Diet Module 4_2019.ppt

Module 4:
The Diet for Chronic
Kidney Disease (CKD)
Healthy eating patterns may be beneficial in CKD

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 health system change to facilitate effective CKD detection and management.
To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from
NIDDK, please visit: http://www.niddk.nih.gov.
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Meet our Presenters
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Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.
Ms. Kuracina is the lead author of the Academy of Nutrition and Dietetics’ CKD
Nutrition Management Training Certificate Program and NKDEP’s nutrition resources
for managing patients with CKD.
Ms. Kuracina has more than 25 years of clinical dietetics experience focused on
diabetes and CKD with the Indian Health Service (IHS). Until her retirement in 2017,
she served as a co-coordinator for a diabetes self-management education program at
the IHS Albuquerque Indian Health Center in New Mexico. For more than 9 years,
she has supported NKDEP with expertise regarding medical nutrition therapy for
diabetes and CKD patients, first as a member of the NKDEP’s Coordinating Panel and
more recently as a senior clinical consultant for the Program.

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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. Prior to joining the NKDEP in 2006, he
served as Director of the Kidney Disease Program for the Indian Health Service
(IHS). Dr. Narva continues to serve as the Chief Clinical Consultant for Nephrology
for IHS and to provide care for patients at Zuni Pueblo through a telemedicine clinic.
Dr. Narva is a member of the American Board of Internal Medicine Nephrology
Subspecialty Board. He has served as a member of the Eighth Joint National
Committee (JNC 8) Expert Panel, the National Quality Forum Renal Steering
Committee, the Kidney Disease Outcomes Quality Initiative Work Group on Diabetes
in Chronic Kidney Disease, and the Medical Review Board of End Stage Renal
Disease Network 15.
Meet our Presenters

Participants will be able to:
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1. Identify vegetables and fruits as the food groups
consistently associated with positive health outcomes.
2. Identify food preparation techniques for vegetables and
fruits when hyperkalemia is present.
3. Identify national trends in intakes of sodium and protein.

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Brief Review
• Blood pressure control may slow CKD progression.
 Limit sodium to 2,300 milligrams.
• Diabetes control early may lower CKD risk.
 Target A1c is individualized, based on age, comorbid
conditions, and frequency of hypoglycemia.
• In people with lower GFRs, hypoglycemia may be a sign
that kidney disease has progressed.

Brief Review
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• 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 including phosphate retention.

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Review: Complications may increase as
kidney function declines
Fewer nephrons lead to Complication Evidenced by
Inadequate erythropoietin Anemia Low hemoglobin
Reduced urinary excretion
of potassium
Hyperkalemia High potassium
Reduced urinary excretion
of hydrogen ion
Metabolic acidosis Low serum bicarbonate
Inadequate activation of
vitamin D
Bone disorders, soft
tissue and vascular
calcification
• Low 25(OH) Vit D
• High serum
phosphorus
• Abnormal calcium
• Abnormal
parathyroid
hormone (PTH)

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HEALTHY EATING
PATTERNS

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U.S. Healthy Eating Pattern (2015)
INCLUDES
• Variety of vegetables (dark green, red & orange,
legumes, starchy and other)
• Fruits, especially whole
• Grains, at least half whole grains
• Fat-free or low-fat dairy (milk, yogurt, cheese
and/or fortified soy beverages)
• A variety of protein (seafood, lean meats, poultry,
eggs, legumes and nuts, seeds and soy-products)
• Oils
LIMITS
• Saturated fats
 Less than 10% total calories
• Trans fats
• Added sugar
 Less than 10% total calories
• Sodium
 Less than 2,300 milligrams/day
• If alcohol is consumed, consume in moderation
(by adults of drinking age):
 Up to 1 drink/day for women
 Up to 2 drinks/day for men

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https://ndb.nal.usda.gov/ndb/
Use Food Search for an individual food
Use Nutrients List for a detailed report
which can include lists with
• Up to three nutrients for one to ten food
groups in household measures.
https://ndb.nal.usda.gov/ndb/nutrients/index

• Dietary carbohydrate (CHO) and protein are the nutrients used for
microbiota growth and maintenance.
• The ratio of dietary fiber (indigestible complex CHO) to protein
affects type of bacteria and resultant metabolites.
 Without dietary fiber, proteolytic bacteria dominate, and higher levels of
potentially toxic end-products are produced.
 Fiber plus protein means more saccharolytic bacteria (healthier type) and
more short chain fatty acids.
 Fiber is prebiotic = nondigestible food ingredients that benefit certain microbiota.
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What we feed the gut matters
References: Sabatino et al. Curr Diab Rep 2017; 17:16; Conlon et al. Nutrients 2015;7:17-44

