Ckd Nutrition

7/31/2019 Ckd Nutrition

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U.S. Department of Health

and Human Services

National Institute of Health

Theresa Kuracina, MS, RD, CDEDepartment of Health and Human Services

U.S. Public Health ServicesIndian Health Service

Albuquerque Indian Health Center

Nutritional Management of

Chronic Kidney Disease

April 29, 2009

Todays Topics

The perfect diet

The right diet for HTN, DM, high blood cholesterol

The right diet for chronic kidney disease (CKD)

The first steps

Sodium

Blood sugar

Protein

The next steps

Phosphorus

Potassium

What is the Perfect Diet?

Servings sizes

Standardized amounts

Diet therapy

Labels

Portion sizes

How much you eat

What is the Perfect Diet?

What Is the Right Diet?

High blood pressure Sodium

Diabetes

Total carbohydrates

Total fat

Food groups vary

Serving sizes vary

High blood cholesterol Total fat

Saturated fat

Trans fats

Cholesterol

Refer for Medical Nutrition

Therapy

Understanding the Nutrition Facts Label

USDA, 2004


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Chronic Kidney Disease

There is not one rightdiet: CKD diet needs differ

Diet changes as kidney function changes

No specific eGFR to recommend changes

Monitor trends

Medical nutrition therapy is recommended

What is the Right Diet for CKD?

Why the CKD Diet is Important

Delays progression to kidney failure

Maintains nutritional status

Prevents malnutrition

How the Kidneys Function

Regulate composition and volume of blood

Remove wastes from blood into the urine

Source for 1,25-dihydroxycholecalciferol (Active vitamin D),erythropoietin, renin

Involved in metabolism and catabolism

As eGFR Declines

Decreased excretion of waste products

Nitrogen, phosphorus, potassium

Less vitamin D is activated

Less calcium is absorbed

Less erythropoietin is produced

At risk for anemia

The Diet Changes for CKD

The First Steps

Sodium Blood sugar

Protein

The Next Steps

Phosphorus

Potassium

Education Tools

Nutrition Facts label

Ingredient list

National Kidney Disease Education Program (NKDEP) website-tools in development


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Long Term Diet Goal: Prevent Malnutrition

Nutrition status strongly predicts morbidity/mortality in CKD

Spontaneous decrease in intake

Severity increases as GFR declines

Accumulation of uremic toxin(s)

Appetite improves with renal replacement therapy

Starts early in the course of CKD

Carrero, 2009Bossola, 2009

Causes of Malnutrition

Metabolic acidosis

Inflammation

Hormonal derangements

Altered taste and smell

Anorexia, nausea, vomiting

Dietary restrictions

Carrero, 2009Bossola, 2009

The First Steps in Diet Intervention

Sodium

Blood sugar

Protein

Check serving size

20% Daily Value (ormore) is HIGH

The First Steps: Sodium

Sodium in the Diet

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Adequate Intake

Daily Value

Women *

Men *

*What We Eat in America,

2005 2006

Institute of Medicine, 2004

USDA, 2008

FDA, 1999

1500

2400

2933

4178

mg/day

Sodium in Selected Foods

0

500

1000

1500Bouillon cube

Broth

Canned

0

100

200

300Cooked

Instant

Instant,

flavored

0

500

1000

1500

2000

2500

Table

Seasoned

Garlic

1 teaspoon salt * Beef soup

Oatmeal

0

500

1000

1500

Fresh

Stewed

Sauce

Juice

1 cuptomatoes

*Pennington, 2005

USDA, 2008


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Sodium in Selected Foods

0

200

400

600800

100085% Lean

Corned,canned

Stew, canned

0

500

1000

1500Double

cheeseburger

Single

cheeseburger

Taco salad

0

100

200

300

400

500Cream cheese

Fat free creamcheese

Amer, 1 oz.

