2016
Is There Anything Left To Eat?
Is There Anything Left to Eat?
Eileen Carolan, RD & Jennifer Zinetti, RD
[email protected]
[email protected]
Jennifer Zinetti BSc RD and Eileen Carolan BSc RD
Outline
• Illustrate dietary similarities and
differences of a renal diet transitioning
from predialysis to hemodialysis
• Discuss nutritional challenges and
strategies
• Highlight various teaching resources
Joe Becekidnedae
•Retired carpenter
•Married to Norma
Dx: Hypertensive nephroclerosis
Hx: Hyperlipidemia, Gout, GERD
70 years old; Ht 175.2 cm; Wt 80kg; BMI 26.9
Labs: GFR 24, Crea 226, K 5.4, Po4 1.6, iPTH 16.8
Image courtesy of Stockimages @FreeDigitalPhotos.net
Goals of predialysis diet therapy
• Delay progression of disease
• Maintain a healthy weight and QOL
• Reduce protein intake to recommended target
• Reduce potassium and phosphorus intake
• Enhance nutrition label reading skills
• Manage nutrition influenced symptoms
Pre-dialysis Diet Therapy
•
•
•
•
Protein
Phosphorus
Sodium
Potassium
Protein
• Recommendation: 0.75-0.8g/kg body weight
• Consider:
• factors that increase needs
• symptoms
• type of protein
Day 1
3 Day Food Record
7:30 Oatmeal with ½ cup 1 % milk
½ banana
1 piece of toast with cheese
coffee with cream
10:30 apple
1:00
ham sandwich
Soup with crackers
water
5:00
chicken breast
peas, corn, carrots
rice
1 glass of milk
9:00
2 cookies
water
Protein intake : 8.5 oz
Day 2
7:30
Shreddies with 1 cup of 1% milk
½ banana
1 piece of toast with cheese
coffee with cream
Day 3
7:30
2 eggs
2 toast with jam
1 glass of juice
1 coffee with cream
10:00
grapes
10:30
fruit yogurt
12:30
avocado, cheese, cucumber and
tomato sandwich
baby carrots
water
1:00
tuna sandwich
soup with crackers
water
5:00
pork roast
baked potato
cauliflower and broccoli mix
1 glass of 1% milk
5:00
Chinese food
green tea and water
9:00
2 cookies
water
9:00
water
7 oz
? 7-9 oz
Protein Assessment
Joe’s estimated requirements: 5-5.5 oz/d
Joe’s protein intake : 8.5 oz, 7 oz , more than 7-9 oz
 Excess Protein Intake - increase acid and phosphorus load, and demand
on the kidney
Recommendations:
• Decrease milk intake to 1 cup/d, try milk substitute at dinner
• Decrease cheese - focus on lower phosphorus choices eg: cream cheese
• Keep protein at breakfast to 0.5 - 1 oz
• Keep protein at lunch to 1.5 oz and dinner 3 oz.
Need to consider:
• Requirements vs Recommendations: Realistic? Achievable?
• Calorie reduction and satiety with diet changes; need to explore suitable
food options to add or increase portions of.
Phosphorus
Recommendations for CKD Stage 4
800mg/d
Phosphorus
Protein – amount and type
Chicken
breast 5 oz
Kidney Beans
1 cup
Protein: 43 g
Protein: 13 g
Potassium:
554 mg
Potassium:
395 mg
Phosphorus:
366 mg
Phosphorus:
186 mg (93)
Audience Live Poll
is Joe’s daily phosphorus intake…
A. 800-1000 mg
B. 1001-1200 mg
C. 1201- 1500 mg
D. 1501 - 2000 mg
Phosphorus additives
•
•
•
•
•
•
Sodium hexametaphosphate
Sodium Polyphosphate
Sodium Tripolyphosphate
Phosphoric Acid
Monocalcium Phosphate
Potassium Pyrophosphate
Found in: refrigerator biscuit, breads, cookie dough, spreadable cheeses,
instant puddings and sauces, processed meats such as chicken nuggets,
bologna and hot dogs, “seasoned” meats, pancake and waffle mix.
Oven Roasted 6 “ Chicken Sub
CHICKEN PATTY: Chicken breast meat with rib meat, water, seasoning [corn syrup
solids, brown sugar, modified tapioca starch, salt, dextrose, maltodextrin,
modified corn starch, garlic powder, hydrolyzed corn protein, onion powder,
tetrasodium pyrophosphate, vinegar solids, yeast extract, vegetable oil shortening
(soybean), thiamine hydrochloride, lactic acid, disodium inosinate and disodium
guanylate], soy protein, sodium phosphates.
With NO sauce or cheese
No Phosphorus Additive Alternatives
Subway
•Veggie 6 “ Sub (280 mg of sodium)
•Egg Salad 6 “Sub ( 510 mg of sodium)
•Tuna Mini subs 4” ( 330mg of sodium)
•Egg and Cheese Breakfast Sandwich (770mg of sodium)
Tim Horton's
Starbucks
•Oatmeal
Egg and cheddar on English muffin (460 mg)
•Greek Yogurt
Cheese and Fruit Bistro Box ( 520mg)
•12 grain Bagel and peanut butter
•Garden Vegetable Sandwich (640 mg)
Sodium
• Goal 1500-2000mg/day
• Hidden sources
• Impact on BP,
edema, SOB,
proteinuria
Sodium
*Subway Chicken sub on 9 Grain bread- 560 mg , add cheese ( 80mg), add ranch dressing (210mg),
make it into a wrap (610 mg vs 270 for 9 grain bread) : 1200 mg
*Tim Hortons Breakfast sandwich: English muffin, cheese (processed), egg omelette: 610 mg
Egg Omelette: Whole eggs, water, process cheese food [cheese (milk, bacterial culture, salt, calcium
chloride, lipase, microbial enzyme, colour), natural cheese flavour, modified milk ingredients, sodium
phosphate, cellulose, lactic acid, salt, ascorbic acid, citric acid, colour], onions, liquid butter
alternative (soybean oil, hydrogenated soybean oil with salt, soy lecithin, artificial flavour, TBHQ and
citric acid added as preservatives, artificial colour and dimethylpolysiloxane), cheese powder type
flavour natural, cream cheese powder [cream cheese, (cream, milk, salt, bacterial culture), sodium
phosphate, sodium citrate, tocopherols], modified corn starch, soybean oil, salt, xanthan gum, liquid
pepper extract, citric acid.