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Healthy eating patterns, food groups and
impact on health outcomes
Health outcomes include lower risks of obesity, cardiovascular
disease, hypertension, type 2 diabetes and certain cancers
Effect on Health
Outcomes
Strength of Evidence
Vegetables and fruit Positive Strong
Whole grains Positive Moderate to strong
Low- or non-fat dairy,
seafood, legumes, nuts
Beneficial for some
Higher intake of red and
processed meats
Detrimental Moderate to strong
Sugar-sweetened foods &
beverages; refined grains
Detrimental Moderate to strong
Reference: USDA Scientific Report of the 2015 Dietary Guidelines

• ARIC study: High intakes of red and processed meat may increase risk of developing CKD;
and nuts, low-fat dairy or legumes may lower risk (excluded DM). Haring et al. JRN 2017; 27:233-242
• NIH-AARP Diet and Health Study: A healthier diet with less sodium and higher potassium
was associated with reduced risk of mortality or self-reported dialysis initiation. Smyth et al. JRN
2016; 26:288-298
• Healthy eating patterns with adequate vegetable and fruits and limited alcohol may delay
CKD progression and improve survival. Wai et al. JRN 2017;27175-182
• Meta-analysis found higher fruit and vegetable, fish, legume, whole grain and fiber intake
and reduced red meat, sodium and refined sugar intake is associated with lower mortality in
CKD. Kelly et al, Clin J Am Soc Nephrol 2017;12:273-279
Healthy eating patterns and kidney disease
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Healthy Eating Patterns for 2,000 calories
Food group Healthy US* Vegetarian* Med-Style* DASH**
Vegetables 2 ½ cups 2 ½ cups 2 ½ cups 2 ½ cups
Fruit 2 cups 2 cups 2 ½ cups 3 cups
Whole grains
(half of total)
3 oz. eq. 3 oz. eq. 3 oz. eq. 3 oz. eq.
Dairy 3 cups 3 cups 2 cups 2 ½ cups
Protein 5 ½ oz. eq. 3 ½ oz eq. 6 ½ oz. eq. < 6 oz. eq.
Processed soy
(per week)
½ oz. eq. 8 oz. eq. ½ oz. eq.
Oils 27 g per day 27 g per day 27 g per day 27 g per day
*Scientific Report DGA 2015 ** DASH diet brief

What counts as one equivalent?
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Vegetables One cup equivalent 1 cup raw or cooked
1 cup juice
2 cups leafy green salad
Fruit One cup equivalent 1 cup raw or cooked
1 cup juice
Whole grains One ounce equivalent ½ cup cooked pasta or rice (1 oz. dry)
1 slice bread
1 small muffin (1 oz.)
1 cup ready to eat cereal
Dairy One cup equivalent 1 cup milk or yogurt
1 ½ ounces natural cheese
2 ounces processed cheese
Protein One ounce equivalent 1 ounce lean meat, poultry or fish
1 egg
¼ cup cooked dry beans or tofu
1 tablespoon peanut butter
½ ounce nuts or seeds

Dietary Reference Intakes for Adults Women Men
Protein per day (RDA: 0.8 g/kg) 46 g 56 g
Sodium (UL) 2,300 mg 2,300 mg
Phosphorus (RDA) 700 mg 700 mg
Potassium (AI) 4,700 mg 4,700 mg
Fiber (AI) 19-50 y
[14 g/1,000 calories] > 51 y
20 g
25 g
30 g
38 g
Dietary Reference Intake: The Essential Guide to Nutrient Requirements.
http://ww.nap.edu/catalog/11537.html
UL = Tolerable Upper Intake Level (highest level of nutrient intake that is likely to pose no risk of adverse health effects).
RDA = Recommended Dietary Allowance (average daily intake sufficient to meet nutrient requirements for 97-98% of
healthy individua ls in a group).
AI = Adequate Intake (Not enough scientific evidence available to determine RDA).
GOOD NEWS: Dietary Reference Intakes for chronic disease are being
discussed by the National Academies of Sciences, Engineering and Medicine.
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Nutrient profiles of the eating patterns
Nutrients/ 2,000 kcal. Healthy U.S. Vegetarian Med.-Style
Protein (% RDA) 91 g (198%) 73 g (155%) 89 g (194%)
Protein (% calories) 18 % 14 % 18 %
Fat (% calories) 72 g (33%) 73 g (34%) 72 g (32%)
CHO (% calories) 256 g (51%) 283 g (55%) 259 g (52%)
Fiber (% AI) 31 g (109%) 36 g (126%) 31 g (112%)
Sodium (% UL) 1,787 mg (78%) 1,447 mg (61%) 1,685 mg (73%)
Phosphorus (% RDA) 1,717 mg (245%) 1,642 mg (235%) 1,572 mg (225%)
Potassium (% AI) 3,348 mg (71%) 3,358 mg (70%) 3,353mg (71%)
Vitamin D (% RDA) 274 IU (46%) 226 IU (37%) 251 IU (42%)
Adapted from: Scientific Report of the 2015 Dietary Guidelines

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Nutrient digestion and absorption
• Food composition data provide estimates of nutrient contents in a
specific amount of food.
• Bioavailability can be defined as the amount of a nutrient that is
digested, absorbed and utilized in metabolism.
 Factors affecting bioavailability include individual variability, physiologic
state, dose and presence of other components in the meal.
Reference: Parada and Aguilera. Journal of Food Science. 2007;72:R21-R32;
Palafox-Carlos et al. Journal of Food Science 2011; 76:R6-R15.

