium (Na) = 1,500 mg for CKD  Phosphorus (P) RDA = 700 mg  Potassium (K) AI = 4,700 mg DRIs are used as comparative standards when assessing intake Reference: Dietary Guidelines for Americans, 2010; IOM, 2006
  • FOOD GROUPS Foods grouped together because they share similar nutritional properties.
  •  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 for health and chronic disease focus on specific content
  • 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 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 Oils Solid fats and added sugars Diabetic Exchange Carbohydrates: Starch Fruits Milk Other Nonstarchy vegetables Meat/meat substitutes Fats Alcohol
  • USDA Food Pattern* for 2,000 Calories is very similar to DASH diet * Previously referred to as MyPyramid Grains Whole (> 3 servings) 6 ounces (oz.) Vegetables Dark-green, red & orange, beans & peas, other, starchy 2 ½ cups (c.) Fruit and juices 2 cups Milk and milk products 3 cups Protein foods Meat, poultry, eggs, fish/seafood, beans & peas; nuts, seeds, and soy products 5 ½ oz. Oils 27 grams Solid fats and added sugars 258 calories (13% total kcal)
  • Selected nutrient contents of USDA Food Pattern Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107. Food Group Pro (g) Na (mg) P (mg) K (mg) Grains (1 oz.) Whole 2.4 87 85 91 Grains (1 oz.) Refined 2.2 153 33 29 Vegetables (1/2 cup) Dark-green 1.6 30 39 229 Vegetables (1/2 cup) Red & orange 0.7 41 25 214 Vegetables (1/2 cup) Beans & peas 8.0 3 119 363 Vegetables (1/2 cup) Starchy 1.7 5 43 286 Vegetables (1/2 cup) Other 0.9 57 21 162 Fruit and juices (1/2 cup) 0.7 3 17 213 Milk (1 cup) 8.3 103 247 382 Meat & beans (1 oz.) 6.9 93 63 91 Oils (1 tsp.) 0 13 0 0 Discretionary calories Added sugars 0 0 0 0 Discretionary calories Solid fats 0 16 1 2
  • Amount Pro (g) Na (mg) P (mg) K (mg) Meat 1 ounce 7.0 145 62 105 Poultry 1 ounce 8.2 24 56 70 Fish & seafood 1 ounce 6.5 51 59 82 Beans & peas ¼ c. cooked 4.0 2 60 182 Egg 1 large 6.3 62 86 63 Egg white* 1 large 3.6 55 5 54 Nuts, seeds ½ ounce 3.3 16 70 93 Milk 1 cup 8.3 103 247 382 Soymilk (with added Ca, vitamins A&D)* 1 cup 6.4 153 250 284 * Data from http://www.nal.usda.gov/fnic/foodcomp/cgi-bin/list_nut_edit.pl Most protein-rich foods are a source of phosphorus (P) and potassium (K) Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107.
  •  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. Summary: Basic Food Groups
  • Diabetic food exchanges are grouped primarily by carbohydrate content Reference: Adapted from http://nutritioncaremanual.org/vault/editor/docs/Choose_Your_Foods_lists_bw_Layout_1.pdf Food Carbohydrate (g) Protein (g) Fat (g) Calories Starch 15 0–3 0–1 80 Fruit 15 - - 60 Milk 12 8 0–8 100–160 Other carbohydrates 15 Varies Varies Varies Nonstarchy vegetables 5 2 - 25 Meat and meat substitutes - 7 0–8+ 45–100 Fats - - 5 45 Alcohol Varies - - 100
  • National renal diet reflects variability within food groups due to processing Protein (g) Calories Sodium (mg) Phosphorus (mg) Potassium (mg) High protein High Na High P Vegetarian protein High Na, P, K 6–8 50–100 70–150 20–150 200–400 20–150 10–200 250–400 50–100 100–300 80–150 200–400 50–150 60–150 250–500 Breads, starches High Na, P 2–3 50–200 0–150 150–400 10–70 100–200 10–100 Vegetables Low, medium, high K 2–3 10–100 0–50 10–70 20–150 150–250 250–550 Fruits Low, medium, high K 0–1 20–100 0–10 1–20 20–150 150–250 250–550 Calorie 0–1 100–150 0–100 0–100 0–100 Flavor 0 0–20 250–300 0–20 0–100
  •  Carbohydrate content (diabetes)  Protein content (CKD)  Sodium content (CKD and diabetes)  Phosphorus content (CKD)  Potassium content (CKD) Food groupings are more complicated with chronic disease
  • PROTEIN The RDA for protein is 0.8 g/kg/body weight.
