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Diet and Kidney Disease Louise Wells Clinical Lead for Renal Dietetics at York Teaching Hospital NHS Foundation Trust Diet and lifestyle changes play an important role in the management of Chronic Kidney Disease (CKD) and in the early stages of CKD, appropriate dietary treatment may help prevent or slow the rate of the disease progression. For people with CKD the basic dietary principles are the same as those for the general population; aimed at achieving and maintaining a healthy weight, improving blood glucose control for those with diabetes and supporting effective hypertension management. In more advanced CKD, dietary advice shifts towards the ‘renal specific’ elements. This requires timely specialist renal dietetic intervention to support good biochemical control, continued sodium restriction to address salt and water imbalance alongside assessment of nutritional status and the need to maintain adequate nutrition. Healthy diet and lifestyle measures for CKD: Eat a varied, balanced diet Maintain a healthy body weight Reduce salt intake to a maximum of 6g (1 teaspoon) per day Limit alcohol intake to a maximum of 3 units per day for men and 2 units per day for women Eat at least five portions of fruit and vegetables per day Eat adequate protein for growth and repair but avoid an excessive intake – (A ‘normal’ intake of 0.8-1.0g protein/kg Ideal Body Weight/day is recommended) Take regular exercise Effective blood pressure control is essential to the management of CKD, as hypertension is a major risk factor for further kidney damage and progression of kidney disease. The importance of diet and lifestyle modification alongside anti-hypertensive medication is highlighted in several guidelines. The NICE Hypertension Guidelines (2011) recommend a ‘healthy diet’ - reducing sodium intake, reducing alcohol and caffeine intake where necessary and promoting regular exercise. The Dietary Approaches to Stop Hypertension (DASH) trial (2001) provided robust evidence that a combination diet, emphasising a high intake of fruits, vegetables, low fat dairy products and whole grains, and lower in fat, sugar, salt and meat products, can significantly reduce blood pressure in populations with normal kidney function. The potential for this type of diet to be of benefit in hypertension is clear, but there are concerns about its use in more advanced CKD because of its higher potassium and phosphate content, both of which may be problematic for some people with reduced kidney function. However, the principles of a healthy diet, and in particular a reduction in sodium intake to help manage hypertension, remain valid. Clinical News, September 2014 Reducing salt intake: Avoid adding salt to food at the table Aim to avoid using salt in cooking Cut down on high salt and processed foods Use fresh ingredients where possible Don’t use salt substitutes Most of us eat too much salt and only a small amount is needed for good health. The current advice is that we should aim to have no more than 6g per day. Most of the salt that we eat – around 75% - is ‘hidden’ salt in processed and ready prepared foods, so the aim is to limit intake of these and use more fresh products. The salt content of similar foods can vary greatly so advice on how to interpret the salt, or sodium content on food labels is important. To convert sodium to salt, you need to multiply the amount by 2.5 Greater than 0.6g of sodium/1.5g of salt per 100g in food is high. Less than 0.1g of sodium/0.3g of salt per 100g is low. Remember that a serving of a food may be more than 100g, e.g. if a food contains 1g of salt per 100g, but a serving is 300g, this will provide half a day’s salt intake! From the end of 2014 food labelling guidance changes and only salt content will be indicated, with sodium no longer used Salt substitutes are not advised, since they still contain some sodium, as well as being high in potassium, which can be a problem for some people with CKD. Most importantly, their use does not help people adjust to a reduced taste for salt. Using herbs, spices and other low salt flavourings is preferable and can help people adapt to a lower salt intake. Weight management in CKD: Obesity is a recognised risk factor for cardiovascular disease and type II diabetes. Weight reduction in these patient groups has been shown to reduce blood pressure and improve control of blood lipids and blood glucose. Obesity is also associated with the development and progression of CKD and obese patients may be required to lose weight prior to transplantation. Weight loss programmes should be advised where needed, encouraging a sensible eating plan, combined with regular exercise, in order to achieve a slow, steady weight loss of 0.5-1kg (1-2lb) per week. In the later stages of CKD poor appetite and uraemic symptoms can lead to rapid loss of nutritional status and flesh weight changes may be masked by shifts in fluid balance. Monitoring nutritional status is essential, since malnutrition in established renal failure is associated with poorer outcomes and reduced patient survival. Therefore, sensible weight loss in CKD patients with multiple dietary needs should be managed by specialist renal dieticians, who can assess the various and sometimes Clinical News, September 2014 conflicting nutritional requirements of these patients, can determine the priorities and address nutritional concerns. Phosphate and potassium control Phosphate and potassium restrictions are commonly required in the later stages of CKD as blood levels rise. Dietary manipulation to control high phosphate and high parathyroid (PTH) levels is a recognised factor in the effective management of CKD-Mineral Bone Disorder in stage 4 and 5 CKD patients. There is increasing focus on restricting inorganic phosphates, found in food additives, as a way of controlling phosphate levels without compromising protein intake. A healthy diet as described above will therefore potentially also help phosphate management. The UK Renal Association CKD Guidelines propose that dietary advice in this area should be delivered by renal dieticians and there is now considerable evidence showing improvements in bone biochemistry with dietetic-led interventions. Potassium is found in many foods, particularly fruit and vegetables, so over restriction can conflict with the dietary advice to lower blood pressure. There are many reasons why blood potassium levels may rise and non-dietary causes should be excluded before focussing on high potassium foods. Specialist dietetic advice will help to ensure that wherever potassium restriction is necessary, it can be achieved without affecting the balance or adequacy of a healthy diet. Many people diagnosed with CKD may already be aware of the dietary advice recommended for management of diabetes or high blood pressure. They can be reassured that making simple changes to achieve a healthy, balanced diet can also support good management of chronic kidney disease. Educational resources are available at: http://www.britishrenal.org/getattachment/CKD-Forum/Educational-Resources/CKD-Nutrition-Leaflet.pdf.aspx Clinical News, September 2014