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• Sodium is almost completely absorbed (≈ 98 percent).
• About 85 percent of potassium is absorbed.
• 55-70 percent of phosphorus is absorbed.
 The majority of phosphorus is absorbed passively and
active absorption requires Vitamin D.
Not all the minerals in food are bioavailable
Reference: IOM, 1997
DRIEssentialGuideNutrientsRequirements

Phosphorus bioavailability varies
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• Phytic acid is the storage form of phosphorus found in plant seeds (beans,
peas, cereals, nuts).
• Absorption of phytate requires phytase, found in some foods and some
colonic bacteria. Phytates are thought to be poorly absorbed.
• Phytates in leavened whole grain breads are hydrolyzed by yeast and the
phosphorus is more bioavailable than in unleavened bread or breakfast
cereals.
Reference: DRIEssnetialGuide Nutrients at www.nap.edu/catalog/11537.html;

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Urinary phosphorus excretion may differ
based on food source
• Urinary excretion of phosphorus by source varies:
 ≈ 40 - 50% of plant phosphorus may be excreted
 ≈ 40 - 70% of animal phosphorus may be excreted
• Sodium-based phosphate additives may be absorbed at much higher rates (almost
completely).
• Phosphate additives which have calcium, magnesium or aluminum may not be as readily
absorbed.
• Phosphoric acid is absorbed.
• “PHOS” still identifies foods with added phosphorus; however, how much is absorbed is
not known. Reference: St-Jules et al. JRN. 2017;27:78-83

Phosphorus in foods and serum phosphorus
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References: Moore et al. Am J Clin Nutr 2015; 102:444-453. Moe et al. C J Am Soc
Nephrol; Sullivan et al. JAMA 2009;301:629-635.
• In NHANES 2003-2006 population, Moore et al. controlled for eGFR, BMI, and
UACR and found:
 Dairy with PHOS additives may have greater effect on serum phosphorus than with dairy
without additives.
 Cereals and grains with PHOS additives may have greater effect than those without
additives.
• In CKD (average GFR 32), Moe et al. found that a week of vegetarian diet led to lower
serum phosphorus and decreased FGF-23 compared to the meat (casein) diet.
• In hemodialysis, people who read labels to avoid PHOS additives had modestly lower
serum phosphorus levels.

SODIUM
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A healthy eating pattern limits sodium to 2,300 mg a day
https://health.gov/dietaryguidelines/2015/

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Food sources of sodium
Scientific Report of the 2015 Dietary Guidelines

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NKDEP - Tips for Eating Right with CKD - SODIUM
https://www.niddk.nih.gov/health-information/kidney-
disease/chronic-kidney-disease-ckd/eating-nutrition

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CAUTION: Lower sodium items may use potassium
chloride to replace sodium chloride
• Read ingredient lists on lower sodium items for
potassium chloride (KCl).
Sodium
(mg)
Potassium
(mg)
Tomato juice, canned, regular, 1 cup 680 430
Tomato juice, canned, low sodium, 1 cup 141 921
Turkey sausage, Italian, smoked, 100 g 928 197
Turkey sausage, Italian , lower sodium, 100 g 446 1,062

*Also Available in Spanish
https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/eating-nutrition
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Potassium will be listed on
new food labels.
This new version was
scheduled to be in place in
July 2018.
The FDA proposed extending
compliance dates depending
on manufacturer’s annual
sales:
> $10 million – in 2020
< $10 million – in 2021
https://www.fda.gov/downloads/food/guidanceregulation/guidancedocuments
regulatoryinformation/labelingnutrition/ucm501643.pdf

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Dietary Reference Intakes for Adults % Daily Value on
Label
Sodium UL 2,300 mg 2,400 mg
Protein RDA 46 g for females
56 g for males
50 g
Phosphorus RDA 700 mg 1,000 mg
Potassium AI 4,700 mg 3,500 mg
Fiber AI 14 g/1,000 kcal 25 g
https://www.fda.gov/downloads/Food/GuidanceRegulation/UCM265446.pdf
UL = Tolerable Upper Intake Level (highest level of nutrient intake that is likely to pose no risk of
adverse health effects).
RDA = Recommended Dietary Allowance (average daily intake sufficient to meet nutrient requirements
for 97-98% of healthy individuals in a group).
AI = Adequate Intake (Not enough scientific evidence available to determine RDA).

