1. ©2010 DaVita Inc. All rights reserved. 1 Nutrition and Kidney Disease Sara Colman, RD, CDE DaVita.com Nutrition Project Specialist

2. ©2010 DaVita Inc. All rights reserved. 2 What this talk means to you tomorrow What you eat matters to your health in chronic disease prevention and treatment Diet goals change with stages of chronic kidney disease (CKD) and dialysis What you do now makes a difference tomorrow

3. ©2010 DaVita Inc. All rights reserved. 3 Today’s Discussion What to eat to prevent kidney disease What is a kidney diet? Making changes in eating habits Healthy foods to include Tools and resources Questions and answers

4. ©2010 DaVita Inc. All rights reserved. 4 Audience Question #1 Which one best describes the way you eat? A. Regular, no restrictions B. Heart healthy diet C. Diabetic diet D. Low sodium diet E. Kidney diet

5. ©2010 DaVita Inc. All rights reserved. 5 Audience Question #2 Have you ever had to make changes in the way you eat due to your health? A. Yes, I made changes for health reasons B. No, I never needed to make changes C. I should but haven’t made changes yet

6. ©2010 DaVita Inc. All rights reserved. 6 Audience Question #3 Which one are you most interested in knowing about nutrition and kidney disease? A. How much protein to eat B. Healthy foods for a kidney diet C. Phosphorus and potassium guidelines D. Sodium and fluid guidelines

7. ©2010 DaVita Inc. All rights reserved. 7 1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2008 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: CDC Behavioral Risk Factor Surveillance System

8. ©2010 DaVita Inc. All rights reserved. 8 2008 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI ≥30 kg/m 2 ) Diabetes 1994 2000 No Data 26.0% No Data 9.0% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics 2008

9. ©2010 DaVita Inc. All rights reserved. 9 Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008 CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

10. ©2010 DaVita Inc. All rights reserved. 10 Nutrition and chronic disease link Nutrition Heart Blood Pressure KidneysDiabetesWeight

11. ©2010 DaVita Inc. All rights reserved. 11 Maria Married with four children ages 7, 9, 12, 15 High blood pressure At risk for kidney and heart disease

12. ©2010 DaVita Inc. All rights reserved. 12 High in… Fiber Potassium Calcium Magnesium Low in… Sodium Fat Lower systolic (upper number) blood pressure 11 points Could lead to… Prevention: DASH* Diet Dietary Approaches to Stop Hypertension *Free booklet available at www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf *NOTE: Not recommended for people with advanced kidney disease

13. ©2010 DaVita Inc. All rights reserved. 13 Nuts & Seeds 4-5 servings Vegetables 4-5 servings Fat-free/ Low-fat Dairy Products 2-3 servings Fruit 4-5 servings 6 oz or less -lean meat -poultry -fish Grains 6-8 servings Dash Diet: Dietary Approaches to Stop Hypertension Limit fats, oils, sweets and added sugars

14. ©2010 DaVita Inc. All rights reserved. 14 Most peopl e don’t recog nize a porti on Clean plate vs satisfied Is more really better? Portion Distortion

15. ©2010 DaVita Inc. All rights reserved. 15 Common Portion - References

16. ©2010 DaVita Inc. All rights reserved. 16 Laverne Retired widow, two grown daughters, 5 grandchildren Type 2 diabetes High blood pressure Stage 3 CKD

17. ©2010 DaVita Inc. All rights reserved. 17 Diet in Early Kidney Disease Important Nutrients Sodium Protein Phosphorus (stage 3) Calories Focus on… Individual Differences Size Stage of CKD Nutrition Lab results Diet Goals Weight Good nutrition Management of Blood pressure Glucose

18. ©2010 DaVita Inc. All rights reserved. 18 Tips to Decrease Sodium Intake Eat out less (especially Fast Food) Cook at home with low-sodium ingredients Read labels 1000-3000 mg sodium/day for ALL kidney diets Cut out: Salt High-sodium condiments Processed, cured foods Add: Herbs Spices Lemon Vinegar