  • Most U.S. adults eat more protein than recommended Reference: http://www.ars.usda.gov (IOM, 2005; FDA, 2009)
  •  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. Adequate, not excessive, protein for CKD
  •  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. Which type of protein is best in CKD? Animal or vegetable? References: Maddox et al. Kidney Int 2002; 61(1):96–104; Bernstein et al. J Am Diet Assoc 2007; 107(4):644–650.
  •  Evidence is lacking or limited in CKD.  ADA Evidence Library has no recommendation or supporting literature.  Recommendations vary. How much high biological value (HBV) protein is needed in CKD? 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
  •  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] Adequate protein may seem like a protein restriction (“a lot less meat”)
  • 50% HBV 56 g protein total − 28 g HBV protein 28 g other protein How much protein remains for other food groups? 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 Answer: Not much Lower Protein Pro (g) Grains (1 oz.) 2.2–2.4 Vegetables (1/2 cup) 0.7–1.7 Fruits (1/2 cup) 0.7 Fats and oils 0 Sugars 0 Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107.
  • 50% HBV Protein remaining 28 g 9 grains (2 g) −18 g 10 g Protein remaining 10 g 4 vegetables (1 g) −4 g 6 g Divide the remaining protein between the other food groups Protein remaining 6 g ½ cup milk (4 g) −4 g 2 g Protein remaining 2 g 3 fruit (0–1 g)…. −2 g 0 g
  •  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. − ½ cup = 4 g protein  Eat a smaller bowl of beans. − ½ cup = 4 g protein  Eat a small amount of nuts or seeds. − 1 ounce = 6.6 g protein Work toward smaller portions of protein foods
  •  National Kidney Disease Education Program Protein Tips for People with CKD http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508 Educational resource for dietary protein
  • Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf
  • Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf
  •  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. Protein: Take-home messages
  • SODIUM Limit sodium to 1,500 mg a day.
  • U.S. adults’ sodium intake exceeds the UL Reference: http://www.ars.usda.gov (2009), IOM (2006), FDA (2009)
  •  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. 2010 Dietary Guidelines recommend 1,500 mg sodium for CKD patients Reference: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Chapter3.pdf
  •  About 90% of total intake is from salt.  Most (98%) is absorbed in small intestine.  Most is excreted in the urine. Sodium intake ≅ sodium excretion
  • 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 middle-aged Americans Reference: Adapted from Anderson et al. J Am Diet Assoc 2010; 110(5):736–745.
  • High-sodium foods are not the only source; frequent consumption of lower sodium foods adds up Reference: Dietary Guidelines for Americans, 2010
  •  National Kidney Disease Education Program Sodium Tips for People with CKD http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508 Educational resource for dietary sodium
  • 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
  •  Compare Na and K contents of 100 g of vegetable soup. http://www.nal.usda.gov/fnic/foodcomp/search/ ACTIVITY Look up these specific items Na K Soup, vegetarian vegetable, canned, condensed (06068) - - Soup, vegetable, canned, low sodium, condensed (06217) - -
  •  Compare Na and K contents of 100 g of vegetable soup. http://www.nal.usda.gov/fnic/foodcomp/search/ ACTIVITY Look up these specific items ANSWERS Na K Soup, vegetarian vegetable, canned, condensed (06068) 672 171 Soup, vegetable, canned, low sodium, condensed (06217) 385 433
  •  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. Sodium: Take-home messages
  • PHOSPHORUS Inorganic phosphorus is absorbed more readily than organic phosphorus.
  •  The reference range is 2.7–4.6 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. Review: Control of serum phosphorus References: Liu & Quarles, J Am Soc Nephrol 2007; 18(6):1637–1647; Fadem & Moe, Adv Chronic Kidney Dis 2007; 14(1):44–53.
  •  Absorption is both passive and active.  Only 40–60% 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. Phosphorus absorption ≅ excretion Reference: IOM, 1997; Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519–530.
  • 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 40–60% 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):519–530.
