Treating Kidney Failure and Eating Healthy

II. Managing Your Special Diet

You will be able to get help with your diet from s dietitian who has specialized training in diets for kidney patients. This dietitian (called a renal, or kidney, dietitian) will offer you tips that make it easier to change your eating habits. Don't be shy about asking questions and telling the dietitian what foods you like and don't like. Eventually, between the two of you, you'll find a diet that's as satisfying as it is healthy.

The following section offers advice and helpful hints about following your special diet. No one expects you to follow all of these hints, or change what you eat overnight. For one thing, your kidney condition may not require it. For another, you aren't superhuman. Doctors and dietitians know that it takes time and practice to adjust your eating habits over the long term. But the payoff, as you'll soon find out, is more than worth the effort: You'll feel stronger, healthier and better when you follow your diet.

The "helpful hints" that follow are general, and may not apply to your individual needs. If you have special questions about your diet, be sure to ask your doctor and renal dietitian.

HINT #1: GET THE RIGHT AMOUNT OF PROTEIN
Protein is an important part of good health. It builds and repairs muscles and tissues, keeps skin healthy and protects the body from disease. Your dietitian will tell you how much protein you need to eat each day. This will depend on your stage of kidney disease and on your treatment. Lab tests will be done to check your protein intake (see Section X on “Monitoring Your Diet”).

If you need to add more protein to your diet and are having trouble eating the right amount each day:

Concentrate on high quality proteins, such as meat, eggs, fish, chicken and turkey.
Try chicken or fish if beef is not a favorite.
Add meat, chicken or fish to cold salads.
Add herbs and spices to your entrees, to enhance flavor.
If the smell of meat cooking turns you off, leave the kitchen while it's being prepared.
Try cold entrees instead.
Eat smaller amounts more often.
Use allowed gravy or sauce to moisten meat.
Identify the protein foods you think you could tolerate and ask your dietitian if these foods can be included in your meal plan.

HINT #2: KEEP FLUIDS LEVEL
When your kidneys don't work right, you can retain too much fluid in your body, causing a variety of problems--from breathing difficulties to swelling, to heart trouble. That's why it's so important to follow the fluid guidelines your dietitian gives you. Here are four daily routines that can help:

Watch Your Weight. Every day, at about the same time, step on the scale and jot down your weight. This will tell you three important things:

Your total weight. This includes your body weight (the weight of all the solid things in your body, such as bones, muscles and fat); and your fluid weight (the extra fluid retained in the body). Body weight is not only bones, muscles and fat...
Changes in your weight. You don't want to gain too much weight from day to day. By comparing what you weigh today with what you weighed yesterday, or earlier in the week, you can quickly find out whether you've gained or lost any weight. Your dietitian will tell you what is a reasonable weight gain between your dialysis treatments.
The kind of weight you've gained. If you notice a slow but steady gain in weight over the course of a week or so, you're probably gaining body weight, and may need to reduce calories. If the gain is sudden, however, it means your fluid weight is going up, because you're taking in too much fluid.

Check Your Skin. If it looks puffy or swollen, especially around your ankles, eyes or fingers, you're taking in too much fluid or salt. The extra amount of fluid is building up and moving beyond your blood vessels, into the tissues under your skin.
Check Your Blood Pressure. When fluid levels in your body get too high, your blood pressure begins to rise. By learning to take your own blood pressure reading (or having someone else take it for you) every day, you'll be able to notice any increases or decreases before they get serious. A higher-than-normal blood pressure may mean you're gaining too much fluid weight.
Evaluate What You Eat. Fluids don't just come in the form of water and beverages. Any food that contains liquid or is liquid at room temperature counts as a fluid. That includes ice cubes, gelatin, milk on cereal, and soup. Keep an eye out for these "hidden" sources of fluid, so you won't be "tricked" into taking in too much.

HINT #3: TAME YOUR THIRST
If you're having trouble sticking to your fluid limit because you're feeling thirsty:

Add a drop or two of peppermint oil or lemon juice to a small amount of water in a spray bottle and spritz your mouth now and then.
Eat frozen grapes and blueberries (in allowed amounts), to cool down a parched mouth.
Avoid foods that are high in sodium, such as table salt and foods with added salt like chips, luncheon meats, cured or smoked meats or fish, canned soups and vegetables, and TV dinners. Read labels for sodium content when shopping for food.
Ask your doctor about using products that can enhance saliva production such as chewing gum.
If you're on peritoneal dialysis, ask your doctor about using a dialysate with a lower concentration of sugar; if you're on hemodialysis, find out whether an adjustment in your treatment prescription would help.
If you have diabetes, make sure your blood sugar is under control.
Speak to your dietitian about using these tips. The dietitian may have other suggestions to help you control your thirst.

HINT #4: GET THE RIGHT AMOUNT OF CALORIES
Getting the right amount of calories from food each day is very important. Many hemodialysis patients have poor appetites, and they may not get enough calories. Many transplant and PD patients must limit calorie intake to offset the effects of their medications or dialysis prescription, and they may need to cut calories. Your dietitian can tell you how many calories you need each day and help you plan your diet to meet your needs. Following are some tips to help you reach and maintain a healthy weight.

