Time Saving Tips for Kidney Diet Planning

By Staci Hemesath, Board Certified Specialist in Renal Nutrition, Registered Dietitian

Time-Saving

The renal diet has lists. Lots and lots of lists. While they seem simple enough to dietitians, they are confusing and overwhelming to patients. Patients want menus. They want personalized advice. They want help. And they need it.

The problem is that most renal dietitians are covering multiple dialysis clinics over a large geographic area, and it has become increasingly difficult to provide individualized menus to patients, taking into account food preferences, budget, time, and dietary prescriptions. Yet, we are ultimately responsible for patients’ lab outcomes.

So, how can renal dietitians help patients plan kidney-friendly meals and navigate this intricate web of a diet, in the most efficient, effective way possible?

Here are some resources and tips you can share with your patients or use in your practice:  

  • Online Menu Planning Tools: One option is www.davita.com/diethelper , which provides customized meal plans from a database of over 1,000 recipes (If a patient isn’t Internet-savvy, offer to guide them through it, and provide printed copies of meal plans.)
  • Kidney Diet App:  Download on a Smartphone that will track daily intake (e.g. KidneyDiet)
  • Home-Delivered Meal Service:  Refer patients to a service that offers renal-friendly meals, such as Mom’s Meals NourishCare, which offers a renal dietitian-approved menu specially designed to support those with kidney disease.
  • Prepare Extra Food:  Prepare large batches of favorite kidney-friendly recipes and freeze leftovers for later use. Best to do on days when they have more energy.
  • Network with other kidney patients, either in person or online, and share meal planning strategies, recipes and even grocery store circulars with kidney-friendly sale items.
  • Cookbooks & Recipes: Recommend the purchase of a kidney-friendly cookbook and/or offer copies of tried and tested recipes in your office or dialysis clinic. You may even want to feature recipes during a sampling day.

Living with chronic kidney disease is an immense burden. Adhering to a strict diet is one of the most difficult aspects of the disease.  For most, it is a life or death matter. Helping our patients plan enjoyable menus and inspiring them to try new recipes or sign up for a renal-friendly meal service will not only enhance their quality of life, but it may actually save their life.

Should “Nutrition Reconciliation” Become a New Industry Standard?
nutrition beth

By Dr. Sam Beattie, Nutrition Services

In recent US News and World Report and Wall Street Journal articles, it was cited that over 50% of hospitalized elderly are malnourished.  The Academy of Nutrition and Dietetics and American Society for ASPEN American Society for Parenteral and Enteral Nutrition define malnutrition as “the presence of two or more of these conditions: Insufficient energy intake; Weight loss;Loss of muscle mass;Loss of subcutaneous fat;Localized or generalized edema;Decreased functional status including grip strength”.  The result is most likely what is called Protein Energy Malnutrition (PEM), which is the greatest concern and identified as a cause of complications in readmits.

At the recent American Society for Aging conference in San Diego, Beth Burrough and I presented a workshop on the concept of Nutrition Assessment andReconciliation. Basically stated, how to identify who is malnourished and how to get the right nutrition to remedy it.This phrase was coined by Drs. Preston Maring and Phillip Tuso of Kaiser Permanente and is somewhat analogous to Medication Reconciliation.  Medication Reconciliation is designed to ensure that a patient’s medication history is identified and addressed in the hospitalization process.

Nutrition Reconciliation is the process of identifying and addressing the nutritional status and needs of the patient throughout the hospitalization cycle (at admissions, during and post-discharge) to best support the patient’s recovery and ability to control their condition as prescribed by their medical team.  This involves a simple screening for malnourished patients at admission.  Those patients who are at-risk for malnutrition are then fully assessed to determine if they require nutritional intervention by means of meals, calories, oral supplementation or even more drastic feeding tube or other.  Once the “Nutrition Prescription” is identified in the hospital, the patient is monitored and assessed for malnutrition before discharge.