  • Whole grains > refined grains  Phytates reduce absorption Protein-rich foods have phosphorus Phosphorus content by food group (organic sources) Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107. Food Group P (mg) Grains (1 oz.) Whole 85 Grains (1 oz.) Refined 33 Vegetables (1/2 cup) Dark-green 39 Vegetables (1/2 cup) Red & orange 25 Vegetables (1/2 cup) Beans & peas 119 Vegetables (1/2 cup) Starchy 43 Vegetables (1/2 cup) Other 21 Fruit and juices (1/2 cup) 17 Milk (1 cup) 247 Meat & beans (1 oz.) 63 Oils (1 tsp.) 0 Discretionary calories Added sugars 0 Discretionary calories Solid fats 1
  • More typical intake 6 ounces steak  372 mg phosphorus 1 cup beans  240 mg phosphorus Phytates reduce absorption Still high potassium 2 egg whites  10 mg phosphorus * http://www.nal.usda.gov/fnic/foodcom Most protein-rich foods are a source of phosphorus Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107. Food Amount P (mg) Meat 1 ounce 62 Poultry 1 ounce 56 Fish 1 ounce 59 Beans & peas ¼ c. cooked 60 Egg 1 large 86 Egg white* 1 large 5 Nuts/seeds ½ ounce 70 Milk 1 cup 247 Soymilk (fortified)* 1 cup 250
  • Many products may have added phosphate Reference: Adapted from http://www.foodadditives.org/phosphates/phosphates_used_in_food.html Baked goods Self-rising flour, cake mix, waffle mix, pancake mix, muffin mix, reduced sodium mixes Monocalcium phosphate Dicalcium phosphate Calcium acid phosphate Beverages Dry mixes, fruit juices, soymilk Tricalcium phosphate Cereals Cooked cereals, extruded dry cereals Tricalcium phosphate Dairy Grated cheese, instant puddings Monocalcium phosphate Fruit & vegetables Canned fruits and vegetables Monocalcium phosphate Potatoes Baked potato chips Monocalcium phosphate Pharmaceuticals Vitamin and mineral supplements, enteral products, prescription and over-the-counter tablets Tricalcium phosphate Dicalcium phosphate
  •  National Kidney Disease Education Program Phosphorus: Tips for People with Chronic Kidney Disease (CKD) http://www.nkdep.nih.gov/resources/nkdep-nutritionfactshee Educational resource for dietary phosphorus
  • 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
  •  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. Phosphorus-to-protein ratio is a new way to look at phosphorus in foods Reference: Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519–530.
  • Reference: Adapted from Kalantar-Zadeh et al., 2010 P-to-Protein Ratio 5 < 10 - Lamb, 3 oz. 6.3 Tuna, water packed, 3 oz. 6.4 Chicken drumstick 6.5 Beef, 3 oz. 7.0 Ground beef, 3 oz. 7.5 Chicken breast, 3 oz. 7.5 Turkey, 3 oz. 7.5 Pork sausage, 2 links 8.6 Taco, fast food 9.8 Soy protein isolate, 1 oz. 9.6 P-to-Protein Ratio 10 < 15 - Egg substitute, ¼ c. 10.1 Salmon-sockeye, 3 oz. 10.1 Bagel, 4” 10.2 Cheeseburger, fast food 10.5 Bologna, 2 slices 10.7 Cottage cheese, ½ c. 10.7 Tuna, oil packed, 3 oz. 10.7 Tempeh, ½ c. 10.8 Tofu raw, ½ c. 12.0 Peanut butter, 1 T. 13.1 Whole egg, large 13.3 Frankfurter, beef, 1 14.1 Lima beans, ½ c. 14.7 P-to-Protein Ratio < 5 - Egg white, large 1.4 Orange roughy, 3 oz. 4.5
  • Reference: Adapted from Kalantar-Zadeh et al., 2010 P-to-Protein Ratio > 25 - Egg/sausage biscuit, fast food 28.1 Milk 2%, 1 c. 28.3 Pecans, 20 halves 30.4 Half and half, 1T. 31.8 Cashews, 1 oz. 32.3 Tahini, 2 T. 43.1 Sunflower seeds, 3 T. 59.7 Nondairy creamer, liquid, 1 oz. 63.3 P-to-Protein Ratio 15 < 25 - Peanuts, 1 oz. 15.1 Baked beans/franks, ½ c. 15.5 Edamame, ½ c. 15.6 Black beans, ½ c. 15.8 Ricotta cheese, ½ c. 16.1 Pinto beans, ½ c. 16.2 Cream cheese, 1 T. 16.7 Soymilk, ½ c. 17.4 Mozzarella, 1 oz. 20.1 Cheddar, 1 oz. 20.4 American cheese, 1 oz. 22.8 Walnuts, 14 halves 25.0
  •  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. The amount of phosphorus in foods is not easy to discern
