Healthy Eating. Patient Education Chapter 8 Page 1 KEEP Notebook. Eat well and eat smart

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1 Patient Education Chapter 8 Page 1 Healthy Eating Eat well and eat smart Objectives: 1. Describe three nutrients that may need to be restricted. 2. Understand how diet restrictions can change. As your kidney function gets worse, waste and excess fluid will build up in your system. This can cause you to lose your appetite, eat less, lose weight, and feel weaker. Sodium, phosphate, calcium, potassium, protein, and calorie intake affect your health. By controlling these nutrients in your diet, you can reduce the waste build-up in your blood, feel better, and protect your kidneys. Your diet prescription will change as your kidney function changes. Your doctor and dietitian will help you balance your diet. American Nephrology Nurses Association Greater Puget Sound Chapter

2 Chapter 8 Page 2 Why should I control my sodium? Healthy kidneys excrete extra sodium. When your kidneys don t work well, sodium builds up in your blood and acts like a sponge, holding extra water in your body and making your blood pressure high. To stay healthy and feel your best, limit your sodium to 2000 mg or less per day. What does diet have to do with your kidneys? When you eat or drink, your body uses what it needs and makes waste products out of the rest. Your kidneys filter your blood and turn the waste products into urine. If your kidneys are not working well, this build-up of waste products can cause you to have a poor appetite. Although it is common for people with kidney disease to eat less, lose weight, and have low energy, it is not healthy. By controlling the kinds and amounts of foods you eat and drink, you can reduce the waste build-up in your blood, feel better, and protect your kidneys. If you already follow a special diet for diabetes, heart disease or another condition, your dietitian will work with you to balance your kidney diet with your other special diet needs. What should I watch in my diet? There are several nutrients that you can control with your diet, including protein, sodium and phosphorus. Some people with kidney disease also need to control their potassium and fluid intake. Calories are important too, because they provide the energy you need to use the other nutrients. What is protein? Protein is used by the body to build new tissues and replace old or damaged tissues. Eat protein every day so you have the building blocks you need. Otherwise you will use your own protein (your muscle!) for building blocks! There are two kinds of protein, animal protein and plant protein. Animal proteins include meat, fish, poultry, eggs, and milk. Plant proteins include legumes, vegetables, breads, and cereals. There is a great deal of debate about whether or not low-protein diets can slow the rate of kidney damage. Some studies have shown they do and some studies have shown they don t. Talk to your doctor about whether a low-protein diet would be right for you.

3 Chapter 8 Page 3 Sodium Sodium is a mineral that increases blood pressure. Normally when you eat sodium, your kidneys get rid of what your body doesn t need. When your kidneys aren t working well, sodium builds up in your body. This can make your blood pressure go up, which will damage your kidneys and heart. The sodium in your diet comes from the food you eat and the salt you add. Salt (sodium chloride) is 40% sodium. Do not add salt to your food. Avoid foods that have extra salt already in them. Examples of high-salt foods include canned soup, luncheon meats, pickles, cured meats, snack foods, cheese, TV dinners, soy sauce, seasoning salt, and fast foods. See Table 1 - Sodium Guidelines on the next page to learn more about reducing your sodium intake. Below are more tips for keeping your sodium under control. Check the ones that you will try: Sodium is listed on the label of all processed foods. Compare labels of similar products. Choose brands that are lowest in sodium. Your daily goal should be about 2000 mg. Keep a journal. Write down what you eat and how much sodium is in the food (from the label). This will give you an overall picture of how much sodium you are eating each day. Some canned foods are safe to eat if you rinse the salt off. Drain the food and empty it into a colander. Place under running tap water for a minute or two. Then prepare as usual. Use herbs and spices instead of salt at the table or in cooking. Your dietitian has cookbooks and handouts about seasoning without salt. Ask for help with ideas. If processed pasta and rice dishes are not something you think you can give up, throw away the spice packets (they are loaded with salt!), and add your own fresh or dried herbs and spices. Table 1 Sodium Guidelines (See page 8-4.) Sodium is a mineral that is found in table salt. It is also added to foods during processing. Most processed and convenience foods have more sodium than the same food made from scratch. The food chart on the next page lists healthy food choices and foods that you should avoid because they have too much sodium. Take a look at Table 1 on the next page and circle the choices you enjoy that are lower in sodium.