The “Nutrition Prescription” follows the patient though the hospitalization cycle and to home.  The basic steps are: 

  • STEP 1 — Identifying patients who require nutrition support
  • STEP 2 — Creating a custom “Nutrition Prescription”
  • STEP 3 — Helping patients fill the “Nutrition Prescription”

By identifying the malnourished patient either before or at admission, a nutrition prescription can be requested to address the basic needs of the patient while in the hospital.  By filling the prescription with enhanced nutrition support, the nutritional status of the patient can be improved or maintained.  This will result in shorter length of stay, reduction in the likelihood of being readmitted and/or being admitted to a Long Term Care facility and having a poor overall outcome from the hospitalization.  Of course, the nutrition prescription must follow the patient into the post-hospitalization period.  Providing adequate nutrition to patients after discharge has clearly shown benefits on the outcomes and a reduction in readmission.

The bottom line is that through Nutrition Reconciliation and a nutrition prescription, we can reduce the cost of hospitalization and improve the quality of life for many of our most fragile folks.  The cost of feeding people one meal per day is less than $200/month while the average daily cost for long term care is approximately $4,500/month and hospitalization is over $7,000/stay.  Easy access to healthy, disease specific, ready to heat and eat food matters for making people better, happier and creating major Medicaid savings.

What’s Missing from the Proposed FDA Nutrition Facts Label?

FDA logo

By Staci Hemesath, Board Certified Specialist in Renal Nutrition, Registered Dietitian

As a renal dietitian, I know how hard it is for patients to follow a renal diet. It’s certainly a tricky one. How many people even know what phosphorus is before suffering kidney failure? And then there is potassium, sodium, protein, and fluid. Oh, but let’s not forget carbohydrate, sugar, and fat, as many kidney patients also struggle with diabetes and heart disease. To make it even more complicated, phosphorus and potassium aren’t even listed on food labels.

This is why the FDA’s proposal to update the current nutrition label is welcome news to the kidney community. The new labels would include potassium, calcium, and added sugars, helping fill in missing pieces of the renal diet puzzle. Vitamin D, a beneficial nutrient for kidney patients, will also be listed. Phosphorus is not part of the proposal, but the National Kidney Foundation has stated they will rally for its inclusion. (Wouldn’t that be wonderful?)

Be Heard – FDA Encourages Public Comments for Proposed Label

The FDA is accepting comments from experts and members of the public until June 2, 2014 before making the final ruling. This is your chance to weigh in and be heard by the FDA.

Click here to submit your comments (look for blue “Comment Now” Buttons).

Renal diet prescriptions would certainly be easier for patients to follow if they knew how much potassium, calcium, and phosphorus were actually in the food they purchased. For many, this is a life or death matter. On behalf of the 26 million Americans with chronic kidney disease, let’s speak up and bring forth change.

fda labels 2

Malnourished and ICU Lead to Very Poor Outcomes

By Dr. Sam Beattie, Nutrition Services

icu

For several years, we have been writing about how malnutrition impacts hospitalization and is a leading co-factor in readmissions.  A white paper outlining the evidence for the importance of nutrition in transition from the hospital is available here.

Now there is more evidence that malnutrition creates negative outcomes post discharge.  A clinical study conducted by researchers at Brigham and Women’s Hospital evaluated the nutritional status of patients admitted to Intensive Care Units (ICU) and determined outcomes for those patients.

The study compared ICU outcomes for patients who were not malnourished upon admission, to those with either protein energy malnutrition (PEM) or nonspecific malnutrition.  This was a relatively large study with over 3000 patients who survived hospitalization and were discharged into their homes.

Findings showed ICU patients who were malnourished upon admittance to ICU were:

  • More likely to be readmitted within 30 days of discharge
  • More likely to die within 90 days of discharge

chart 104

In looking at the data, it is clear that PEM upon admission to ICU is a contributor to readmissions and mortality in discharged patients.  Importantly, the study also found that use of various drugs increased with malnourished patients.