Cottage

cheese

1% milk

Buttermilk

Fast foods

Beef Dairy

USDA, 2008

Take Home Message: Sodium

Daily Value of 20% or more is high

Prepare fresh food at home more often

Use less salt in cooking and at the table

Try lower sodium versions: canned soups, canned vegetables,convenience foods

The First Steps: Blood Sugar Control Blood Sugar (Diabetes)

Target A1c < 7%

Avoid hyperglycemia

Avoid hypoglycemia

Increased risk with declining eGFR

Decreased clearance of insulin and oral medications

Less gluconeogenesis by the kidneys

NKF, 2007

The Diet Changes for Diabetics with CKD

Avoid high protein diet

Any kind of juice can treat hypoglycemia

As GFR declines, refined grains help manage phosphorus andpotassium levels

May need to add more fats/carbohydrates in diet

Needed for calories

Take Home Message: Blood Sugar

Hypoglycemia risk increases with declining eGFR

Diet will change as eGFR declines

Intake of protein, carbohydrates and fats may need to beadjusted regularly


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The First Steps: Protein Protein in the Diet

0

20

40

60

80

100

120

RDA women

RDA men

Daily Value

Women *

Men *For CKD 0.8 g/kg

RDA 0.8 g/kg

42

5650

70

102


2005-2006

USDA, 2008


FDA, 1999

g/day

Protein

Quality matters

High biological value: at least 50% of total

Low biological value

Quantity matters

Less is better

Lower protein may slow progression and reduceproteinuria

No storage for extra nitrogen (N) urea

Fewer nephrons increased blood urea N

High Biological Value (g) Low Biological Value (g)

Egg

Egg white

6

3.6

c. Legumes

1 oz. Nuts

7

4

1 oz. poultry,

meat or fish

~7 Bread /grains 2 - 4

8 oz. milk 8 Vegetables 2 - 3

1 c. soybeans

1 c. soy milk

14

8

Fruit 0 - 1

Sources of Protein

USDA, 2008

Breakfast menu:2 eggs

3 slices bacon

2 wheat toast

Soft margarine

1 cup potatoes

2 cups coffee

Protein12

7

6

0

5

0

30 g

Alternative menu:2 egg whites

2 wheat toast

Soft margarine

cup potatoes

1 cup strawberries

2 cups coffee

Protein7

6

0

2

1

0

16 g

Breakfast and Protein

USDA, 2008

The Diet Changes for Protein

Start with portion control, if needed Deck of cards = portion size

~ 3 ounces (21 grams protein)

As eGFR declines and BUN elevates

What can you eat?

What kinds of protein taste good?


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Take Home Message: Protein

Most of us eat more protein than we need

Start with portion control: About size of deck of cards (3 ounces)

Fill only plate with these foods

The Next Steps

Phosphorus

Potassium

Read Ingredient List for PHOSPH

The Next Steps: Phosphorus Phosphorus in the Diet

0

200

400

600

800

1000

1200

1400

1600

1800

RDA

Daily Value

Women *

Men *


2005-2006

USDA, 2008

FDA, 1999


700

1000

1148

1600

mg/day

Phosphorus

Bones can get soft

Blood vessels & soft tissuescan calcify

Involves:

Vitamin D

Calcium

Parathyroid hormone

NEWFibroblastic GrowthFactor 23 (FGF-23)

Gutierrez, 2005

Phosphorus Balance

~ 60% absorbed due topassive absorption

Increases to ~ 75% withvitamin D

High intakes of phosphorus

stimulate FGF-23

FGF-23 works at the kidneysto shut off phosphorusreabsorption ( phosphaturia)

FGF-23 turns off enzyme inkidneys that activates VitaminD (less P absorbed)

Serum P levels normal

Institute of Medicine, 1997Gutierrez, 2005


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X

FGF-23 increasesphosphaturia

FGF-23decreasesphosphorusabsorption

FGF-23 Helps Maintain Serum Phosphorus Levels

Gutierrez, 2005Knochel, 2007

Sources of Phosphorus

Organic phosphorus

~ 60% absorbed

Dairy products Meat, poultry, fish

Soy (soy milk, tofu)*

Nuts and seeds*

Dried beans and peas*

Whole grains*

*Less absorbed due to phyticacid

Inorganic phosphorus

~90 100 % absorbed

Food additives

Anyphosph in theingredient list


Phosphorus Intake Has Increased

Both extent of usage of phosphate salts as additives andthe amount per serving have increased substantially overthe past 20 years, and the nutrient databases may notreflect these changes..phosphorus intake may beunderestimated for certain individuals who rely heavilyon processed foods.

these data suggest a substantial increase in phosphorusconsumption, in the range of 10 to 15 percent, over the

past 20 years.


0

50

100

150

200

250

Biscuit Cornbread

0

100

200

300

400

500

600

One Pancake

Phosphorus: How the Food is Prepared Matters

Homemade recipe (green)is lowest in phosphorus.