  •  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. Use ingredient list to find phosphorus additives, look for PHOS References: http://www.nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf; http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabe
  • Reference: http://www.nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf
  •  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. ACTIVITY Nutrient analysis: Beverages Reference: http://www.nal.usda.gov/fnic/foodcomp/search/
  • Beverage Volume P (mg) K (mg) Na (mg) Carbonated beverage, cola, contains caffeine 12 oz. - - - Carbonated beverage, low calorie, cola or pepper type, with aspartame, contains caffeine 12 oz. - - - Carbonated beverage, lemon-lime, without caffeine 12 oz. - - - Tea, ready-to-drink, (Brand A) iced tea, with lemon flavor 12 oz. - - - Tea, ready-to-drink, (Brand B) iced tea, with lemon flavor 12 oz. - - - Tea, ready-to-drink, (Brand C) iced tea, with lemon flavor 12 oz. - - - Nutrient analysis: Beverages
  • Beverage Volume P (mg) K (mg) Na (mg) Carbonated beverage, cola, contains caffeine 12 oz. 37 7 15 Carbonated beverage, low calorie, cola or pepper type, with aspartame, contains caffeine 12 oz. 32 28 28 Carbonated beverage, lemon-lime, without caffeine 12 oz. 0 4 33 Tea, ready-to-drink, (Brand A) iced tea, with lemon flavor 12 oz. 4 37 15 Tea, ready-to-drink, (Brand B) iced tea, with lemon flavor 12 oz. 95 70 77 Tea, ready-to-drink, (Brand C) iced tea, with lemon flavor 12 oz. 132 70 77 Nutrient analysis: Beverages
  •  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. Phosphorus: Take-home messages
  • POTASSIUM Restrict dietary potassium when serum levels are elevated.
  • U.S. adults do not meet the AI for potassium intake Reference: http://www.ars.usda.gov (2009), FDA (2009), IOM (2006)
  •  The reference range is 3.5–5.0 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 Review: Control of serum potassium
  • 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. Dietary Guidelines 2010 includes foods rich in potassium for general population Reference: Dietary Guidelines for Americans, 2010
  •  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. Key Recommendations (continued) Reference: Dietary Guidelines for Americans, 2010
  •  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. Need to restrict dietary potassium when serum level is elevated
  • Numerous sources contribute to potassium levels in CKD  Potassium-rich foods  Salt substitutes − Low-sodium products may have added KCl.  Herbs and dietary supplement (examples) − Noni juice (56 mmol/L) − Alfalfa − Dandelion − Horsetail − Nettle  Medications: − K supplements  KCl, K citrate − Impair excretion  ACEi  ARBs  K+-sparing diuretics  Nonsteroidal anti- inflammatory drugs  Potassium food additives References: Palmer, N Eng J Med 2004;351(6):585–92; Hollander-Rodriguez & Calvert, Am Fam Physician. 2006;73(2):283–90.
  •  National Kidney Disease Education Program Potassium Tips for People with CKD http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium Educational resource for dietary potassium
  • Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf
  • Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf
  •  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. Potassium: Take-home messages
  • FOOD PREPARATION TECHNIQUES Boiling foods may reduce levels of oxidants and potassium.
  •  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. Food preparation techniques may play a role in CKD References: Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11, Bethke & Jansky, J Food Sci 2008; 73(5):H80–H85; Burrowes & Ramer, J Renal Nutr 2006; 16(4):304–311.
  •  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. Dietary protein and fat may play a role in AGE formation Reference: Uribarri & Tuttle, Clin J Am Soc Nephrol 2006; 1(6):1293–1299.
