Questions and Answers about Your New Diet

Part 1: Basic ESRD Diet Guidelines

• Why do I need to follow a special diet?
• Should I increase or or decrease the amount of protein in my diet?
• What is potassium and why do I have to control my intake?
• Why do I need to limit my phosphorus from foods if I take binders?
• Why do I have to limit my sodium and fluids?

Part 2: Other Nutritional Concerns

• How do I make all these changes with everything happening at once?
• What if I don’t have an appetite?
• Do I need to be concerned if my cholesterol is high?
• What about my diabetes?

Part 1: Basic Kidney Diet Guidelines

Why do I need to follow a special diet?

The healthy kidney functions to filter waste products and excess minerals from digested foods out of the body. It regulates sodium and fluid balance, conserving when the body is low and excreting with excess. In addition to the kidney's many important functions is its ability to maintain normal bone health with the delicate balance of phosphorus and calcium.

When your kidneys are not working properly they cannot rid the body of excess waste products and fluids. Minerals obtained from food such as potassium, phosphorus, and sodium may also accumulate in your body endangering you heart, bones, lungs, and overall health. The goal of the diet is to control your protein, potassium, phosphorus, calcium, sodium (salt), and fluid intake to assist your dialysis treatments in ridding the body of the build up of waste products, minerals, and excess fluid.

Scientific studies have stressed the importance of achieving and maintaining optimal nutritional status in the person with kidney disease. Therefore an additional goal of the diet is to provide you with adequate calories to support a healthy body weight and preserve protein. In addition, a Registered Dietitian will monitor your nutritional status and consequently develop a nutrition care plan based on your unique and changing needs.

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Should I increase or or decrease the amount of protein in my diet?

Protein has many bodily functions and is well known for its ability to build and repair body tissue. Adequate protein consumption can help keep your immune system strong to defend your body from infections, which is especially important for the person receiving dialysis. However, when your body digests protein it breaks it down into waste products that build up in the blood and become toxic to the body. Healthy kidneys or an artificial kidney (dialysis) filter these waste products out of the body to prevent serious medical complications from occurring.

Scientific studies suggest that consuming a low protein diet prior to the initiation of dialysis may help preserve kidney function and delay the need for dialysis. This may be the result of a decrease in the kidney's workload by decreasing the amount of waste products it must filter. Your Physician will determine whether a low protein diet is appropriate for you and refer you to a Registered Dietitian who can determine your specific protein and nutritional needs.

Once dialysis is initiated, the loss of nutrients and the stress of the dialysis procedure may be the cause for the increase protein and calorie needs in the kidney patient. Protein needs are increased but still need to be controlled. Inadequate protein can cause muscle breakdown, weakness, and increase your chance of infection. Over consumption of protein can create unpleasant symptoms such as nausea, vomiting, fatigue, and taste changes by contributing too many waste products to be filtered by your dialysis treatments. Protein foods also provide high amounts of potassium and phosphorus, minerals that can dangerously accumulate in the body and will be discussed later. Your physician and dietitian will determine your unique protein needs and monitor your laboratory values to adjust your nutritional care plan as needed.

High quality protein foods (from soy and animal protein: chicken, fish, beef, eggs, dairy) are better absorbed by the body versus poor quality protein (from plant foods: bread, vegetable, beans). In addition, animal protein can help you reach your optimal protein intake in smaller quantities than plant protein foods therefore reducing waste products from its digestion. To preserve protein for it's essential functions adequate calories must be consumed. Furthermore, the body utilizes protein best when distributed in smaller portion sizes frequently during the day versus at one or two large meals. Your physician and dietitian will monitor your protein status and again adjust your nutritional care plan as needed.

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What is potassium and why do I need to control my intake?

Potassium is a mineral that is required by the body for proper nerve and muscle activity. It is found in all types of foods including meat, dairy products, dried beans, and is especially high in fruits and vegetables. When your kidneys no longer can filter excess potassium out of the body, it begins to build up in the blood endangering your heart muscle. Serious complications can occur with potassium accumulation in the body such as muscle breakdown, irregular heartbeat, and cardiac arrest. Potassium levels can also become too low in the dialysis population and the person may experience muscle weakness, shakiness, and tingling sensations. Therefore, the goal of the diet is to maintain a desirable potassium level in the blood. Your physician and dietitian will monitor your potassium blood level and adjust your diet as needed.