4 Chapter 8 Page 4 Table 1 Sodium Guidelines Food Group Healthy Choices Avoid These Foods Protein Milk and Dairy Vegetables Fruits Breads Cereals, Rice, Pasta Fats Beverages Seasonings Fast Foods Fresh or frozen meats: beef, chicken, lamb, pork, veal, and poultry Fresh or frozen fish and shellfish Meats and fish are okay if canned without salt Unsalted or low-sodium cheeses Milk, yogurt Ice cream, sherbet, or ice milk All fresh vegetables Frozen and canned vegetables labeled no salt added Fresh, frozen or canned fruits canned without salt Breads with no visible salt added Unsalted or no salt added crackers, pretzels, popcorn, rice cakes, chips Cooked or ready-to-eat cereals: Cream of Quick-cooking cereals (read labels, as Wheat, Cream of Rice, oatmeal; dry cereals some may be okay) Rice and Food pastas Group packaged with no salt Some Healthy ready-to-eat Choices (dry) cereals Avoid have Thse extra Foods salt (read labels) Packaged rice, pasta, stuffing mix (macaroni and cheese, Rice-a-Roni, etc.) Butter, margarine, vegetable oil, shortening, low-sodium salad dressings and mayonnaise, oil and vinegar Coffee, tea, fruit juices and fruit drinks, lemonade, Kool-Aid, Hawaiian Punch, soda pop, unsalted vegetable juices Herbs and spices, lemon or lemon juice, flavoring extracts, low-sodium meat tenderizers, garlic, onion and celery powder, low-sodium catsup, mustard, horseradish, vinegar, Tabasco, pepper, Mrs. Dash, Vegit, Lawry s Seasoned Pepper, other spice blends with no salt added (read labels) Ask for plain hamburgers and sandwiches order them without salt or cheese, light or no mayonnaise, catsup, pickles, etc. Lettuce and tomatoes are okay Order French fries without salt Order sauces and gravies on the side so that you can control how much you eat Most restaurants can prepare your order fresh if you explain you cannot have salt Salted or smoked meats: bacon, ham, bologna, corned beef, frankfurters, luncheon meats, salt pork, sausage, imitation bacon, smoked fish, etc. Meats or fish canned with salt Salted cheeses, cottage cheese Commercial milkshakes, malted milk, buttermilk Canned vegetables and vegetable juices, olives, sauerkraut, pickles, relishes, other vegetables in brine Any fruits with salt added in processing (read labels) Visibly salted products such as saltines, pretzels, chips, snack crackers Commercial salad dressing, dips or dressing mixes, regular mayonnaise Instant flavored coffee mixes, instant cocoa mixes, Gatorade and other power drinks, tomato or vegetable juices Salt, monosodium glutamate (MSG), catsup, steak sauce, soy sauce, chili sauce, barbecue sauce, garlic salt, onion salt, celery salt, commercial salsas, Worcestershire sauce Many salt substitutes are not safe to eat ask your dietitian before using Asian foods, commercial hamburgers, pizza, tacos, TV dinners, frozen entrees, deli meals

5 Chapter 8 Page 5 Next time you are at a fast food restaurant, ask for the Nutrition Facts Brochure. Find the lowest sodium foods or share the brochure with your dietitian and she/he can help you make the best choices. Don t be fooled by claims of low sodium. Just because it says low sodium does not make it a good food choice for you. Read food labels carefully for the total amount of sodium per serving. Some foods contain potassium chloride instead of salt, which is dangerous for people on dialysis. Always check with your dietitian when you are not sure! Convenience foods may be quicker, but they may make you feel sicker! Convenience foods are higher in sodium, leading to higher blood pressure and edema. Fresh foods are the better choice because you have control over extra sodium. If low sodium is new for you, remember that within 45 days of following a low-sodium eating plan, your taste buds will change and high sodium foods will no longer taste appealing. Try low sodium for 6 weeks and you will be pleasantly surprised! Phosphorous In addition to watching protein and sodium, you may be told to reduce your phosphorus intake. A low phosphorus diet has been linked to slowing kidney damage. Phosphorus is a mineral that combines with calcium in the body to make bones and teeth. Normally kidneys get rid of extra phosphorus. When your kidneys aren t working well they can t get rid of the extra phosphorous and it builds up in your blood. High blood phosphorus makes blood calcium go down. Your body tries to fix this by taking calcium from the bones which makes them weak. The extra phosphorus and calcium in your blood can damage your heart, lungs, and blood vessels. To prevent this from happening you should restrict your phosphorus intake. Phosphorus is found in almost all foods but is especially high in meat, milk, cheese, cottage cheese, yogurt, dried beans, and nuts. See Table 2 - Phosphorus Guidelines and Food List on the next page for a more complete list.