The researchers underscored the importance of post-hospitalization nutrition.  The fact that we discharge patients without knowing if they have food at home is a concern and has been shown to be a contributing factor to readmissions and emergency department visits.

Currently, estimates are that readmissions in the Medicare populations are costing $15 billion every year.  Simply feeding people prior to admission and post discharge could go a long way to improving outcomes and reducing overall healthcare costs in the United States.

Mogensen K, et al. “The association of malnutrition and 30-day post discharge hospital readmission in ICU survivors: A registry based cohort study” SCCM 2013; Abstract 54.

Investigation: Sodium in Full-Service Restaurant Meals

By Dr. Sam Beattie, Nutrition Services

chicken and pasta

A recent article in the Journal of Nutrition Education and Behavior provides some startling information about restaurant foods.  The investigators analyzed the nutrient content of meals at full-service restaurant chains (as opposed to fast food restaurants).

As part of the Affordable Care Act, restaurants (full service or fast food) with more than 20 locations will be required to provide nutrition information.

The findings from the investigation were that, on the average, full-service restaurant meals are extremely high in sodium at over 3500 milligrams and high in calories at nearly 1500 per meal.

For comparison, the American Heart Association recommendations for sodium intake are 1500 to 2400 milligrams PER DAY.  But the average citizen consumes around 3400 milligrams each day, which is too much.

Further, the average citizen needs only 2000 calories PER DAY.  Eating a typical restaurant meal leaves only 500 calories for breakfast, lunch and snacks.

I read the article with some skepticism.  We see these “OMG” releases fairly frequently.  This one struck a note with me since the sodium was so high in the restaurant meals, with the average meal having over 4 times the recommended level of sodium per meal.

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I think that if it is necessary to eat at full-service chain restaurant or a fast food restaurant, I will pay very close attention to the nutrition facts and select those meals that are lower in sodium.

If you cannot cook your own meals, an alternative to eating out is finding restaurant-quality meals that meet your nutritional requirements, like those provided by Mom’s Meals.

Source: Nutritional Value of Meals at Full-service Restaurant Chains, Auchincloss,A., et al. Journal of Nutrition Education and Behavior Volume 46, Issue 1, Pages 75-81, January 2014

Over the river & through the woods to low sodium meals for Thanksgiving

low sodium thanksgiving

The last thing anyone wants to hear before Thanksgiving is diet advice.  But if you want to ensure a better chance that you’ll celebrate many more holiday seasons with your loved ones, consider cutting back on sodium, starting now.

Heart disease, cardiovascular disease, high blood pressure, stroke, and other heart-related ailments are America’s number one killer. 

A recent study conducted at the University of Michigan, showed that healthy eating habits can significantly reduce high blood pressure and improve heart function, even in heart failure patients.

“We all look forward to sharing a feast with those we love,” said Rick Anderson, president of Mom’s Meals.  “But that doesn’t mean we can lose sight of what’s most important to our health, especially if we want many more years with those gathered around the table.  Cutting back on salt, which hides in so many of our foods, is crucial.”

The Michigan study had patients only eat meals prepared for them in the kitchen of the university’s Clinical Research Unit, and according to the DASH (Dietary Approaches to Stop Hypertension) recommendations.  Meals were high in potassium, magnesium, calcium, and antioxidants, and low in sodium, with just 1,150 milligrams or less, far lower than the average intake of an American adult of 4,200 mg a day for men and 3,300 a day for women.

Most participants in the study were in their 60s and 70s.  

In the study, participants only ate the provided diet, which met the recommendations for high blood pressure treatment by the American Heart Association and the U.S. National Institutes of Health. After three weeks, they saw a drop in blood pressure, similar to that achieved by taking medication for the condition, suggesting that diet plays an important role in the progression of heart failure.

“It is interesting to note that a change was seen in only three weeks,” said Anderson.  “Our heart-healthy menu has meals with 600-mg or less of sodium, and feedback on their taste has been nothing less than stellar.”

Kidney disease and meals for kidney patients: What you don’t know, but need to.