As a dialysis patient it is important to become familiar with the amount of potassium in different foods so that you can make informed choices when planning your meals. Unfortunately there isn't any obvious characteristic of foods that would clue you in to how much potassium they contain.

For example, these common foods all have a high potassium content:

• 1 medium orange; 250 mg
• 1 medium raw avocado; 1097 mg
• ½ cup baked beans; 455 mg
• ½ cup boiled spinach; 419 mg
• 1 baked sweet potato with skin; 397 mg

These foods are all low in potassium:

• 1/2 cup unsweetened applesauce: 91 mg
• 1/2 cup blueberries: 65 mg
• 1/2 cup canned no salt added green beans: 78 mg
• 1/2 cup frozen and boiled carrots: 115 mg
• 1 slice white bread: 27 mg

Click here to view a larger list of potassium containing foods

Portion control is essential in limiting your potassium content in foods. Boiled carrots provide 115 mg of potassium per ½ cup. However, if you eat 1 ½ cups of boiled carrots the potassium content will of course triple to 345 mg. This can also work to your benefit. For example a high potassium tomato (1 small) provides 273 mg of potassium. If you cut a thin slice to accent your sandwich it provides much less; 1/6th of 1 small tomato provides 45 mg of potassium. Discuss your concerns and questions with a Registered Dietitian who may be able to teach you moderation techniques to include some favorite foods. You may also learn methods that can decrease the potassium content in foods such as buying canned fruits and vegetables versus fresh. In addition, you may be provided with a more detailed list and recommendations that are based on your unique and individual nutritional needs.

Why do I need to limit my phosphorus from
food if I take phosphorus binders?

Your body maintains a delicate balance between the minerals phosphorus and calcium, which are essential to bone health. The healthy kidney plays an important role in this balance by producing the active form of vitamin D which help's the body to absorb more calcium if needed.

In kidney disease, phosphorus found in many foods may accumulate in the blood disrupting the balance and causing a decrease in blood calcium levels. This sets off an alarm in the body which signals a gland located in your neck to produce parathyroid hormone. Parathyroid hormone in turn tells the kidneys to make active vitamin D to absorb more calcium. The diseased kidney can't recognize this signal nor can it make active vitamin D. The body continues to produce parathyroid hormone and the body begins to pull calcium from the bones endangering the skeletal system. Over time this can cause your bones to become brittle and easily broken, a condition referred to as "renal bone disease".

You can help prevent renal bone disease from occurring with the help of your renal care team consisting of your physician, nurse, and dietitian. Dialysis can not remove all the phosphorus in your blood, so following a low phosphorus diet is crucial. Taking phosphorus binders (most often calcium supplements) in the manner your physician prescribes is equally important. Phosphorus binders are typically taken with meals to bind some of the phosphorus obtained from food in the stomach before it enters the blood. Furthermore, to ensure good control of your phosphorus levels it is essential that the binders be taken in a consistent manner.

Your physician will monitor your laboratory values to determine if supplementation with the active form of vitamin D is necessary. This active form of vitamin D must be administered intravenously (IV) during your dialysis treatments and is different from oral supplementation of vitamin D. Your part in controlling your phosphorus intake is crucial. A high phosphorus diet and/or forgetting to take phosphorus binders may stop vitamin D therapy if used. In addition too much calcium in the blood, which can occur from overuse or misuse of calcium containing phosphorus binders, may also stop vitamin D therapy.

Your role in balancing your phosphorus intake from food with your binders as prescribed by your physician is essential to maintaining strong bones. Discuss with your dietitian any concerns or questions you have regarding your phosphorus and calcium balance. You may learn methods that help you to remember your binders at mealtime. For example, before you begin to eat make it a habit to leave room for your binders on your plate. Then when you finish your last bite, the binders will be insight for you to take. Your dietitian can also provide you with a list of high phosphorus foods to limit or avoid such as dairy foods, beans, colas, and peanut butter.

Click here to see examples of foods high in phosphorus

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Why do I need to limit my sodium and fluids?

One of the important functions of the healthy kidney is its ability to regulate sodium (salt) and fluid balance. The kidneys will reserve sodium or fluids if body concentrations become too low. Furthermore, they will rid the body of excess fluids or sodium to maintain the body's proper balance. This delicate balance of sodium and fluid helps to regulate blood pressure.

