diet training module 4 diet ckd 508

U.S. Department of Health and Human Services

National Institute of Health

The “Diet” for Chronic Kidney Disease (CKD)

The Diet Must Be Individualized and Will Change as CKD Progresses.

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.

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 MenProtein (g/day)

> 19 years EAR RDA

38 g 46 g* (0.8 g/kg)

46 g 56 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

EAR RDA UL

580 700

4,000 3,000

580 700 4,000 3,000

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 DietBreads, Cereals, Grains High Na High P

Vegetables Low, medium, high K

Fruit Low, medium, high K

Protein (including milk) High Na High P Vegetarian High Na High PCalorie Flavoring

Food groups get more complicatedUSDA Food PatternGrains

Vegetables: Dark green Red & orange Beans & peas Starchy and other

Fruit and juicesMilk and milk products

Protein foods Seafood Meat, poultry, eggs Nuts, seeds, soy products

OilsSolid fats and added sugars

Diabetic ExchangeCarbohydrates: Starch Fruits Milk Other Nonstarchy vegetables

Meat/meat substitutes

FatsAlcohol

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 cupsMilk and milk products 3 cupsProtein foods Meat, 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

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)


• 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 80Fruit 15 - - 60Milk 12 8 0–8 100–160

Other carbohydrates 15 Varies Varies VariesNonstarchy vegetables

5 2 - 25

Meat and meat substitutes

- 7 0–8+ 45–100

Fats - - 5 45Alcohol Varies - - 100

National renal diet reflects variability within food groups due to processing

Protein (g)

Calories Sodium (mg)

Phosphorus (mg)

Potassium (mg)

High protein High Na High P Vegetarian protein High Na, P, K

6–8 50–100

70–150

20–150 200–400 20–150 10–200

250–400

50–100

100–300 80–150

200–400

50–150

60–150 250–500

Breads, starches High Na, P

2–3 50–200 0–150 150–400

10–70 100–200

10–100

Vegetables Low, medium, high K

2–3 10–100 0–50 10–70 20–150 150–250 250–550

Fruits Low, medium, high K

0–1 20–100 0–10 1–20 20–150 150–250 250–550

Calorie 0–1 100–150 0–100 0–100 0–100Flavor 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


How much protein remains for other food groups?

50% HBV


75% HBV


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 0Reference: Marcoe et al. J Nutr Educ Behav 2006; 38(6 suppl): S93–S107.

50% HBV Protein remaining 28 g 9 grains (2 g) −18 g 10 g Protein remaining 10 g 4 vegetables (1 g) −4 g 6 g

Divide the remaining protein between the other food groups

Protein remaining 6 g ½ cup milk (4 g) −4 g 2 g Protein remaining 2 g 3 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-

sodium-508.pdf

Educational resource for dietary protein

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-

sodium-508.pdf

Educational resource for dietary sodium

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)


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

More typical intake 6 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


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 phosphate Dicalcium phosphate Calcium 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 phosphate Dicalcium phosphate

• National Kidney Disease Education Program

Phosphorus: Tips for People with Chronic Kidney

Disease (CKD)

http://www.nkdep.nih.gov/resources/nkdep-

nutritionfactsheets-phosphorus-508.pdf

• Website for phosphorus in fast foods

http://www.case.edu/med/ccrhd/phosfoods/

Educational resources for dietary phosphorus

Reference: http://www.nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf

Inorganic phosphorus

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


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

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


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

• 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


• 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)


• 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 CKDhttp://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-

potassium-508.pdf

Educational resource for dietary potassium

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/

FoodAdditives/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


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


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.)

267 227

421 358

57 48

Pork, enhanced; loin, tenderloin, separable lean only; cooked, roasted

100 g 316 567 231

Soymilk, original and vanilla, unfortified 1 cup 126 287 124Soymilk (all flavors), lowfat, with added calcium, vitamins A and D

1 cup 151 156 90

Soymilk, chocolate, unfortified 1 cup 124 347 129Orange juice, raw ½ c. 21 248 1Orange 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_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)

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