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VEGETABLES
https://health.gov/dietaryguidelines/2015-scientific-report/

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The eating patterns include a variety
of vegetables each week
Vegetables 1,600 calories 2,000 calories 2,400 calories
Dark green
Red/orange
Dry beans/peas
Starchy
Other
1 ½ cups
4 cups
1 cup
4 cups
3 ½ cups
1 ½ cups
5 ½ cups
1 ½ cups
5 cups
4 cups
2 cups
6 cups
2 cups
6 cups
5 cups
Per DAY 2 cup equivalents 2 ½ cup
equivalents
3 cup equivalents
One cup equivalent = 1 cup raw or cooked vegetables, 1 cup
vegetable juice, 2 cups leafy salad greens, or ½ cup dried vegetable

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Examples of vegetable subgroups
Dark green Red-orange Dried beans Starchy Other
Broccoli
greens (collard,
mustard, or
turnip)
Kale
Romaine
Spinach
Carrots
Pumpkin
Red peppers
Sweet potatoes
Tomato
Winter squash
Black beans
Chickpeas
Edamame
Kidney beans
Lentils
Pinto beans
Split peas
White beans
Cassava
Corn
Green lima beans
Green peas
Plantains
White potatoes
Cabbage
Celery
Cucumbers
Green beans
Green peppers
Iceberg lettuce
Mushrooms
Onions
Zucchini

Nutrient Profiles for vegetable subgroups
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1/2 cup
Protein
(g)
Carbohydrate (g) Fiber
(g)
Phosphorus
(mg)
Potassium
(mg)
Dark green 1.4 3.2 1.7 31 189
Red-orange 0.8 5.0 1.2 22 222
Beans & peas 7.9 21.8 7.7 135 370
Starchy 2.0 17.4 1.9 50 302
Other 1.0 4.6 1.3 23 133
Adapted from: www.cnpp.usda.gov/USDAFoodPatterns
Consumption-weighted average nutrient content, based on NHANES
2009-2010 consumption data for 2 days of food intake

Dark Green Vegetables
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FOOD PHOTOS https://www.choosemyplate.gov/myplate/vegetables/gallery
Potassium in 1 c. raw: arugula < watercress
< green leafy < romaine < mixed greens < spinach
Potassium in ½ c. fresh cooked : collards <
mustard < turnip < bok choy < swiss chard

Dark Green Vegetables
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One-half cup Potassium (mg) Fiber (g)
Broccoli, raw 139 1.1
Broccoli, frozen, chopped, boiled 131 2.8
Broccoli, frozen, spears, boiled 166 2.8
Broccoli, chopped, boiled 229 2.6
Kale (1 cup loosely packed 1” pieces) 79 0.6
Kale, cooked, boiled 148 1.3
Spinach, raw (1 cup) 167 0.7
Spinach, frozen, chopped or leaf, boiled 287 3.5
Spinach, canned, drained solids 370 2.6
Spinach, boiled 419 2.2
Vegetables are cooked without salt

Red-Orange Vegetables
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Red-Orange Vegetables
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Carrots, frozen, boiled, drained 140 2.4
Carrots, boiled, drained 183 2.3
Carrots, raw, grated 176 1.5
Carrots, raw, chopped 205 1.8
Carrot juice 345 1.0
Tomato, cherry (5) 201 1.0
Tomatoes, canned, no added salt 229 2.3
Tomatoes, red, cooked 262 0.8
Tomato juice, low sodium 278 0
Tomatoes, sun-dried (1/4 cup) 463 1.7

Starchy Red-Orange Vegetables
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One-half cup Potassium
(mg)
Fiber
(g)
Sweet potato, canned, syrup, drained (25 g CHO) 189 2.9
Sweet potato, frozen, baked without salt (21 g CHO) 332 1.6
Sweet potato, boiled without skin, mashed (29 g CHO) 377 4.1
Sweet potato, baked in skin, flesh (20 g CHO) 475 3.3
Winter squash, acorn, boiled (11 g CHO) 322 3.2
Winter squash, acorn, baked (15 g CHO) 448 4.5

Starchy Vegetables
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Starchy Vegetables
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Corn, canned, drained, rinsed with tap water 87 1.3
Corn, canned, drained 108 1.6
Corn, boiled, drained, cut 162 1.8
Corn, frozen, microwaved 195 1.8
Potato, mashed, dehydrated, milk/butter (sodium 172
mg)
172 0.8
Potato, baked, flesh 239 0.9
Potato, boiled, peeled 256 1.4
Potato, microwaved, cooked in skin, flesh 321 1.2
Potato, microwaved, cooked in skin, skin 377 3.2

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Other Vegetables

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Other Vegetables
Cabbage, raw, shredded 60 0.9
Cabbage, raw, chopped 76 1.1
Cabbage, boiled, drained 147 1.4
Cauliflower, boiled, drained 88 1.4
Cauliflower, frozen, boiled, drained 125 2.4
Cauliflower, raw, chopped 160 1.1
Green beans, canned , NAS, drained 73 1.5
Green beans, frozen, microwaved 132 1.9
Green beans, microwaved 187 2.0
Green beans, raw, ½” pieces 211 2.7
NAS = No Added Salt

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SUMMARY: Preparation may impact potassium
content of vegetables
Generally speaking, potassium contents vary, when cooking:
 Canned < boiled < baked
 Frozen boiled < fresh boiled
 Boiled < microwaved
 Smaller pieces < larger pieces (chopped vs. spears)
Generally speaking, for raw vegetables:
 Smaller pieces < larger pieces (grated vs. chopped)
 Juice has more based on comparable serving size (how many pieces
does it take to make one half cup?)