When your kidneys are not working properly the regulation of sodium and fluid balance is lost. High dietary intakes of sodium can lead to the body's natural response of triggering its thirst sensation to increase your fluid intake in an attempt to flush the excess sodium out of the body. In kidney disease this natural response to drink more may cause your body to swell and gain weight, often called edema. Your heart may become enlarged as it works harder to pump blood with the excess fluid weight. You may experience shortness of breath and an elevated blood pressure. Over time, your dialysis treatments may not be able to remove excessive fluid gains and it can dangerously settle in your lungs.

Reducing your intake of high sodium foods and utilizing methods to control your fluid intake is essential to mastering your fluid prescription. Putting down the salt shaker is not enough. You will need to reduce your intake of high sodium foods such as canned foods, frozen dinners, olives, soy sauce, deli-style lunch meats, cheese, canned soups, and packaged food items. Many restaurants offer healthier choices, so call ahead to see if low sodium items are available on the menu. Talk to your dietitian to learn which foods you'll need to reduce and how to read food labels for sodium content. You may be surprised to learn how much sodium is in some food items.

Keep track of the fluids you consume and remember to count any food item that melts at room temperature such as sherbet, Jell-O, and ice cubes. Drain all liquids from canned fruits and low sodium vegetables. Count on water as being a true thirst quencher versus sodas or sugar containing beverages. Try to learn from past mistakes. If you gain too much fluid weight, look back at the previous days and try to identify what contributed to the fluid gain. Did you have a high sodium meal? Did you lose track of you fluid intake when socializing at a family gathering? Talk with your dietitian who may be able to offer assistance in finding solutions to mastering these problem areas.

Part 2: Other Nutritional Concerns

How do I make all these changes with everything happening at once?

Making changes in your eating habits that you have developed over many years is not easy. You may feel frustrated, overwhelmed, or angry. It is even scary to change old familiar habits for new ones. The following tips may help you approach the necessary changes in your diet.

1. Recognize that your feelings of frustration, fear, and/or anger are normal. Discuss these feelings with your social worker and/or dietitian.
2. Learn why the changes are necessary. Refer to the above, "Part One: Basic Kidney Diet Guidelines" to learn more about your potassium, phosphorus, sodium, and fluid prescription(s).
3. Think positive - what foods can you have instead of what foods you can't have.
4. Try to develop motivational factors to help you approach the changes. Such as, "This is an area of my treatment I can help control", or "I want to keep my heart, bones, and body strong so I can feel better."
5. Discuss favorite foods with your dietitian, who MAY be able to teach you moderation techniques to fit some forbidden foods back into your diet.
6. Discuss any concerns or problems with your team of physician, nurses, dietitian, and social worker to assist you in developing additional strategies.

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What if I don’t have an appetite?

People who are new to dialysis often complain of a poor appetite. This may be associated with recent hospitalization and illness. Emotionans prior to and when starting dialysis can also effect one's appetite. In addition, the accumulation of waste products can cause taste changes, nausea, and vomiting and effect the desire to eat. Once dialysis begins and the accumulation of waste products in the blood is decreased, appetite may improve.

Remember it is important to discuss any appetite changes with your dietitian who can provide you with individual and specific recommendations based on your unique needs. The following tips may be useful if you are experiencing a decrease in your appetite:

1. Good nutrition is an important component of the treatment of kidney disease. Scientific studies have stressed how valuable it is for the kidney population to obtain optimal nutritional status. Poor nutrition can weaken the immune system leading to an increase in chance of infection and illness. Remembering the effect that good nutrition has on your health may encourage you to eat.
2. If large meals are overwhelming, try eating smaller meals or snacks more frequently.
3. Make smaller portions of food count. Raise the calories by adding nutrient dense sugar and fat to your food. If you have diabetes, discuss with your dietitian how to fit sugar in your diet.
4. Your dietitian or physician may recommend a nutrition drink or supplement. Products have been developed for the kidney patient population and their special nutritional needs.
5. Have already prepared foods and snacks on hand. You may find it easier to eat when food is already prepared instead of having to make it.
6. Talk to your dietitian who may be able to provide you with additional tips to ensure adequate nutrition.
   

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Do I need to be concerned if my cholesterol is high?

