My experience with nutrition…. And the good advice of Dr Vitor Martins 

Nutrition is one the main points of a renal patient’s life. It is through a balanced and rich diet that we have a more energetic daily routine, with bigger vitality, and manage to prevent the decrease of our health. One of the first things I have learn when I started dialysis is that is essential to avoid several compounds, like phosphorus and potassium…. and the list of foods that contains them is extensive. So the challenge starts! 

When I realized my diet had to change, I thought this would be a great change not only for me, but for the whole family. With good medical advice, organization, and love we managed to have good food for everyone.

Every day I have several questions to take in consideration: What can I eat, knowing potassium is present in many fruits and vegetables? How can I manage Protein? Which are the ingredients I should control? What is the most proper diet to follow? How can Ieducate my body and mind to intake fewer liquids?

Because it´s always useful to remind those answers, I asked Dr Vitor Martins, nutrition manager at @diaverum_portugal, to help me clarify some of my questions, which I believe you may have in common. Let´s learn from the expert, and don´t forget to complement the information you need for your specific case with your nutritionist.

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Filipe: What are the major changes we have to do in our daily diet when we know we have CKD?

Dr Vitor Martins: That depends on how far your CKD has progressed and how is your kidney function. In early stages of CKD, it is important to nutritionally intervene in the major problems, if they exist, such as obesity, diabetes, dyslipidemia. So at this time, general recommendations for an healthy diet should apply, such as eating 2 -5 portions of fresh fruits and vegetables per day, control the total amount of daily calories that you eat, avoiding “empty calories foods”, such as sweets, sodas, fried snacks, fast food, choosing, when possible, to prepare your meals, instead of eating processed foods.  It is also important “to respect and treat well” your foods, that is to say: avoid overcooking, avoid frying and add as less salt as possible to let their natural flavors get noticed, just to name a few dietary recommendations. As CKD progresses, you’ll might need to adapt and individualize your diet, which has to be defined between you, your nephrologist and your nutritionist/dietitian, to help the kidneys cope with the decreased function and delay the progression of the disease, if possible.  At this stage, the nutritional guidelines would be: to adjust the intake of total daily protein to your individual needs (or a little less, if clinically needed), to reduce the intake of salt and to control the intake of potassium and phosphate. Assuring that you eat an adequate amount of calories every day is also important, because there is a high risk of malnutrition, since the appetite usually decreases in this phase, and to avoid protein and muscle degradation, by which increases the production of urea.  However, when kidney function has severely decreased and a substitution therapy is needed, such as hemodialysis, those recommendations change. In hemodialysis, the recommendation is to increase the daily intake of protein.

Filipe: Can we eat every kind of food, although in controlled quantities, or is there forbidden ingredients (I refer to my particular case – I don’t have diabetes or any other disease).

Dr Vitor Martins: Managing your diet is like managing a budget. For example, for potassium you will have an estimated daily needs. If all the foods that you ate in one day give a lot more potassium than what you need and what is possible to be removed by the hemodialysis treatment, your body will accumulate and you will be at risk of hypercalemia, that in severe cases leads to cardiac arrest and death. When you start hemodialysis, your nutritionist/dietitian will estimate your nutritional needs and design an individual food plan taking into account your food habits and preferences. This food plan has the amounts, portions and serving sizes of foods, and will help you to manage your “eating budget”, according to what you want without any risk. Of course, there are foods that, due to high mineral content per usual portion, such as avocado, banana, melon or cantaloupe, should be avoided.  However, if you are keen on eating a particular one, you can discuss it with your nutritionist/dietitian and he can estimate the portion size of that food with a safe amount of potassium and/or phosphate. Nevertheless, be aware in advance, that in some cases, the food portion could be very small. In the avocado it is about one fifth of a medium avocado (around 50g)… In some foods, such as potatoes, you can reduce the amount of potassium by slicing in medium to small pieces and soaking them one or two times on water for some hours, or boiling them before cooking.

Filipe: What kind of diets should we avoid? A Low calories diet is acceptable for a dialysis patient like me?

Dr Vitor Martins: Patients on hemodialysis should avoid the diets or eating patterns with high content in salt, potassium, phosphate, and fluids. About half of the patients on hemodialysis are at risk of protein and energy malnutrition.
We recommended a normo to hypercaloric diet. It is important to give the right amount of energy to your body for their vital functions, to produce proteins, to maintain or renew cells and tissues, and even to maintain fat stores, because you do not know when you might need them. The energy deficit of a low calorie diet has to be analyzed and defined between patient, nephrologist and nutritionist/dietitian, addressing the goals, gains and risks, because a great reduction of the energy intake could affect your body’s functions, such as the ability to manage correctly protein metabolism.  Increasing the energy expenditure through daily routines activities (walking, climbing stairs,…) and physical activity could help reach the goal, but please check with your nephrologist what are the best approaches to physical activity in your clinical situation. 

Filipe: What diet do you suggest to my family? The idea is to have a diet that can be healthy for everyone, taking in consideration my specific needs?

Dr Vitor Martins: The Mediterranean Diet is a recommended eating pattern to the general population, which benefits have been shown. With your individualized food plan you can adjust some foods and portions, so you can share the meals with your family.

Filipe: Dialysis takes us energy. Are there any ingredients that we can eat to balance this lack of energy? Which ones? Any recipes you suggest?

Dr Vitor Martins: The hemodialysis procedure itself increases the energy and protein needs. It is estimated, depending on the studies, to be around more 330kcal and 7g of protein/day of hemodialysis, which should be compensated. A good way to compensate this increase is to have an extra meal on the day of hemodialysis, if possible during the treatment: 1 or 2 loafs of bread with turkey ham, fresh cream cheese or jam and small cup of tea, coffee or juice (low on potassium), will fulfill those needs and compensate the impact of the hemodialysis treatment. 

Filipe: What kind of advice can you give to educate my body and mind to intake fewer liquids?

Dr Vitor Martins: We have to be our own coaches and address clearly the situation. There is no other way but to control thirst and all that increases it. Once you are thirsty it is very difficult to control the urge to drink, some patients even refer that it is harder to control than hunger. So you’ll have to train yourself, adapting gradually your taste, reducing day by day the amount of salt added to foods (to the minimal or even none), increasing the flavor of foods with spices and herbs at the same time, controlling other factors, such as body temperature (avoid exposure to heat), air conditioning, having a good oral hygiene, etc. The same goes to all the fluids you take during the day, keeping a daily record, using small bottles or glasses and reducing gradually the intake. Staying focused and reducing interdialytic weight gain to the recommended (less than 4% of your “dry weight”), and all that was previously said, will keep you on the right track. It is a continuous effort.

Filipe: How can a diet work in a preventive way to all of those who
don´t have CKD?

Dr Vitor Martins: You are what you eat, and your diet is like a fuel to your body, if the fuel is good and adequate to your needs, you will keep the motor of your car running for a long, long time and in a great shape. A good nutrition that satisfies macro and micronutrients needs, and with the right amount of calories, will decrease the risk of several diseases, namely the “civilizational” ones, such as obesity and diabetes.There is now a few recommended healthy patterns, such as the Mediterranean diet, as I said before, that guide in the food choices if you do not have any particular health condition. You can always count on health professionals to guide on your options depending on your culture, preferences and eating behavior.

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