Food as Medicine: No More Renal “Diet”

Health food stores abound in strip malls. Vitamin shops are a multibillion dollar business. Consumer labeling such as “gluten free,” “heart healthy,” “organic,” “non-GMO” and “contains anti-oxidants” adorn food labels, encouraging purchase. Organic foods and farmers markets have become the newest trend. The overall goal of equating nutrition with health is becoming better recognized, but messaging is filled with contradictions from food marketers, the media, and health care. People generally want to be healthy and recognize that good food may be the way to go, but following a “diet” can have a negative, forced, or even punitive connotation. “Diet” usually implies restricting food, either to lose weight or for medical reasons. Renal patients faced with the conflicting messages of the importance of good food and the mandate to follow the “renal diet” are left feeling unsure which way to turn.

“Many foods that are culturally relevant to me are completely off-limits. Foods that I can have often conflict with my diabetic diet. Almost all foods have some phosphorus. Renal-friendly food labels would make better selections more obvious.”

—Angela Davis, dialysis patient, President, 4kidneyssake

In May 2016, The Rogosin Institute and its Center for Health Action and Policy in New York (see end note) convened a Roundtable of patient activists, health care professionals (including physicians, nurses, social workers, and dietitians), health/food policy advocates, scientists, and community organizations to brainstorm about changing the focus in chronic kidney disease (CKD) away from the “renal diet” and toward “nutrition health.” The goals of the discussion were identification of the major issues/problems in renal nutrition, generation of pilot projects to improve nutrition health for individuals with kidney disease, and publication of reports on project outcomes. The consensus of the panel was that we need to move away from the negative and punitive connotations of a restrictive renal diet and instead educate patients about the reality that healthy food promotes kidney and overall health. We have to be realistic about what we can expect the patient and their family members to be able to do. We also have to be cognizant of the contextual factors of what they eat. We want to empower our patients to be advocates to take more responsibility for their own nutrition health through education and encouragement.

The renal diet—restricting sodium, potassium, phosphorus, and liquids—is complex and is certainly not easy to follow. While it has a sound basis in what we know about malfunctioning and failed kidney physiology, it contributes no value if patients cannot comply with it. In early CKD, patients are faced with conflicting recommendations about the dietary balance of protein and carbohydrates from their nephrologist and endocrinologist. And, of course, a low-sodium diet is nearly impossible to follow if a patient wants to eat outside the home or consume convenience foods. With progression of kidney disease and the initiation of dialysis, potassium and phosphorus restrictions are added. Adherence to a renal diet requires the patient to read and fully understand food labels; understand that “sodium” means “salt”; know exactly what a portion size in milligrams is; and do arithmetic to determine how much potassium, for example, is in a portion by multiplying portion weight by milligrams. Beyond that, he/she has to be able to look for one or more of the over 300 types of phosphate food additives. Still further, there are carbohydrates and sugar, saturated and unsaturated fats, and cholesterol, among other terms. It is like learning a new language!

New FDA food labels coming out over the next few years may offer some help. These labels will have more appropriate portion sizes and potassium quantification. But phosphorus additives remain in very small font and are not quantified. Patients will still have to do multiple calculations of portion size times milligrams (http://www.fda.gov/downloads/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/UCM501646.pdf).

Dietary commercial weight-loss programs have demonstrated through years of experience that a diet’s ease of use and lack of overly restrictive provisions are the keys to success. Empowering patients to learn how to make reasonable choices—through reading food labels, employing easy-to-use apps, and participating in support groups and chat rooms—has been critical to the success of programs. Some go so far as to prepare properly nutritious food for participants. But for the renal diet, we give patients lists, ask them to read labels, and focus on what not to eat.

Compounding the problem is the fact that physicians and caregivers often provide piecemeal information when patients are seen: “avoid salt” if the intradialytic weight gain is high; “avoid fruits and vegetables” if the potassium is high; “no dairy or cola” if the phosphorus is high. We physicians often focus on what not to eat and not enough on what to eat. Valuable office visit time is spent discussing diets, with limited time to fully understand the realities of what patients are eating. This leaves the patient confused, and sometimes with conflicting information as physicians usually do not have the time to help guide patients through the complexities of the renal diet.

Dieticians are trained to look at the overall diet and help patients individualize meal plans. Yet this important role of the dietician is undervalued in the dialysis industry, with a patient-to-dietitian ratio that does not always facilitate the education time needed for the patient to understand the complexities and dynamics of the renal diet goals. Further, Medicare mandates do not take into account the stages of change to ensure successes when patients are ready to improve their diet. Unfortunately, many patients with CKD stage 1–5 do not have access to a dietitian to provide education on healthy food choices to slow the progression of renal disease, and thereby delay the time to initiation of dialysis or prepare a patient for nutritional stability before transplant.