USDA, 2008

Homemade

Refrigerated

Dough

Fast Food

Boxed Mix

Read Ingredient Labels For PHOSPH

Turkey Breast & GravyINGREDIENTS: TURKEY BREAST (TURKEY BREAST MEAT,WATER, SALT, BROWN SUGAR, SODIUM PHOSPHATE,DEXTROSE, MODIFIED FOOD STARCH, VEGETABLE OIL),GRAVY

Dipotassium phosphate (buffer)

Disodium phosphate (texturizer, emulsifier)

Monocalcium phosphate (leavening, chip surface)

Monosodium phosphate (color)

Phosphoric acid (acidulant)

Potassium tripolyphosphate (retain moisture)

Additives with Phosphorus

International Food Additives Council, 2007


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Additives with Phosphorus

Sodium acid pyrophosphate (leavening, color)

Sodium hexametaphosphate (emulsifier)

Sodium tripolyphosphate (flavor enhancer)

Tetrasodium pyrophosphate (retain moisture)

Tricalcium phosphate (calcium fortification)

Trisodium phosphate (antimicrobial, emulsifier)


Hidden Phosphorus

Baked goods

Baking powder

Cake mixes

Cake donuts

Refrigerated dough

Beverages

Some soft drinksincluding cola, icedteas, fruit punch

Flavored milk

Ca-fortified orangejuice

Cereals

Cooked ( cookingtime, Ca fortified)

Extruded dry: Cafortified

Dairy /Cheese

Cottage cheese, dips/sauces, imitationcheese slices, startercultures, ice cream


More Hidden Phosphorus

Imitation dairy

Non-dairy creamer

Whipped topping

Egg products

Egg substitutes

Meat /poultry products

Enhanced

Pasta cooking time

Potatoes

Baked chips

Fries, hash browns,potato flakes

Desserts

Instant pudding

Cake mixes

Seafood shrimp, cannedcrab/tuna, surimi


Protein Foods Have Phosphorus

0

50

100

150

White

Substitute

Yolk

0

100

200

300

Ground beef

Salmon

Peanuts

Pinto beans

0

100

200

300

400Cream cheese

Fat free cream

cheese

American

Cottagecheese

Buttermilk

Dairy Egg

Various Proteins

0

100

200

300Double

cheeseburger

Single

cheeseburger

Taco salad

Fast Foods

USDA, 2008

Take Home Message: Phosphorus

Additives with phosphorus increase total phosphorus intake

Read ingredient lists for phosph

Less dietary protein means less phosphorus

Refined grains are lower in phosphorus

However, 100% is not absorbed

1. Monitor trends in serum potassiumlevels

2. Consider restricting dietarypotassium if trending up

3. Potassium-sparing medications

The Next Steps: Potassium
http://catalog.niddk.nih.gov/ImageLibrary/detail.cfm?id=23


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Potassium in the Diet

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Adequate Intake

Daily Value

Women *

Men *


2005-2006


USDA, 2008

FDA, 1999

4700

3500

2366 3174

mg/day

Potassium in Foods

Salt substitutes have potassium in place of sodium (600 3,200mg / teaspoon)

Most food groups have some potassium

Fruits and vegetables have the most variation (low/medium /high)

Whole grains have more than refined grains

Edwards, 2008

Potassium in Selected Foods

0

20

40

60

80

100

Coffee, brewed

Coffee, instant

Tea

0

100

200

300

400

500

Milk

Choc.

Soy

8 ounce Milk/Substitutes

6 ounce Coffee/Tea

0

200

400

600

800

Ground beef

Salmon

Peanuts

Pinto beans

Proteins

0

100

200

300

400Corn flakes

Wheat branflakes

Bran

Oatmeal

Cereals

USDA, 2008

0

50

100

150

200

250

300

Cranberry

Apple

Grape

Pineapple

Grapefruit

Orange

Tomato

Potassium In Juice (4 ounces)

USDA, 2008

Potassiumper serving

Potassium in Selected Vegetables

0

100

200

300

400

Green beans

Peas

Spinach

0

100

200

300

Carrots

Corn

Pumpkin

Wax beans

0

50

100

150

200

Green leaf

Iceberg

Romaine

Spinach

Green, canned, cup

Yellow/Orange, canned, cup

0

200

400

600

800

Flesh, baked

Skin, baked

Boiled, peeled

Fries (10)