  • Dry heat or added fat may increase AGE formation during cooking Reference: Adapted from Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11
  •  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. Tips to lower AGE formation References: Uribarri & Tuttle, Clin J Am Soc Nephrol 2006; 1(6):1293–1299; Vlassara, Kidney Int 2009; 76 (suppl 114): S3-S11
  •  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. Boiling alone removes enough potassium from tubers References: Bethke & Jansky, J Food Sci 2008; 73(5):H80–H85; Burrowes & Ramer, J Renal Nutr 2006; 16(4):304–311.
  • FOOD ADDITIVES Over 2,300 food additives are currently in use.
  •  Food additives may: − Provide nutrition − Help maintain quality and freshness − Aid in processing and preparation − Increase food appeal Food additives have a purpose Reference: http://www.foodadditives.org/pdf/Food_Additives_Booklet.pdf
  •  Listing of Food Additive Status at FDA: http://www.fda.gov/Food/FoodIngredientsPackaging/FoodAdditi The FDA approves the use of food additives in any food
  •  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 Some food additives contain phosphorus, sodium, potassium
  • ACTIVITY: Food additives may increase phosphorus, potassium, and/or sodium content Reference: http://www.nal.usda.gov/fnic/foodcomp/search/ Breakfast Amount P(mg) K (mg) Na (mg) Pancake, plain, prepared from recipe 4” - - - Pancake, plain, dry mix, complete, prepared 4” - - - Pancake, whole-wheat, dry mix, incomplete, prepared 4” - - - Egg, white, raw, fresh 1 large - - - Egg, yolk, raw, fresh 1 large - - - Egg substitute, liquid or frozen, fat-free ¼ c. - - -
  • ACTIVITY: Enhanced and fortified foods may have more P, K, or Na * “Phosphorus content varies among brands, depending upon calcium compound used (calcium phosphate, calcium citrate, etc.).” Amount P(mg) K (mg) Na (mg) Pork, fresh; loin, tenderloin, separable lean only; cooked, roasted 100 g (3 oz.) - - - Pork, fresh, enhanced; loin, tenderloin, separable lean only; cooked, roasted 100 g - - - Soymilk, original and vanilla, unfortified 1 cup - - - Soymilk (all flavors), lowfat, with added calcium, vitamins A and D 1 cup - - - Soymilk, chocolate, unfortified 1 cup - - - Orange juice, raw ½ cup - - - Orange juice, includes from concentrate, fortified with calcium (* read footnote) ½ cup - - -
  • ACTIVITY: Food additives may increase phosphorus, potassium, and/or sodium content Reference: http://www.nal.usda.gov/fnic/foodcomp/search/ Breakfast Amount P(mg) K (mg) Na (mg) Pancake, plain, prepared from recipe 4” 60 50 167 Pancake, plain, dry mix, complete, prepared 4” 127 66 239 Pancake, whole-wheat, dry mix, incomplete, prepared 4” 164 123 252 Egg, white, raw, fresh 1 large 5 54 55 Egg, yolk, raw, fresh 1 large 66 19 8 Egg substitute, liquid or frozen, fat-free ¼ c. 43 128 119
  • ACTIVITY: Enhanced and fortified foods may have more P, K, or Na * Phosphorus content varies among brands, depending upon calcium compound used (calcium phosphate, calcium citrate, etc.). Amount P (mg) K (mg) Na (mg) Pork, fresh; loin, tenderloin, separable lean only; cooked, roasted 100 g (3 oz.) 267 227 421 358 57 48 Pork, enhanced; loin, tenderloin, separable lean only; cooked, roasted 100 g 316 567 231 Soymilk, original and vanilla, unfortified 1 cup 126 287 124 Soymilk (all flavors), lowfat, with added calcium, vitamins A and D 1 cup 151 156 90 Soymilk, chocolate, unfortified 1 cup 124 347 129 Orange juice, raw ½ c. 21 248 1 Orange juice, includes from concentrate, fortified with calcium (* read footnote) ½ c. 59 * 222 2
  • 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
  •  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
  •  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. Summary (continued)
  • 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).
  • 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.