Grilled Cheese Panini: 1530 mg
Potassium
Images courtesy of Stockimages @FreeDigitalPhotos.net
Potassium Additives
Potassium Acetate & Potassium Diacetate
Brawn; Headcheese; Meat by-product loaf; Meat loaf; Potted meat; Potted meat by-product; Prepared meat; Prepared meat by-product;
Prepared poultry meat; Prepared poultry meat by-product; Preserved meat; Preserved meat by- product; Preserved poultry meat;
Preserved poultry meat by-product; Sausage
+ another ?
14+
Schneider’s All Beef Wiener ( 37g portion) –POTASSIUM LACTATE
= 76% total potassium from additive;
207 mg of potassium per wiener vs 52mg
NOT Required to be listed on the Nutrition Facts Table!!!
Low sodium/ less salt products
Regular Baby Dill Pickle
Potassium 37mg
50% Less Salt Baby Dill Pickle
1%
Resources
Food & Nutrition Websites and Apps for People with Kidney Disease
BC Renal Agency
http://www.bcrenalagency.ca/patients/dietary-information
Canadian Nutrient File
http://webprod3.hc-sc.gc.ca/cnf-fce/index-eng.jsp or
USDA National Nutrient Database http://ndb.nal.usda.gov/
Handouts and videos from BC renal dietitians on
many topics including phosphorus, sodium,
shopping guide, diabetes.
Look up the complete nutrient content of any
food (such as potassium, phosphorus, sodium).
DaVita Kidney-Friendly Recipes
http://www.davita.com/recipes
Renal recipes, menu planning, food analyzer,
phosphorus challenge, dietitian’s blog.
Kidney Foundation of Canada Community Kitchen
http://www.kidneycommunitykitchen.ca/
Browse the recipes and cooking tips.
Check out the dietitian’s blog.
Ontario Renal Network
http://www.renalnetwork.on.ca/info_for_patients/
Click on Fact sheets for information on diet.
Spice It Up http://www.myspiceitup.ca/
Many great recipes and cooking tips.
Recipes analyzed by renal dietitians.
Cell phone apps:
• Pocket Dietitian (free)
• Kidney Diet (low cost)
• Sodium 101 (free, only tracks sodium)
• Waterlogged (free, only tracks fluids)
Island Health Central/North Renal Dietitians, Nov/2015
Track your nutrient intake.
Look up nutrient information quickly.
Note: There is a lot of incorrect nutrition & diet
information on the internet. If you are
accessing other websites, check with your
Dietitian to ensure the information is accurate.
Hemodialysis
Symptoms:
•Nausea
•Poor appetite
•Weight loss
Weight Pre-dialysis 72 Kg
Image courtesy of Stockimages @FreeDigitalPhotos.net
Dry Wt: 69 Kg BMI: 22.5
Labs: GFR 6, Creatinine 626, K 6
Na 130 ,PO4 2.2, iPTH 40
Goals of HD diet therapy
Joe will:
- achieve a healthy weight
- consume enough protein
- maintain fluid balance
- achieve acceptable potassium
and phosphorus levels
24 hour Diet Recall
Breakfast: 1 cup of Tim Horton’s coffee with cream
Snack: Toast with peanut butter
Lunch: Soup and sandwich, grapes
****Misses lunch on dialysis days
Supper: 1 pork chop, rice, carrots and milk
Water and juice with medications
blue - fluid/ sodium , green - potassium, red - phosphorus
The 4 P’s
•
•
•
•
Protein
Phosphorus
Potassium
Phulids
Image courtesy of Master isolated images at FreeDigitalPhotos.net
Protein
Recommended Intake:
1.2 – 1.4 grams/kg body weight
Joe needs 83 – 97 grams a day
Fresh, unprocessed, no salt added
Phosphorus
Recommended intake: 800 mg – 1000 mg
•7 ounces fresh meat = 490mg
•½ cup milk = 125mg
•1 higher phos food 3x a week = adds 60mg/day
•other foods 400 mg
1075 mg phosphorus !!!
½ cup a day
Potassium
Recommended intake: 2 – 3 grams
• Urine out put
• Dialysate bath
• Food choices
½ cup serving size
Portion Size Counts
Low
5 strawberries = 92 mg potassium
Medium
8 strawberries = 147 mg potassium
High
15 strawberries = 275 mg potassium
Very High
25 strawberries =450 mg potassium
½ cup serving size
Sodium
Recommended intake: Less than 2 grams
 Canned soup = 700 mg Na/ cup
 Mr. Noodles = 830 mg Na /64grams
Phluids
Recommended intake: 1000 mL
Audience Live Poll
is Joe’s large Tim Horton’s coffee…
A. 300 mL (1 ¼ cups / 10 ounces)
B. 420 mL (1 ¾ cups / 14 ounces)
C. 600 mL (2 ½ cups / 20 ounces)
D. 720 mL (3 cup/ 24 ounces)
Putting it all together
www.renalrd.ca
www.myspiceitup.ca