A few tips for vegetables when someone
has hyperkalemia
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• Choose lower potassium vegetables.
• Buy frozen vegetables without added sauces or seasoning.
 Some frozen Asian stir fry mixes may have added soy sauce.
• Boil vegetables instead of microwaving them.
• Choose no-added salt canned vegetables, drain and rinse.
• Drain and rinse regular canned vegetables to lower sodium (and maybe some potassium).
• Top sandwiches with veggies such as green leaf lettuce, sliced cucumbers, grated carrots, and others.
• Add grated carrots and zucchini to meatloaf or meatballs.
• Top tacos with green cabbage and lettuce.

Fruit
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https://health.gov/dietaryguidelines/2015-scientific-report/

Healthy eating patterns include fruit;
whole fruit is preferred
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1,600 calories 2,000 calories 2,400 calories
1 ½ cups 2 cups 2 cups
Adapted from: : www.cnpp.usda.gov/USDAFoodPatterns
One cup equivalent = 1 cup raw or cooked, 1 cup fruit juice, ½ cup dried fruit
Protein
(g)
Carbohydrate (g) Fiber
(g)
Phosphorus
(mg)
Potassium
(mg)
0.6 12.3 1.2 14 156
One-half cup has:
Recommended intakes per day for selected calorie levels

FRUIT and FIBER
< 100 mg potassium per serving
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< 1 gram fiber 1-3 grams fiber 1-3 grams fiber
Apple, raw, peeled (50) Apples, dried* (95) Raspberries, raw (95)
Cranberry juice Apple, raw (65) Raspberries, frz (95)
Cranberries, raw (45) Applesauce (90)
Grapes, slip skin (90) Blueberries, frz, thawed (70)
Peach nectar (50) Blueberries, raw (55)
Pear nectar (15) Fruit cocktail, hvy syr (95)
Watermelon balls (85) Pear, raw (80), hvy syr (65)
Pineapple, raw (90)
One serving: ½ cup fresh, canned, cooked or frozen (frz) or ¼ cup dried*

Fruit and Fiber
101-200 mg potassium per serving
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< 1 gram fiber 1-3 grams fiber 1-3 grams fiber
Apple juice (125) Grapes, European (145) Pineapple, frz (125)
Casaba melon (155) Mango (140) Plums, raw (130)
Grape juice (130) Nectarine (145) Strawberries, raw (115) frz
Grapefruit juice (195) Orange (165) Tangerine, raw (160) cnd (130)
Honeydew melon (195) Papaya (130) > 3 grams fiber
1-3 grams fiber Peach, raw or frz (≈160) Apricots, heavy syr (155)
Cherries, sweet (155) Peach, hvy syr drain’d (105) Blackberries, raw (115)
Grapefruit (155) Pineapple, juice pk (110) Raspberries, frz, thaw (140)
Canned peaches, solids and liquids (potassium in one half cup)
• extra light syrup 90 mg
• heavy syrup 120 mg
• juice pack 160 mg
• water pack 120 mg
One serving: ½ cup fresh, canned (cnd), cooked or frozen (frz)

Fruit and Fiber
201-300 mg potassium per serving
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One serving: ½ cup fresh, canned,
cooked or frozen; or ¼ cup dried*
< 1 gram 1-3 grams > 3 grams
Cantaloupe balls (235) Apricots, raw (201) Figs, dried* (253)
Orange juice (220) Cherries, frz, thawed (260) Pears, dried* (240)
Pomegranate juice (260) Kiwi (280)
Pummelo (205) Plantains, green fried (285)
< 3 grams > 3 grams >5 grams
Banana, raw (403) Apricots, dried* (380) Avocado, Calif. pureed (585)
Plantains, cooked (465) Apricots, dried, stewed (515) Avocado, Florida, pureed (405)
Prune juice (355) Guava (345) Figs, dried, stewed (380)
Raisins, golden seedless (310)* Peaches, dried* (400)
Plums, dried* (320)
Prunes, stewed (400)
301 mg plus potassium per serving

Size and processing makes a difference
in potassium content
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PEACHES

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Tips for fruit when someone has hyperkalemia
• Choose lower potassium fruits.
• If a higher potassium fruit is preferred, eat a small amount.
• Canned fruits have less potassium than fresh. Drain and
rinse.
• Use peeled fruit for fruit salad.
• Although the fruit “nectars” are lower in potassium, they
have added sugar and are lower in fiber.