  • American Dietetic Association. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Standardized Language for the Nutrition Care Process. 3rd ed. Chicago, IL: American Dietetic Association; 2011. American Dietetic Association. Nutrition care manual (internet). Nutritioncaremanual.org website. http://nutritioncaremanual.org/content.cfm?ncm_content_id=78568 . Accessed June 14, 2011. American Dietetic Association. The food lists. NutritionCareManual.org website. http://nutritioncaremanual.org/vault/editor/docs/Choose_Your_Fo ods_lists_bw_Layout_1.pdf. Accessed June 14, 2011. References
  • American Dietetic Association evidence analysis library. Recommendations summary chronic kidney disease (CKD) anthropometric assessment options. July 2010. American Dietetic Association website. http://www.adaevidencelibrary.com/template.cfm? template=guide_summary&key=2412. Accessed August 30, 2011. American Dietetic Association evidence analysis library. Recommendations summary chronic kidney disease (CKD) protein intake. July 2010. American Dietetic Association website. http://www.adaevidencelibrary.com/template.cfm? template=guide_summary&key=2409. Accessed June 14, 2011. Anderson CAM, Appel LJ, Okuda N, et al. Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: The INTERMAP Study. Journal of the American Dietetic Association. 2010;110(5):736– 745. References
  • Bernstein AM, Treyzon L, Li Z. Are high-protein, vegetable-based diets safe for kidney function: a review of the literature. Journal of the American Dietetic Association. 2007;107(4):644–650. Bethke PC, Jansky SH. The effects of boiling and leaching on the content of potassium and other minerals in potatoes. Journal of Food Science. 2008;73(5):H80–H85. Burrowes JD, Ramer NJ. Removal of potassium from tuberous root vegetables by leaching. Journal of Renal Nutrition. 2006;16(4):304–311. Byham-Gray, LD. Weighing the evidence: energy determinations across the spectrum of kidney disease. Journal of Renal Nutrition. 2006;16(1):17–26. References
  • Case Center for Reducing Health Disparities. Fast food, phosphorus containing food additives, and the renal diet. 2009. Case Western Reserve University website. http://www.case.edu/med/ccrhd/phosfoods/. Accessed August 30, 2011. Fadem SZ, Moe SM. Management of chronic kidney disease mineral- bone disorder. Advances in Chronic Kidney Disease. 2007;14(1):44–53. Guidance for industry: a food labeling guide. 14. Appendix F: Calculate the percent daily value for the appropriate nutrients. U.S. Food and Drug Administration website. http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformat ion/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuid e/ucm064928.htm. October 2009; updated May 23, 2011. Accessed June 14, 2011. References
  • Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. American Family Physician. 2006;73(2):283–290. Institute of Medicine. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, D.C.: National Academies Press; 2000. Institute of Medicine website. http://iom.edu/Reports/2000/Dietary-Reference-Intakes- Applications-in-Dietary-Assessment.aspx. Accessed June 14, 2011. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, D.C.: National Academies Press; 1997. Institute of Medicine website. http://iom.edu/Reports/1997/Dietary-Reference-Intakes- for-Calcium-Phosphorus-Magnesium-Vitamin-D-and-Fluoride.aspx. Accessed August 30, 2011. References
  • Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino acids. Washington, D.C.: National Academies Press; 2005. Institute of Medicine website. http://iom.edu/Reports/2002/Dietary-Reference-Intakes-for- Energy-Carbohydrate-Fiber-Fat-Fatty-Acids-Cholesterol-Protein- and-Amino-Acids.aspx. Accessed August 30, 2011. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, D.C.: National Academy Press; 2004. Institute of Medicine website. http://iom.edu/Reports/2004/Dietary-Reference-Intakes-Water- Potassium-Sodium-Chloride-and-Sulfate.aspx. Accessed June 13, 2011. Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, D.C.: National Academy Press; 2006. http://iom.edu/Reports/2006/Dietary- Reference-Intakes-Essential-Guide-Nutrient-Requirements.aspx. Accessed August 30, 2011. References
  • Institute of Medicine. Strategies to Reduce Sodium Intake in the United States. Washington, D.C.: National Academy Press; 2010. Institute of Medicine website. http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium- Intake-in-the-United-States.aspx. Accessed June 14, 2011. Kalantar-Zadeh K, Gutekunst L, Mehrotra R, et al. Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease. Clinical Journal of the American Society of Nephrology. 2010;5(3):519–530. Listing of food additive status part I. U.S. Food and Drug Administration website. http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAddi tivesIngredients/ucm091048.htm. Last updated June 7, 2011. Accessed August 30, 2011. References