Renal diet foods

Although this blog might buck the trend in terms of length, the topic is important, since about 45% of those over age 65 older have some chronic kidney disease (CKD) that, if untreated, could lead to “End Stage Kidney Disease” (ESRD) and the hemodialysis that accompanies this condition.

For many, simple changes in the way we eat can stop the progression of CKD. 

CKD is one of the most prevalent and expensive chronic conditions in the United States.  Approximately 26- million people have CKD and it is estimated that over 17% of the costs in the fee-for-service component of Medicare are for mild to moderate CKD related issues (2012 US Renal Data System).  If dialysis and kidney transplants (ESRD) are added to the total costs, almost 25% of Medicare expenditures are on CKD and ESRD. 

In the most basic sense, kidneys serve as a blood filtering organ.  Indeed, blood flow through the kidneys is one of the highest of all organs, with over 20% of blood flow from the heart going directly to them.  The kidneys serve to filter out wastes from daily metabolism and ingested foods, and in doing so, they help regulate and maintain a proper fluid and chemical balance to produce urine. 

During normal metabolism and health, kidneys operate with a large filtration rate (glomerular filtration rate, GFR) range.  At this level, kidneys are able to filter wastes including protein breakdown products and water.  The filtration rate of certain molecules (albumin or creatinine, which can be tested by simple blood tests) can be measured to estimate GFR.  As we age, GFR may decrease a bit. 

However, chronic kidney disease is recognized when GFR and the ability to filter out waste reaches a certain level that is below normal GFR. End stage renal disease (ESRD) is stage five, and usually means the kidneys are operating at less than 15% of normal GFR. 

The importance of nutrition in the development and progression of CKD is clear.  High blood pressure and diabetes are recognized as being the cause of two thirds of the cases of CKD as both put undue strain on kidneys.  In many cases these can both be controlled by an awareness of what and how much of certain foods should be consumed.

Typical ESRD patients require weekly hours of being hooked up to a dialysis machine, which literally filters the blood through a series of different devices.  I have heard dialysis being comparable to running a half marathon with the same amount of fatigue. 

In between dialysis session patients must keep their fluid intake, salt, and other mineral intakes low to avoid fluid buildup in the body.  As the fluid builds up in the body between dialysis sessions, fatigue and other issues may arise.  Excessive fluid buildup can impair heart and lung function and lead to death.

What can you do to prevent or slow kidney disease? 

Recommendations for prevention of diabetes and hypertension apply.  Eat a healthy diverse diet with fresh prepared meals, avoiding high salt, high fat processed foods, eat vegetables and fruits, and get some exercise – 30 minutes a day will do it. 

If you are diagnosed with CKD, the first step is to follow the advice of your doctor.  It might also be wise to consult with a Registered Dietitian well versed in renal nutrition.  While each stage of CKD has some specific nutrient requirements, diets in the earliest stages focus primarily on consumption of a normal, heart healthy diet. 

Recommendations for a renal friendly diet include consuming the amount of calories to that normally required for the level of activity, observing sodium and potassium intakes to keep within heart healthy guidelines, restricting the amount of phosphorus consumed and enjoy certain fruits and vegetables, grains, and likely restrict protein.  If you have high blood pressure, sodium intake levels are critical and must not exceed those recommended by your health providers. 

 

 

Heart Failure & Diet by Dr. Sam Beattie

Salt

A colleague had a chance to go to the Heart Failure Society of America conference recently held in Florida.

One of the most important talks he heard was about low sodium diets and how they impact heart function.

Dr. Scott Hummel of the University of Michigan and several colleagues reported on patients that were fed the D.A.S.H. diet for 21 days.  (The DASH diet refers to the Dietary Approaches to Stop Hypertension diet, which is a diet that controls sodium intake to less than 2300 mg/day and is recommended by the National Institutes of Health to reduce high blood pressure.)  It has been shown in many studies to effectively reduce blood pressure in pre- and hypertensive individuals.

