How to move patients with CKD away from a diet of processed foods
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Traditionally, the diet for patients with chronic kidney disease restricts certain nutrients to help control serum blood levels of phosphorus and potassium.
This restriction would include whole foods, such as whole grains, beans, legumes, and certain fruits and vegetables. White bread, white rice, milk substitutes and other processed foods were thought to better control phosphorus and potassium intake.
In the renal community, we are finding that restriction of whole foods may contribute to the consumption of more processed foods that ultimately limits patients’ diet of healthy foods and leads to higher sodium intake.
Health risks
Two new studies published in the British Medical Journal review findings on how highly processed foods may contribute to heart disease, bowel/colon cancer and death. The findings of this study are relevant and renal dietitians are acutely aware that processed foods contain phosphorus additives and need to be restricted in patients with CKD because of decreased clearance by the kidneys and its contribution to cardiovascular and soft tissue calcification.
Researchers involved in a clinical trial published in the Journal of Renal Nutrition recommend diet counseling by a renal dietitian that incorporates more foods with less additives and focuses more on whole foods. Foods with organic, or naturally occurring, phosphorus have an absorption rate of about 60% for phosphorus. Conversely, phosphorus additives in foods have at least a 90% absorption rate.
The broader nephrology community is recognizing the need to incorporate more whole foods back into the renal diet.
Plant-based diets
In recent years, plant-based diets have been receiving long overdue recognition in our CKD population. Grains, legumes, seeds, beans and nuts have many health benefits including fiber, vitamins and minerals. When food is highly processed, many of these nutrients are stripped away. A study by Karp and colleagues references the digestibility of high phosphorus foods that were historically restricted in the CKD diet.
The authors intended to show that a lower sodium intake (another additive) can reduce volume overload and help control blood pressure. Lowering phosphorus additives, as well as incorporating more whole foods, will increase fiber and antioxidants in the diet, which can help reduce the risk of CVD.
Fruits, vegetables
Interesting research is emerging on potassium and the impact of incorporating more fruits and vegetables into the CKD diet. These studies are revealing that potassium control is not just about diet consumption. This is further validation for supporting a whole foods diet in CKD patients.
In research published in the Journal of Renal Nutrition, patients reported frustration with their limited diet. Not having enough choices causes them to ignore nutrition recommendations all together, because the recommendations are too strict.
As always, it is important to monitor blood levels and adjust diet as needed. This gives flexibility to the CKD diet that allows for individualization. In fact, the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Nutrition in CKD: 2020 Update emphasizes individualizing diets to the patient. Diet modification considerations should include the source of select minerals, patient comorbidities and factors, such as stage of CKD, and, if the patient is on dialysis, the modality.
Renal dietitians are modifying their approach to include diet education on incorporating whole foods and liberalizing the CKD diet, steering patients back to whole grains, nuts, legumes, some dairy, and fruits/vegetables and limiting processed foods. As diets are liberalized in the CKD community, more research will be needed to assess the impact of these changes on our patients’ overall health and quality of life.
- References:
- Biruete A, et al. J Ren Nutr. 2017;doi:10.1053/j.jrn.2016.06.001.
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- Jacqueline Termont, RD, is the lead dietitian in the Cardinal Division of DaVita Kidney Care and is based in Richmond, Virginia. She can be reached at jacqueline.termont@davita.com.
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