Most “bread” has salt; phosphorus in whole grain
yeast bread may be more bioavailable
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May need to recommend different cold cereal;
read the labels
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Phosphorus in plant foods not completely absorbed

Some instant hot cereals may be higher in sodium
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Dietary protein transiently increases the GFR
PROTEIN

Protein and the kidneys
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• Amino acids are the source of nitrogen in the diet.
• We do not store extra nitrogen, the kidneys excrete excess as urea.
• Glucagon secretion is stimulated by dietary protein.
• Glucagon stimulates urea excretion by the kidneys and the GFR increases for a few hours
after eating protein.
• Protein-rich foods are a source of phosphorus and potassium. Sulfur amino acids (in
animal protein) are thought to increase acid load.
• For people with CKD, a lower protein diet reduces nitrogenous waste, and decrease intakes
of phosphorus and potassium. Smaller amounts of animal protein may lower acid load.
Reference: Bankir et al. Am J Physiol Renal Physiol. 2015;309:F2-F23.

Which type of protein is best for CKD?
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Animal protein
• May contribute to acidosis (due
to sulfur-amino acids) and
uremic toxins in CKD.
• More than half of dietary
phosphorus is from animal
protein in our diets.
• High intakes of processed and
red meat may be associated
with CVD.
Plant protein
• May contribute to bicarbonate
levels.
• May be associated with fewer
uremic toxins.
• May improve lipid levels.
• May be associated with lower
mortality in CKD.
Reference:. Chen et al. Am J Kidney Dis 2016;67:423-430.

High protein diets are not recommended
for people with CKD
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• Protein contributes to phosphorus and
potassium intake.
• Animal protein intake may increase acidemia.
• Most Americans eat more protein than needed,
averaging 1.2 to 1.4 grams/kilogram per day.
• Some protein foods have salt added to them.

Which weight should be used to
estimate protein needs?
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The best weight to use in CKD is unknown.
No one weight or method is best. Examples include:
• Ideal body weight (life insurance data)
• Standard body weight (NHANES data)
• Hamwi method (based on height and gender)
• Body Mass Index (BMI)
• Adjusted body weight: theoretical estimation using ([actual weight –
ideal weight] +/- 25%); subtract in obese and add in underweight

Use your clinical judgment
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• When using current body weight you may:
 Overestimate dietary needs with obesity
 Underestimate dietary needs with underweight
• No adjustment method is better than any other.

The healthy eating patterns include a variety
of proteins each week
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Food group Healthy US Vegetarian Med-Style
Vegetables
- Legumes 1 ½ cups 3 cups 1 ½ cups
Dairy 3 cups per day 3 cups per day 2 cups per day
Protein
-Meat
-Poultry
-Seafood
-Eggs
-Nuts/seeds
12 ½ oz. eq.
10 ½ oz. eq.
8 oz. eq.
3 oz. eq.
4 oz. eq.
3 oz. eq.
7 oz. eq.
12 ½ oz. eq.
10 ½ oz. eq.
15 oz. eq.
3 oz. eq.
4 oz. eq.
Processed soy ½ oz. eq. 8 oz. eq. ½ oz. eq.
For 2,000 calories pattern
One ounce equivalent = 1 ounce lean meat, poultry or fish; 1 egg; ¼ cup cooked dry
beans or tofu; 1 tablespoon peanut butter; ½ ounce nuts or seeds

Nutrient Profiles for protein subgroups
Slide 65 of 89
Consumption-weighted average nutrient content, based on NHANES 2009-2010 consumption data for 2 days of food intake
1 ounce equivalent Protein
(g)
Sodium
(g)
Phosphorus
(mg)
Potassium
(mg)
Fiber
(g)
Beans & peas (1/2 c.) 7.9 3 135 370 7.7
Milk (1 cup) 8.7 202 232 235 0
Meat 7.1 127 65 93 0
Poultry 7.8 59 60 76 0
Fish high n3 6.5 41 73 104 0
Fish low n3 6.1 118 74 82 0
Eggs 6.3 62 86 63 0
Soy 10.1 116 103 27 0.7
Nuts/seeds 3.1 20 65 96 1.2
n3 = long chain
fatty acids (such
as EPA, DHA)
Adapted from:
www.cnpp.usda.gov/USDAFoodPatterns

For females, most of the protein comes from meat,
poultry and eggs
Slide 66 of 89
Meat, Poultry, Eggs Seafood Nuts, Seeds & Soy
Adapted from: health.gov/dietaryguidelines/2015/guidelines
Ounce
equivalents

Many adult men eat more meat,
poultry and eggs than recommended
Slide 67 of 89
Adapted from: health.gov/dietaryguidelines/2015/guidelines
Meat, Poultry, Eggs Seafood Nuts, Seeds & Soy

of 89
Convenience items contribute to mineral intakes

Cow’s milk has more phosphorus compared to soy;
all contribute potassium
Slide 69 of 89

of 89
Processed cheese has more sodium
than natural cheeses
One ounce equivalent
for dairy = 2 ounces of
processed cheese or 1 ½
ounces of natural
cheese