Given the complexities of the renal diet and a goal of improving nutrition health for patients with kidney disease, some have asked whether digital technology can help address the dietary problems faced by patients. In fact, over the past 5 years, apps designed to help patients with CKD navigate the complexities of the renal diet have appeared. But the current level of technology may be beyond the financial, educational, or generational norms for the preponderance of people with CKD or currently on dialysis.

On another front, new research demonstrates that fruits and vegetables help improve some metabolic complications of CKD and supports the notion that they may be as beneficial as pills of sodium bicarbonate in the prevention of the progression of kidney disease. This research supports the concept of good nutrition as positive medicine for renal patients and suggests that nephrologists should put more emphasis on nutrition as therapy. Still other research has demonstrated that not all forms of phosphate are equally absorbed so that naturally occurring phosphate in foods (legumes, nuts) can be eaten, while artificial phosphate additives in many foods contribute to high phosphorus levels. In other words, these studies indicate that patients should eat fresh foods, including fruits and vegetables, as opposed to processed foods.

Despite the progress, many obstacles remain. Health literacy levels remain low among many of our patients. Generalized recommendations for diet don’t make cultural sense to many patients, or point to ingredients that are not available to them. Still more patients on dialysis may live in “food deserts” where they simply do not have access to fresh produce or affordable foods. Knowledge of how to cook basic meals has been in decline. Further, patients on dialysis may miss meals owing to their hectic and long dialysis schedules and can feel so poorly after dialysis that the fast food “drive-thru” is more appealing than preparing a meal from scratch. Transportation issues may make shopping difficult and/or leave no time to eat or prepare a meal. Clearly broad-based, multisector efforts are needed to ameliorate the social, cultural, and medical challenges faced by patients with kidney disease.

The consensus at the summit sponsored by The Rogosin Institute was that we need to make the radical change from a focus on the renal diet to a focus on Good Food First, and the recognition that food is as critical as medications in the management of patients with CKD. In order to achieve this change, there must be an emphasis on the A, B, C, D’s of kidney nutrition health:

A. Access to affordable, fresh foods

B. Back to basics

C. Cooking: You can do it!

D. Deliver Information a patient can understand

In short, we need to make good food (and nutrition) cool, fun, funky, and fresh.

Putting nutrition in its proper place as a positive therapeutic tool in kidney diseases and making good nutrition attractive to the people we serve will require a multi-pronged approach. Many ideas were exchanged at The Rogosin Roundtable. Five overall goals were agreed upon:

 

Make nutrition health a priority by eliminating the negative connotations of the renal diet and by empowering people to make healthier food choices. This will require a broad-based, but targeted, outreach campaign through various media, including social media outlets, to change the focus in nutrition education curricula for kidney health providers and patients.

Explore, and perhaps endorse, the best of technology-based tools for nutrition management, ascertaining their relevance to the different subgroups of patients we serve and maintaining a high level of scrutiny for cultural meaning and appropriateness.

Increase access to fresh foods by activating and working with community leaders to bring fresh food to patients. For example, programs exist in many communities to bring unused but still healthy foods from restaurants to those in need. Why not bring food to the dialysis unit, where most patients are on fixed incomes? Many produce distributors or farmers would gladly donate surplus produce rather than discard it in the trash. Promoting farmers’ markets in communities has the potential to be yet another important effort in this regard.

Educate and encourage patients and their families to cook healthy, kidney-friendly, meals and to enjoy it while they are doing it. Among the possibilities are cooking demonstrations at dialysis units, development of patient-friendly, culturally relevant cookbooks, and provision of sample ingredients that a patient can purchase to prepare his/her own meal.

Promote policy changes at the national and state levels that promote better dietician-to-patient ratios (in CKD stages 1–5 as well as ESKD), improve reimbursement for SNAP benefits for kidney patients, insurance coverage for food post-hospitalization, and provide for mandatory phosphate quantitation on food labels. The latter is a prerequisite for a fully functional nutrition app to empower patients.

The road to optimal kidney nutrition health may ultimately be long and winding, but we need to begin to make the needed changes now for the sake of the well-being of our patients with both CKD and ESKD. It is time to put Good Food First with the A, B, C, D’s of kidney nutritional health.

End note

The Rogosin Institute is an independent, not-for-profit treatment and research center that has been providing care to patients for over five decades. Rogosin is affiliated with New York-Presbyterian Hospital, Weill Cornell Medical College, and is a member of New York-Presbyterian Healthcare System, Kidney Care Partners, and the Kidney Care Council. Rogosin provides patient-centered care for individuals with chronic diseases, including kidney disease, diabetes, hypertension, cholesterol or triglyceride disorders, and cancer. Having worked over the past 25 years with health promotion and basic health care in 30 countries around the world, The Institute is uniquely equipped to advance programs that prevent disease and to promote good health in underserved communities.

October/November 2016  (Vol 8, Issue 10/11)