6 Chapter 8 Page 6 In addition to limiting foods high in phosphorus, you may need to take phosphate binders like Tums, PhosLo, or Renagel pills. These medications should be taken when you eat to bind with the phosphorus from food once it is in your stomach. Bound-up phosphorus passes out of your body through the stool. Your doctor will tell you if you need phosphate binders. If you follow a low-phosphorus diet, you may not eat many dairy products. As a result, you won t get enough calcium. Many people on a low-phosphorus diet take calcium supplements. Your doctor will tell you if you need them. Do not take calcium supplements unless you talk with your doctor first. Table 2 Phosphorus Guideline and Food List Choose only 1 of these foods per day, in the serving size noted. Milk (8 ounces or 1 cup) Pizza (1/4 of 12-inch pizza) Cheese (2 oz.) Pancakes, waffles (2-4 inch) Cottage cheese (1/2 cup) Nuts (2 ounces or 1/2 cup) Ice cream (1 cup) Macaroni and cheese (8 oz. Pudding (1 cup) or 1 cup) Custard (1 cup) Bran cereals: All Bran, 100% Yogurt (1 cup or 8 ounces) Bran or Bran Buds (1/3 cup) Cooked dried beans or peas (1 cup) Potassium As kidney failure progresses, you may also need to watch potassium. Potassium is a mineral found in many foods, but mostly in fruits and vegetables. Normally when you eat potassium, your kidneys get rid of what your body doesn t need. When your kidneys aren t working well, they may not get rid of excess potassium so it builds up in your blood. If your blood potassium is high, your kidney doctor may refer you to a dietitian who can help you plan a low potassium diet. See Table 3 - Potassium Food List on the next 3 pages for a listing of high, medium and low potassium foods.

7 Chapter 8 Page 7 Table 3 Potassium Food List High Potassium (250 to 500 mg) Choose 1 each day (All servings are ½ cup unless noted otherwise) Fruits Apricots (3) Nectarine (1) Avocado Orange (1) Banana (1) Prunes (5) Dates Raisins Honeydew Tangelo (1) Kiwi (1) Watermelon (1 cup) Vegetables Artichokes Bamboo shoots (fresh, raw) Rutabagas Beans (kidney, lima, navy, pinto) Beets Chard Greens (beet, collard, mustard) Kohlrabi Okra Winter squash Drinks and Other Foods Chocolate chips (1/2 cup) Milk, soy milk Nuts (1/4 cup) Parsnips Potatoes Spinach Split peas, black-eyed peas, lentils Sweet potatoes Tomatoes Tomato sauce Wax beans Yams Orange juice, prune juice V-8 juice Salt substitutes (1/8 tsp)

8 Chapter 8 Page 8 Medium Potassium (150 to 250 mg) Choose 2 each day (All servings are ½ cup unless noted otherwise) Fruits Cherries Papaya Cantaloupe Peach, fresh (1) Figs (2) Pear, fresh (1) Grapefruit (1/2) Plums (2) Mango Vegetables Asparagus Broccoli Celery Green peas Kale Drinks and Other Foods Grape juice Grapefruit juice Mixed veggies Peppers Summer squash Turnips Zucchini Pineapple juice

9 Chapter 8 Page 9 Low Potassium (20 to 150 mg) Choose 3 each day (All servings are ½ cup unless noted otherwise) Fruits Apples (1) Lemon, lime (1) Applesauce Peach, canned Blackberries Pear, canned Blueberries Pineapple Cranberries Raspberries Fruit cocktail Strawberries Grapes Tangerine Vegetables Alfalfa sprouts Bamboo shoots (canned) Bean sprouts Cabbage Carrots Cauliflower Corn Cucumber Endive Eggplant Drinks and Other Foods Apple juice Coffee (1 cup) Cranberry juice cocktails Fruit nectars Green beans Lettuce (all types) Mushrooms Onions Radishes Rhubarb Soaked potatoes Water chestnuts Watercress Fruit drinks Lemonade Tea (1 cup)

10 Chapter 8 Page 10 Calories It is very common for people with kidney disease to have a low appetite. If your appetite has decreased or if you follow a low-protein diet, you may not eat enough calories to stay healthy. If you have cut down on protein, you probably have cut out some calories too. You need to replace those calories or your body will use the protein you eat for energy instead of building blocks. It is very important that you maintain a healthy weight when you have kidney disease. If you are losing body weight, check with your dietitian. Even if you are overweight, it is important to eat enough protein and calories to spare your muscles. Fat Eating too much fat or the wrong kinds of fat has been linked to heart disease. You may need to eat less fat or more healthy fats. Saturated fats like butter, coconut and palm oil, and lard are bad for your heart. Healthy fats include canola oil and olive oil. Ask your doctor if you need a low-fat diet. Your dietitian will help you plan how to do this. Vitamins If you follow a low protein diet you may not consume enough vitamins. You will likely need to take a B-complex vitamin pill. Check with your doctor or dietitian about what vitamins you need to take. Some vitamins also have things in them that are harmful for people with kidney disease, so always check with your doctor before taking any!