19. ©2010 DaVita Inc. All rights reserved. 19 Common Sodium Sources The following has..This much sodium 1 slice of bread110 – 175 mg 1 cup ready-to eat cereal0 – 360 mg ½ cup canned vegetables140 – 460 mg 1 cup tomato or V-8330 mg 1 tsp salt2100 mg 2 oz natural cheese110 – 450 mg 2 oz processed cheese600 mg 1/3 cup salted nuts120 – 200 mg 3 oz canned tuna230 – 350 mg 3 oz ham1020 mg

20. ©2010 DaVita Inc. All rights reserved. 20 All stages – if malnourished Eat additional protein Protein Intake 50% High Quality Protein Sources Example: A 150 lb (68kg) 55 grams 1 cup milk 1 egg or 2 egg whites 4 oz meat 3 – 4 vegetables 6 servings of grains Stages 1 - 3 Eat protein for good health DRI*: *DRI = Dietary Reference Intake

21. ©2010 DaVita Inc. All rights reserved. 21 Benefits of Carbohydrate Counting Has biggest effect on blood sugar (compared to protein and fat) Helps improve glucose control Increases awareness of carbohydrate intake Requires more self-monitoring and decision making Easier than some of the complicated diabetes meal planning methods

22. ©2010 DaVita Inc. All rights reserved. 22 Carbohydrate Counting Which food groups have Carbs? How much carbohydrate to eat at each meal or snack? What is a serving/choice/exchange? How much carbohydrate is in a serving? Label reading for carbohydrates

23. ©2010 DaVita Inc. All rights reserved. 23 Goals for Glucose Control American Diabetes Association Recommends the following ranges: Glucose Pre-meal: 90-130 mg/dL 2 hours after eating: <180 mg/dL HbA1C: < 7%

24. ©2010 DaVita Inc. All rights reserved. 24 When to Monitor Glucose Daily before each meal and bedtime Hypoglycemia or hyperglycemia During insulin adjustment periods Changes in exercise, diet, meal times 1-4 times a day, 3-4 days a week Before breakfast Before and 2 hour after the largest meal Medication changes Changes in exercise, diet, meal times Type 1Type 2

25. ©2010 DaVita Inc. All rights reserved. 25 Alex Married, high school teacher, 2 teenage sons High blood pressure Stage 5 kidney failure Training to start dialysis

26. ©2010 DaVita Inc. All rights reserved. 26 Diet in CKD Stages 4 - 5 Focus on… Individual Differences Size Nutrition Lab results Important Nutrients Calories Protein Sodium Phosphorus Fluid Potassium Calcium Diet Goals Management of Blood pressure Glucose Minerals Fluid Weight loss prevention Nutrition

27. ©2010 DaVita Inc. All rights reserved. 27 Stage 5 - On dialysis Eat MORE protein All stages – if malnourished Eat additional protein Protein Intake 50% High Quality Protein Sources Example: A 150 lb (68kg) 41 – 48 grams ½ cup milk 1 egg or 2 egg whites 2 oz meat 2 – 3 vegetables 5 – 6 servings of grains 82 grams ½ cup milk 2 eggs or 4 egg whites 6 oz meat 3 vegetables 8 servings of grains Stage 4 or 5 - Not on dialysis Eat LESS protein DRI*: *DRI = Dietary Reference Intake

28. ©2010 DaVita Inc. All rights reserved. 28 Usually not restricted Changes in medications that increase potassium Stop using salt substitute and products that have potassium chloride added (check labels) Learn about highest potassium fruits and vegetables—have these less frequently and in smaller portions Learn about other high potassium foods to limit CKD Stages 1 – 3CKD Stages 4 and 5 Potassium and CKD