Seafood can be part of a healthy eating pattern;
intake is low for many
Slide 71 of 89
•
www.fda.gov/downloads/Food/GuidanceRegulation/ucm063478.pdf
Higher sodium choices
(> 200 mg sodium/ 3 oz.)
• Blue crabs, lobster, oysters,
scallops and shrimp
Lower potassium choices
(<300 mg potassium/ 3 oz.)
• Catfish, ocean perch, oysters and
shrimp

Source may impact nutrient content
Slide 72 of 89

For salmon, type and preparation may make
a small difference in phosphorus
Slide 73 of 89

Legumes: fiber, potassium and phosphorus
Slide 74 of 89

Nuts and seeds: fiber, potassium and phosphorus
Slide 75 of 89

ACTIVITY
Slide 76 of 89
• Compare sodium(Na), potassium (K) and phosphorus (P) contents in one cup of various canned
vegetable soups.
http://www.nal.usda.gov/fnic/foodcomp/search/
Look up these specific items Na K
Soup, vegetarian vegetable, canned, prepared
with water (06468)
Soup, vegetable, canned, low sodium, prepared
with water (06967)
Soup, chunky vegetable, canned, ready-to-serve
(06067)
Soup, chunky vegetable, reduced sodium,
canned, ready-to-serve (27060)

ACTIVITY: ANSWERS
Slide 77 of 89
• Compare sodium(Na), potassium (K) and phosphorus (P) contents in one cup of various canned
vegetable soups.
http://www.nal.usda.gov/fnic/foodcomp/search/
Look up these specific items Na K
Soup, vegetarian vegetable, canned, prepared
with water (06468)
815 207 34
Soup, vegetable, canned, low sodium, prepared
with water (06967)
491 549 58
Soup, chunky vegetable, canned, ready-to-serve
(06067)
614 414 67
Soup, chunky vegetable, reduced sodium,
canned, ready-to-serve (27060)
331 838 67

What about beverages?
Slide 78 of 89
• Water should be the preferred choice.
• Milk and fruit juice should be consumed within recommended
food group amounts and calorie needs.
• Beverages with added sugars should be reduced and not
replaced with low-calorie versions; drink water instead.
• Currently, sweetened beverages account for 35% of calories
from beverages in the diet.
• For adults who choose to drink alcohol, per day, up to 1 drink
for women and up to 2 drinks for men. U.S Dietary Guidelines 2015

Beverages may contribute to phosphorus, potassium
and sodium – read ingredient list
Slide 79 of 89
Beverage Volume P (mg) K (mg) Na
(mg)
Cola, with caffeine 12 oz. 33 18 11
Cola with aspartame, with caffeine 12 oz. 32 28 28
Lemon-lime pop 12 oz. 0 4 37
Vitamin water, fortified 12 oz. 4 37 15
Energy drink 8 oz. 226 240 240
Iced tea, with lemon flavor, ready to drink 12 oz. 95 70 77
Milk, 1%, with Vitamins A & D 8 oz. 232 366 107
Milk, 1%, protein-fortified, with Vits. A & D 8 oz. 245 397 127
Nutrient analysis from USDA National Nutrient Database for Standard Reference
http://ndb.nal.usda.gov/ndb/search/list

Tips for eating healthy in CKD
Slide 80 of 89
• Prepare foods from scratch.
• Choose foods without food additives.
• Prepare foods without salt, and if needed, add a small amount at the
table.
• Use liquid vegetable oil instead of solid fats.
• Use less meat, poultry, or fish in recipes.
• Increase vegetable intake.

Online Resources including Cookbooks
Slide 81 of 89
Tasty Recipes for People with
Diabetes and Their Families
https://www.cdc.gov/diabetes/ndep/pdfs/54-tasty-
recipes-508.pdf
Keep the Beat™ and We Can®
Deliciously Healthy Family Meals
• Kid friendly
https://healthyeating.nhlbi.nih.gov/pdfs/KTB_Fami
ly_Cookbook_2010.pdf
Down Home Healthy Cooking https://www.cancer.gov/about-cancer/causes-
prevention/risk/diet/down-home-healthy-
cooking.pdf
What’s Cooking USDA Mixing Bowl https://whatscooking.fns.usda.gov/
Fruits & Veggies-More Matters®
• Recipes, storage, shopping
http://www.fruitsandveggiesmorematters.org/

Brief Summary
Slide 82 of 89
• Healthy eating patterns may be beneficial in CKD.
• Foods rich in fiber are important for gut health.
• Food composition data provide estimates about nutrient content but do not provide information
about nutrient bioavailability (e.g. phosphorus).
• Limiting sodium is part of a healthy eating pattern.
• Preparation of vegetables and fruit impacts potassium content (canned < frozen < fresh).
• Vegetables and fruit generate bicarbonate.
• Foods rich in protein contribute to phosphorus and potassium intake. Some have added sodium.
 Animal proteins contribute to acid load.