Heart disease is a serious concern for the kidney patient. In addition to replacing folic acid, a water -soluble vitamin that can be depleted during dialysis, a low cholesterol and saturated fat diet may help prevent this disease. However, whether it is appropriate for you to follow a low cholesterol, low saturated fat diet is dependent on many factors including your physician's recommendations, current and past medical history, willingness to make additional changes, and your nutritional status.

Fat is an important calorie source for the person receiving dialysis. Initiating a low cholesterol and low saturated fat diet may cause weight loss if calories are not replaced by other sources. Weight loss may or may not be beneficial depending on your nutritional status. Malnutrition accompanied by low body weights and low levels of protein in the body is a major concern for people with kidney disease. A cholesterol restriction may not be appropriate for an elderly or malnourished patient when it is crucial that adequate nutrition is achieved and/or maintained. In addition, cholesterol and saturated fats may improve the taste of foods and therefore contribute to increasing one's appetite and protein intake. Your dietitian may assess your cholesterol value to determine whether you are eating well or poorly.

The following suggestions may be beneficial if low cholesterol and low saturated fat restrictions are warranted:

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What about my diabetes?

It is beyond the scope of this literature to provide an abundance of information regarding diabetes management. Therefore specific topics useful to the patient with kidney disease will be discussed. Many people with diabetes have been educated to increase foods containing fiber, to limit their protein intake, and decrease their total fat intake. These recommendations where ideal prior to the development of kidney disease but some changes may need to occur for people receiving hemodialysis. Foods high in fiber such as fruits, vegetables, beans, and bran/whole grains most often need to be limited or avoided because of their high potassium and phosphorus content. Protein needs are often increased because of losses that occur during the dialysis procedure. In addition, for some people with kidney disease, fat may become an important calorie source that helps them fight undesirable weight loss.

A poor appetite leading to weight loss and malnutrition may increase your need for concentrated sources of calories such as fat and sugar. In addition, maintaining appropriate carbohydrate intake at meals (often difficult with a poor intake) is essential if insulin is used. If a person with kidney disease and diabetes is not eating sufficient calories and carbohydrates then sugar may be beneficial. Talk to your dietitian before adding additional sugar who will be able to make recommendations based on your unique needs.

Carbohydrate counting is a new method to teach diabetes control. It focuses on controlling total carbohydrate intake obtained from starches (breads, pasta, cereal, rice), fruits, milk, and sugar. The new recommendations include sugar, sweets, and desserts used in moderation and often replacing another carbohydrate source. Incorporating sweets in moderation can be a nice treat for the kidney patient with so many diet restrictions but the key word is moderation. Foods high in sugar or sweets will use up a lot of your daily carbohydrate needs and they most likely will be lacking in essential vitamins and minerals. Talk to your dietitian if you would like to learn more about carbohydrate counting and incorporating foods containing sugar into your diet.

Regular meals and snacks consumed at consistent times and consistent in type and quantity of food items is useful to regulate blood sugar levels especially if insulin is used. Skipping meals or scheduled snacks when using insulin can cause frightening low blood sugar levels with symptoms such as shakiness, confusion, blurred vision, and sweating. People with diabetes are often taught to grab some orange juice when a low blood sugar reaction occurs. Most people with kidney disease must limit or avoid orange juice because of the potassium content and must learn appropriate food items to consume during a low blood sugar reaction. The following guidelines may be useful when a low blood sugar reaction occurs:

1. Test blood sugar level.
2. Treat low blood glucose level less then 70 mg/dl or the level determined by your physician with 15 grams of carbohydrates, see list below. Glucose tablets made to treat low blood sugar reactions are also useful.
3. Wait 15 minutes and retest again. If blood glucose level remains less then 70 mg/dl, then an additional 15 grams of carbohydrates is needed. This is to help prevent over treating of low blood sugar reactions but you may overtime learn what amount of carbohydrates works best for you.

15 grams of carbohydrates is equal to:

• 1 Tablespoon of jelly, sugar, or pancake syrup.
• 5 lifesavers hard candy
• 6 - 7 large jelly beans 5 gum drops
• 4 ounces (1/2 cup) of regular Gingerale, & 7-UP, or Sprite sodas
• 4 ounces (1/2 cup) cranberry or apple juice
• 4 ounces (1/2 cup) regular Kool-Aid or Hawaiian Punch

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