29. ©2010 DaVita Inc. All rights reserved. 29 Common Potassium Sources The following has..This much potassium 1 medium baked potato925 mg 1 medium sweet potato540 mg ½ cup cooked spinach290 mg ½ cup fresh tomato210 mg 1 cup cantaloupe430 mg 1 medium banana420 mg 1 orange240 mg ½ cup beans360 mg 1/3 cup nuts or seeds120-310 mg 1 cup milk or yogurt360-490 mg 3 oz meat, poultry, fish200-400 mg

30. ©2010 DaVita Inc. All rights reserved. 30 Usually not restricted 800 to 1000 mg/day for most patients Lower protein diets decrease phosphorus Phosphate binders may be needed Ask your doctor to check phosphorus level and discuss the results Learn about and limit highest phosphorus foods Processed foods and phosphate additives—read labels Early phosphorus control may delay bone disease CKD Stages 1 – 2CKD Stages 3 – 5 Phosphorus and CKD

31. ©2010 DaVita Inc. All rights reserved. 31 High Phosphorus Foods The following has..This much phosphorus 1 oz meat65 mg 2 tablespoons peanut butter100 mg ½ cup milk110 mg 1 cup Hawaiian Punch115 mg 1 oz cheese100 – 150 mg ½ cup beans (pinto, lima)125 mg 2/3 cup bran flakes150 mg Fast food small cheeseburger176 mg 3 tablespoon (1 oz) sunflower seeds328 mg Fast food sausage & egg biscuit490 mg

32. ©2010 DaVita Inc. All rights reserved. 32 1200 – 1500 mg/day based on DRI* May need vitamin D3 Not to exceed 2000 mg/day, including calcium-based binders Activated vitamin D PTH control important CKD Stages 1 – 4CKD Stage 5 Calcium *DRI = Dietary Reference Intake

33. ©2010 DaVita Inc. All rights reserved. 33 Healthy FatsHigh Quality ProteinsFiber Omega 3’s Sardines Salmon Mackerel Trout Fish oil supplements Monounsaturated fats Olive oil Canola oil Flax seed oil Egg white Fish Lean meats & poultry Fruits Berries Apples Vegetables Broccoli Green beans Cabbage Summer squash Bread, cereals & grains Healthy Foods to Eat

34. ©2010 DaVita Inc. All rights reserved. 34 Anti-inflammatory, high antioxidants Vitamin CVitamin EBeta-carotene Fruits Apples Blueberries Cherries Cranberries Raspberries Red grapes Strawberries Vegetables Cabbage Cauliflower Garlic Onion Red peppers Fruits Grapefruit Lemon Strawberries Tangerine Vegetables Bell peppers Broccoli Greens Cabbage Celery Zucchini Oils Canola Sunflower Wheat germ Vegetable Fruits Apricots Vegetables Carrots Leafy greens Broccoli Romaine lettuce Green Peppers Eat the Rainbow for Good Health red, orange, yellow, green and purple

35. ©2010 DaVita Inc. All rights reserved. 35 Educate Learn about foods Best to have What to limit Use existing Kidney Education Support Educate family and friends Join a support group Start a recipe/meal exchange Vary Meals Experiment with new herbs and spices in familiar foods Explore unfamiliar foods Try new recipes Commit to Change Start small Acknowledge successes Keep records/food diary Focus on benefits and motivation sources Making Diet Changes

36. ©2010 DaVita Inc. All rights reserved. 36 Kidney Friendly Recipes Websites* Newsletters Books Kidney organizations Possible Sources Online Meal Planners and Trackers DaVita Diet Helper* Diet and Nutrition Education Videos Magazine articles Kidney Diet Tools and Resources Kidney Community Blogs Discussion forums* *Available at www.davita.com

37. ©2010 DaVita Inc. All rights reserved. 37 Takeaway: What this means to you tomorrow morning What you eat at each meal now makes a difference in your future health Diet goals change with stages of chronic kidney disease (CKD) and dialysis You can make small gradual changes that really add up

38. ©2010 DaVita Inc. All rights reserved. 38 Thank you!