In the study reported by Dr. Hummel, the 13 patients that were given the DASH diet showed significant positive changes to heart function within 21 days of being on the diet.

Improvements included an increase in how much blood was being pumped into the arteries and less wear and tear on the heart.  The patients were all in their 60s and 70s and food was provided to them.  Diet can make a difference in certain chronic conditions, including heart failure.

The incidence of chronic conditions in the aging population is growing, as is the cost to treat the symptoms of these chronic conditions.  Heart disease and hypertension can be treated by drugs, however while these may be effective, they are also expensive.

Diets such as DASH can reduce the need for certain drugs and thereby reduce the overall expenditure on healthcare.

And after all, wouldn’t you rather eat your way to better health rather than taking pills?

Cost of Diabetes screams “Houston, we have a problem!”

diabetes

I had a chance to attend the annual FNCE meeting of the Academy of Nutrition and Dietetics in Houston this week.  Wow, what a lot of information on hot topics in nutrition!

A  very interesting session was on ways to get people, and more importantly, decision makers, to listen to information about diabetes.

Did you know that seven million Americans have diabetes and an astounding 79 million have pre-diabetes, which if not addressed, will progress to full blown diabetes?

An interesting fact is that one in three children born in the first decade of the 2000s will get diabetes in adulthood.  Incredible.

What’s more incredible are the healthcare costs associated with diabetes. 

A patient with diabetes has nearly double the healthcare costs of a patient without diabetes. 

One speaker, Lisel Loy, brought this to our attention with the comment, “we have a huge problem,” yet it is one that is almost entirely preventable. 

If current rates of obesity continue, diabetes rates will continue to climb.

The solution is relatively simple.  Lose 7-10% of your overweight body mass and exercise for 150 minutes per week. 

Losing weight is difficult but can be done if one makes healthier choices in eating.  Instead of fast fat food, try a home-style meal, prepared and delivered fresh to your door.  

Sam Beattie, PhD / Director of Nutritional and Technical Services

Preventing falls is crucial for senior health

grab bar

The health of those we love, especially as they age, is of primary concern.

Believe it or not, falls are the second leading cause of accidental death in the U.S., yet they are an often overlooked problem for seniors. Seventy-five percent of all falls occur in the senior population and statistics show that falls can lead to significant health declines.

Falls are the most common cause of hospital admission for trauma, and the most common cause of injury amongst seniors. Hospitalization due to falls occurs five times as much as from any other cause of injury. It should come as no surprise that the majority of falls occur in two rooms of the house; the bathroom and the kitchen.

Mom’s Meals provides tips for how to prevent falls, allowing seniors a higher quality of life:

  1. Eliminate household hazard like hard to see steps and throw rugs, which can be the cause of a majority of falls.  Seniors should eliminate throw rugs, or make sure they are securely in place so that they do not slide or move, causing an obstacle.
  2. Meal preparation can be particularly precarious, as water or oil may splatter, leaving the floor slippery.  Making the kitchen a more efficient workspace can help reduce falls but when food preparation becomes too hazardous, consider having nutritious meals delivered from Mom’s Meals.  Meals only need to be heated and served, eliminating extra hazards in the kitchen.
  3. Make the bathroom safer with grab bars and non-slip mats. Adding hand rails, non-slip surfaces, grab bars, and even going as far as changing out tubs to allow for entry without having to step over a barrier is very helpful. Permanent grab bars should be installed by the shower, toilet and tub.  Shower seats can be very helpful, as well as adding good lighting and non-skid mats.
  4. Make walkways safer. Clear clutter and other hazards that could cause a trip and fall.  Stairs, walking paths, and hallways in the home should be well lit so that seniors can traverse them without peril, especially at night.
  5. Wear well-fitting shoes and clothes. Shoes that are too big, bathrobes or night wear that drags, pants that are too long, etc. can all lead to tripping, slipping, and falling. Consider wearing fitted slippers with a non-slip sole during the day, and choosing clothing that does not drag on the ground.