11 Chapter 8 Page 11 How is the diet different for each treatment? Your diet will change as your kidney function and treatment change. The table below shows general dietary guidelines for different types of kidney disease treatment. Table 4 Dietary Guidelines for Kidney Disease Treatments Predialysis Dialysis Post-Transplant Protein Varies Not restricted Not restricted Sodium Restricted Restricted Restricted Phosphorus Varies Restricted Not restricted Potassium Varies Restricted Not restricted Calories Not restricted Not restricted Restricted Vitamins Needed Needed Varies

12 Chapter 8 Page 12 Northwest Kidney Centers Patient Education Materials All brochures are also available in Spanish. Food Content Brochures These brochures provide guidelines for renal patients. Foods are grouped according to high/medium/low levels of sodium, potassium, and phosphorus. Includes recommended servings per day and instructions for reducing sodium, potassium, phosphorus, and fluid in the diet. Sodium Content of Foods Potassium Content of Foods Phosphorus Content of Foods Fluid for Dialysis Patients Designed to aid patients in controlling their fluid intake. Includes guidelines and tips for controlling thirst. Protein Content Brochures These brochures provide protein guidelines, information on portion sizes, and ideas for increasing protein intake. Protein Content of Foods for People on Hemodialysis Protein Content of Foods for People on Peritoneal Dialysis Eating Well Designed for the patient with progressive renal disease who has not yet begun dialysis. It describes the types of dietary restrictions usually required when kidney function is decreasing. Eating Away from Home Assists the dialysis patient with choosing appropriate restaurant meals. Sample menu and guidelines for ordering food are included. Emergency Diet Plan Designed for use when patients are unable to dialyze due to a natural disaster. Includes a list of suggested foods that do not require cooking or refrigeration. Information for people with diabetes is included. CAPD Diet Specifically outlines diet and nutrient needs for patients on CAPD (Continuous Ambulatory Peritoneal Dialysis).

13 Chapter 8 Page 13 Nutrition Booklets and Workbooks Nutrition: The Art of Good Eating A workbook for people on chronic dialysis and a valuable reference for nutritionists, nephrologists, and nutrition educators. Includes all basic information dialysis patients need with sections on sodium, fluid, potassium, phosphorus, and protein. Includes information about blood values, peritoneal dialysis, CAPD, diabetes, eating at restaurants, exercise, food preparation, and nutrient content of foods. The Targeted Protein Diet Workbook A patient workbook for the conservation treatment of renal failure. Includes protein, calories, sodium, potassium, and phosphorus information for the dietitian calculating protein recommendations and information on amino acid supplements. A Guide to Good Nutrition: After Your Kidney Transplant A unique booklet for the kidney transplant patient. Structured as a workbook for patients to learn to identify high/medium/low sodium foods and work them into their diets. Also includes sections on protein needs, counting calories, and calcium intake. Nutrition for Children on Dialysis A supplement to Nutrition: The Art of Good Eating. This booklet provides special information for the professional working with the pediatric population. Topics include nutrient recommendations, formula information, meal patterns, and age-specific guidelines. Guide to Good Eating on Dialysis (in Chinese with English translation) Nutrition guide to sodium, potassium, and phosphorus for Cantonese and Mandarin-speaking patients. This food guide is culturally-specific for the Chinese-American diet. Posters The first three posters group foods into high/medium/low levels and list recommended portions and common milligrams. Sodium (11 x 17 ) Potassium (11 x 17 ) Phosphorus (11 x 17 ) Spell of Spices (11 x 17 ) Offers ideas for spicing up food by seasoning and provides recipes for spice mixtures. Basic Food Guide (14 x 20 ) Provides simple diet information for kidney patients. Includes portion recommendations and food examples.

14 Chapter 8 - Page 14 Questions? Your questions are important. Call your doctor or health care provider if you have questions or concerns. Notes American Nephrology Nurses Association Greater Puget Sound Chapter University of Washington Medical Center 07/2004

UW MEDICINE PATIENT EDUCATION. Healthy Eating. Eat well and eat smart. Why should I limit sodium (salt)?

UW MEDICINE PATIENT EDUCATION. Healthy Eating. Eat well and eat smart. Why should I limit sodium (salt)? UW MEDICINE PATIENT EDUCATION Healthy Eating Eat well and eat smart Class Goals 1. Describe 3 nutrients that you may need to limit. 2. Understand how your limits on nutrients may change. Overview As your