  • Listing of food additive status part II. U.S. Food and Drug Administration website. http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAddi tivesIngredients/ucm091048.htm. Last updated May 5, 2010. Accessed August 30, 2011. Liu S, Quarles LD. How fibroblastic growth factor 23 works. Journal of the American Society of Nephrology. 2007;18(6):1637–1647. Maddox DA, Alavi FK, Silbernick EM, Zawada ET. Protective effects of a soy diet in preventing obesity-related renal disease. Kidney International. 2002;61(1):96–104. Marcoe K, Juan W, Yamini S, Carlson A, Britten P . Development of food group composites and nutrient profiles for the MyPyramid food guidance system. Journal of Nutrition Education and Behavior. 2006;38(6 suppl):S93–S107. References
  • McCann L, ed. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York: National Kidney Foundation; 2009. National Kidney Disease Education Program. Eating right for kidney health tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient- 508.pdf. Accessed August 30, 2011. National Kidney Disease Education Program. How to read a food label tips for people with chronic kidney disease. June 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_Food Label_508.pdf. Accessed August 30, 2011. References
  • National Kidney Disease Education Program. Phosphorus tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep- nutritionfactsheets-phosphorus-508.pdf. Accessed August 30, 2011. National Kidney Disease Education Program. Potassium tips for people with chronic kidney disease (CKD). April 2010. NIH publication 11–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep- nutritionfactsheets-potassium-508.pdf Accessed August 30, 2011. National Kidney Disease Education Program. Protein tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets- protein-508.pdf 2010. Accessed August 30, 2011. References
  • National Kidney Disease Education Program. Sodium tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep- nutritionfactsheets-sodium-508.pdf. Updated March 2011. Accessed August 30, 2011. National Kidney Foundations Kidney Disease Outcomes Quality Initiative (KDOQI). Clinical practice guidelines for nutrition in chronic renal failure. American Journal of Kidney Diseases. 2000; 35(suppl 2): S58-S59. National Kidney Foundation website. http://www.kidney.org/professionals/kdoqi/guidelines_updates/do qi_nut.html. Accessed June 14, 2011. References
  • National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI). Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. American Journal of Kidney Diseases. 2007;49(suppl 2): S95-S107. National Kidney Foundation website. http://www.kidney.org/professionals/kdoqi/pdf/Diabetes_AJKD_Fe bSuppl_07.pdf. Accessed June 14, 2011. Palmer BF. Managing hyperkalemia caused by inhibitors of the renin- angiotensin-aldosterone system. New England Journal of Medicine. 2004;351(6):585–592. Phosphates used in foods. International Food Additives Council website. http://www.foodadditives.org/phosphates/phosphates_used_in_fo od.html. 2007. Accessed August 30, 2011. References
  • Renal Practice Group of the American Dietetic Association. National Renal Diet Professional Guide. 2nd ed. Chicago, IL: American Dietetic Association; 2002. Uribarri J, Tuttle KR. Advanced glycation end products and nephrotoxicity of high-protein diets. Clinical Journal of the American Society of Nephrology. 2006;1(6):1293–1299. U.S. Department of Agriculture. Agricultural Research Service. 2010. Nutrient intakes from food: mean amounts consumed per individual, by gender and age. What We Eat in America, NHANES 2007–2008. U.S. Department of Agriculture website. http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/0708 /Table_1_NIN_GEN_07.pdf. Revised August 2010. Accessed June 14, 2011. References
  • U.S. Department of Agriculture. Agricultural Research Service. 2010. USDA National Nutrient Database for Standard Reference, Release 23. Search the USDA national nutrient database for standard reference. U.S. Department of Agriculture website. http://www.nal.usda.gov/fnic/foodcomp/search/ Accessed August 30, 2011. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed., Washington, D.C.: U.S. Government Printing Office. U.S. Department of Agriculture website. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelin es2010.pdf. Accessed June 14, 2011. What are food additives? International Food Additives Council website. http://www.foodadditives.org/pdf/Food_Additives_Booklet.pdf. 2007. Accessed August 30, 2011. References
  • Vlassara H, Torreggiani M, Post JB, Zheng F, Uribarri J, Striker, GE. Role of oxidants/inflammation in declining renal function in chronic kidney disease and normal aging. Kidney International. 2009; 76 (suppl 114): S3-S11. References