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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.
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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 g46 g* (0.8 g/kg)
46 g56 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
EARRDAUL
580700
4,0003,000
580 7004,0003,000
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, GrainsHigh Na High P
Vegetables Low, medium, high K
FruitLow, medium, high K
Protein (including milk)High NaHigh PVegetarian High Na High P
Calorie
Flavoring
Food groups get more complicated
USDA Food Pattern
Grains
Vegetables: Dark greenRed & orangeBeans & peasStarchy and other
Fruit and juices
Milk and milk products
Protein foodsSeafoodMeat, poultry, eggs Nuts, seeds, soy products
Oils
Solid fats and added sugars
Diabetic Exchange
Carbohydrates:StarchFruitsMilkOtherNonstarchy 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 foodsMeat, 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 proteinHigh NaHigh PVegetarian proteinHigh Na, P, K
6–8 50–100
70–150
20–150200–40020–15010–200
250–400
50–100
100–30080–150
200–400
50–150
60–150250–500
Breads, starchesHigh Na, P
2–3 50–200 0–150150–400
10–70100–200
10–100
VegetablesLow, medium, high K
2–3 10–100 0–50 10–70 20–150150–250250–550
FruitsLow, medium, high K
0–1 20–100 0–10 1–20 20–150150–250250–550
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
PROTEINThe 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% HBVProtein remaining 28 g9 grains (2 g) −18 g 10 g
Protein remaining 10 g4 vegetables (1 g) −4 g 6 g
Divide the remaining protein between the other food groups
Protein remaining 6 g½ cup milk (4 g) −4 g
2 g
Protein remaining 2 g3 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-sodi
um-508.pdf
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
SODIUMLimit 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-sodi
um-508.pdf
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 intake6 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/foodcomp/cgi-bin/list_nut_edit.pl
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 phosphateDicalcium phosphateCalcium 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 phosphateDicalcium phosphate
National Kidney Disease Education Program
Phosphorus: Tips for People with Chronic Kidney
Disease (CKD)
http://www.nkdep.nih.gov/resources/nkdep-nutritionf
actsheets-phosphorus-508.pdf
Educational resource for dietary phosphorus
Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf
Inorganicphosphorus
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/FoodLabelingNutrition/FoodLabelingGuide/ucm064928.htm
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
POTASSIUMRestrict 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-p
otassium-508.pdf
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 ADDITIVESOver 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/Foo
dAdditives/ucm191033.htm
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.)
267227
421358
5748
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.
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