1 Potato

Salad greens, 1 cup

USDA, 2008

Take Home Message: Potassium

Salt substitutes are high in potassium

Fruits and vegetables can be low/medium/high in potassium

content

Refined grains are lower in potassium

Hypoglycemia can be treated successfully with low potassiumjuice (cranberry or apple)


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Renal Replacement Therapy

Individualize Hemodialysis(In center 3times perweek)

PeritonealDialysis(Daily at home)

Protein (50% HBV) >1.2 g/kg 1.2 1.3 g/kg

Calories 30 35 kcal 30 35 kcal/kg incl.dialysate

Sodium 1,000 3,000mg

2,000 4,000 mg

Phosphorus 800-1000 mg 800-1000 mg

Potassium 2,000 3,000

mg

3,000 4,000 mg

Fluid Urine output +1,000 mL

As needed

ADA, 2009

Medical Nutrition Therapy (MNT)

Refer to a Registered Dietitian

Medicare Part B benefit for Chronic Kidney Disease (non-dialysis):GFR 13 50

Requires physician referral

Allows 3 hours of MNT in 1st calendar year

Additional hours based on change in diagnosis, medicalcondition or treatment

Covers 2 hours of MNT in subsequent years

Medicare, 2009

Medical Nutrition Therapy (MNT)

Provider Claim Form

Diagnosis (ICD-9) codes for MNT for CKD

CKD Stage GFR ICD-9 code

3 30-59 585.3

4 15-29 585.4

5


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References

American Dietetic Association. Chronic Kidney Disease (Non-Dialysis)Medical Nutrition Therapy Protocol. ADA Evidence-Based Guides forPractice. Chicago, IL: American Dietetic Association; 2002.

Bossola, M, Tazza, L, and Luciani, G. Mechanisms and Treatment of

Anorexia in End-Stage Renal Disease Patients on Hemodialysis. J RenNutr 19: 2-9, 2009.

Carrero, JJ. Identification of Patients with Eating Disorders andBiochemical Signs of Appetite Loss in Dialysis Patients. J Ren Nutr 19:10-15, 2009.

Edwards, A. Salt, Salt Substitutes, and Seasoning Alternatives . J RenalNutr. 18:e23-e25, 2008.

Food and Drug Administration. Food Labeling Guide, 1999. Available athttp://vm.cfsan.fda.gov/~dms/flg-7a.html. Accessed March 2009.

Gutierrez, O. Fibroblast Growth Factor-23 Mitigates Hyperphosphatemiabut Accentuates Calcitriol Deficiency in Chronic Kidney Disease. J Am SocNeph 16:2005-2215.

International Food Additive Council. Phosphates, 2007. Available atwww.foodadditives.org/phosphates. Accessed March 2009.

References

Institute of Medicine (U.S.) Dietary Reference Intakes for Calcium,Phosphorus, Magnesium, Vitamin D and Fluoride. National Academy ofScience, 1997.

Institute of Medicine. (U.S.) Dietary Reference Intakes for Energy,

Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and AminoAcids. National Academy of Science, 2002.

Institute of Medicine. (U.S.) Dietary reference Intakes for Water,

Potassium, Sodium, Chloride, and Sulfate. National Academy ofScience, 2004.

Kochel, James. Micronutrient Information Center. Oregon StateUniversity. Available athttp://lpi.oregonstate.edu/infocenter/minerals/phsophorus/phospth.html April, 2007. Accessed March 2009.

Medicare MNT Provider Part B News for Registered Dietitians, Volume7, Number 9. January, 2009.

United States Department of Agriculture. Nutrition Facts Label, 2004.Available at www.cfsan.fda.gov/~acrobat/foodlab.pdf. AccessedMarch 2009.

References

National Kidney Foundation. Kidney Disease Outcomes QualityInitiative. New York, NY: National Kidney Foundation; 2007.

Pennington, JA, Douglass, JS. Bowes and Churchs Food Values ofPortions Commonly Used(18th ed.). Philadelphia: Lipppincott, Williams& Wilkins, 2005.

U.S. Department of Agriculture, Agricultural Research Service. USDANational Nutrient Database for Standard Reference, Release 21.Nutrient Data Laboratory Home Page,

http://www.ars.usda.gov/ba/bhnrc/ndl

What We Eat in America: www.ars.usda.gov/ba/bhnrc.fsrg

Questions

Please contact NKDEP at [email protected] with any questionsor comments.

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