References
Slide 83 of 89
American Dietetic Association evidence analysis library. Recommendations summary: CKD anthropometric assessment options 2010. American
Dietetic Association website. https://www.andeal.org/template.cfm?template=guide_summary&key=2412&highlight=CKD&home=1
Accessed July 3, 2017.
Bankir L, Roussel R, Bouby N. Protein- and diabetes-induced glomerular hyperfiltration: role of glucagon, vasopressin, and urea. American
Journal of Physiology Renal Physiology. 2015;309:F2–F23.
Chan M, Kelly J, Tapsell L. Dietary modeling of foods for advanced CKD based on general healthy eating guidelines: what should be on the plate?
American Journal of Kidney Diseases. 2016; 69(3):436–450.
Chen X, Wei G, Jalili T, et al. The associations of plant protein intake with all-cause mortality in CKD. American Journal of Kidney Diseases.
2016;67(3):423–430.
Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. Nutrients. 2015;7:17–44.
Cupisti A, Kalantar-Zadeh K. Management of natural and added dietary phosphorus burden in kidney disease. Seminars in Nephrology.
2013;33(2):180-190.

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Haring B, Selvin E, Liang M, et al. Dietary protein sources and risk for incident chronic kidney disease: results from the
atherosclerosis risk in communities (ARIC) study. Journal of Renal Nutrition. 2017; 27(4):233–242.
Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, D.C.: National
Academy Press; 2006. https://www.nap.edu/catalog/11537/dietary-reference-intakes-the-essential-guide-to-nutrient-
requirements Accessed August 1, 2017.
Kelly JT, Palmer SC, Wai SN, et al. Healthy dietary patterns and risk of mortality and ESRD in CKD: a meta-analysis of cohort
studies. Clinical Journal of the American Society of Nephrology. 2017; 12: 272–279.
Kelly JT, Rossi M, Johnson DW, Campbell KL. Beyond sodium, phosphate and potassium: potential dietary interventions in
kidney disease. Seminars in Dialysis. 2017; 30(3): 197–202.
Moe SM, Zidehsarai MP, Chambers MA, et al. Vegetarian compared with meat dietary protein sources and phosphorus
homeostasis in chronic kidney disease. Clinical Journal of the American Society of Nephrology. 2011; 6: 257–264.
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Moore LW, Nolte JV, Gaber AO, Suki WN. Association of dietary phosphate and serum phosphorus concentration by levels of kidney
function. American Journal of Clinical Nutrition. 20015;102:444–453.
Moorthi RJ, Vorland CJ, Hill Gallant KM. Diet and diabetic kidney disease: plant versus animal protein. Current Diabetes Reports.
2017;17:15.
National Academies of the Sciences, Engineering, and Medicine, 2017. Guiding principles for developing dietary reference intakes for
chronic disease. Washington, DC: The National Academies Press, doi:https:doi.org/10.17226.24828.
Palafox-Carlos H, Ayala-Zavala JF, Gonzalez-Aguilar GA. The role of dietary fiber in the bioaccessibility and bioavailability of fruit and
vegetables antioxidants. Journal of Food Science.2011; 76:R6–R15.
Parada J, Aguilera JM. Food microstructure affects the bioavailability of several nutrients. Journal of Food Science. 2007;72:R21–R32.
Sabatino A, Regolisti G, Cosola C, Gesualdo L, Fiaccodori E. Intestinal microbiota in type 2 diabetes and chronic kidney disease. Current
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Smyth A, Griffin M, Yusuf S, et al. Diet and major renal outcomes: a prospective cohort study. The NIH-AARP diet and health
study. Journal of Renal Nutrition. 2016;26(5):288–298.
St-Jules DE, Jagannathan R, Gutekunst L, Kalantar-Zadeh K, Sevick MA. Journal of Renal Nutrition. 2017; 27(20):78–83.
Sullivan C, Sayre SS, Leon JB, et al. Effect of food additives on hyperphosphatemia among patients with end-stage renal disease.
Journal of the American Medical Association. 2009;301(6):629–635.
U.S. Department of Agriculture. Agricultural Research Service. 2016. USDA National Nutrient Database for Standard Reference,
Release 28. U.S. Department of Agriculture website. https://ndb.nal.usda.gov/ndb/
United States Department of Agriculture Center for Nutrition Policy and Promotion. USDA Food Patterns.
https://www.cnpp.usda.gov/sites/default/files/usda_food_patterns/NutrientProfiles.pdf
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U.S. Department of Agriculture. Scientific Report of the 2015 Dietary
Guidelines Advisory Committee. February 2015.
https://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-
Committee.pdf
U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans
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References

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