If You Need to Cut Calories

Eat raw vegetables and fruits allowed in your meal plan.
Choose lean cuts of meat; eat chicken without the skin.
Use no-fat or low-fat dairy products, such as skim milk.
Switch from regular soft drinks to diet ones. (However, avoid cola drinks if you need to limit phosphorus.)
Avoid cooking or eating fried foods.
Use smaller amounts of high-fat spreads like mayonnaise.

If You Need to Add Calories

Make sure you eat something at every meal, even if you don't feel hungry.
If you do not have diabetes, add low-fat, high-sugar spreads--such as jelly, jam, honey or syrup--to your bread, biscuits, toast and pancakes.
Snack on sweets such as hard candy, gum drops, jelly beans and marshmallows.
Increase the use of mayonnaise-type salad dressings and heart-healthy fats, such as vegetable oils (e.g., corn, cottonseed, safflower, soybean, sunflower or olive oils).
Eat canned or frozen fruits in heavy syrup.
Drink regular non-cola soft drinks, or add sugar to beverages whenever you can.
Make an effort to prepare food that looks and smells appetizing.
Eat with other people whenever you can, to make dining more pleasant and enjoyable.
Identify some "comfort" foods--the kinds of foods your parents might have fed you when you were sick as a child and ask your dietitian if these foods are acceptable.
If cooking is a problem, ask a friend to help you prepare some meals ahead of time, so food is available when you are ready to eat.
Ask your dietitian to recommend a high-calorie, high-protein drink you can use if you just can't eat.
Read “How to Increase Calories When You Have Chronic Kidney Disease,” available from the National Kidney Foundation.

HINT #5: LEARN TO LIVE WITH LESS SODIUM
Most patients need sodium to restrict sodium in their diet. Sodium is found in large amounts in table salt and in foods that have added table salt, such as processed meats and lunch meats, most canned and frozen foods, condiments like catsup and mustard, salty seasonings and soy sauce, chips and pickles. Sodium makes you thirsty, and may tempt you to go overboard on fluids.

If you're like most people, a lot of the sodium you normally eat comes from processed foods. Fortunately, food companies are starting to lower the salt content of many popular offerings, such as canned soups and frozen dinners. These reduced sodium choices may not seem as tasty at first, but if you stick with them, your taste buds will adjust.

It also pays to learn to live with less salt when you're cooking and flavoring your own food. Here are some hints that will help:

When cooking, use less salt than the recipe calls for. Try not using any at all. Many foods, such as pasta, rice and hot cereals, taste the same whether they're cooked with salt or not.
Substitute the salt called for in recipes with herbs and spices. Avoid salt substitutes, however, since many contain potassium.
Whenever possible, buy fresh (rather than packaged) foods, since they're generally low in salt.
Avoid condiments such as catsup, steak sauce, barbecue sauce, soy sauce, relish, pickles and mustard, since they tend to be loaded with salt. Instead, use low-sodium substitutes, such as chopped onions, green peppers, lemon juice and spices.

HINT #6: KNOW WHICH FOODS ARE HIGH IN POTASSIUM
Too high or too low a level of potassium in your blood can be harmful to your heart. It is important to follow what your doctor tells you about how much potassium you may have. Potassium is found in nearly all foods. However, it is especially high in fruits and vegetables, including:

prunes, raisins and other dried fruits
cantaloupe and honeydew melons
potatoes
dark green, leafy vegetables such as spinach
oranges and nectarines
bananas
tomatoes
avocados
broccoli
winter squash
dried beans and peas
nuts and seeds

In addition to avoiding certain foods, you can also reduce the amount of potassium you eat by “leaching” your vegetables before you cook or eat them. This basically means peeling and cutting the vegetable thinly, and soaking it in water for several hours. Then, you discard the water and prepare the vegetables as you wish. You should also drain all liquids from canned vegetables or fruits before you use them.

HINT #7: WATCH YOUR PHOSPHORUS INTAKE
Phosphorus is found in almost all foods--some more than others. When your kidneys are not working well, phosphorus can build up in your blood. A high level of phosphorus causes calcium to be pulled from your bones. Over time, this causes bones to become weak and to break easily. Following a low-phosphours diet and taking medications called phosphate binders with your meals and snacks help to keep your phosphorus level under control. Some of the foods that are high in phosphorus include dairy products, dried beans and peas, nuts and seeds, whole grain products, dark cola drinks and chocolate. Ask your dietitian to help you create a daily meal plan that has the right amount of phosphorus. Also, see the NKF fact sheet “Phosphorus and Your CKD Diet.”

HINT #8: DON'T BE AFRAID TO EAT OUT

Once you become familiar with your special diet, you'll begin to see that eating out is still possible. It may even be helpful if you're having trouble working up an appetite. The key is to plan ahead--and order carefully. Here are some tips that will help:

When you know you'll be eating out at a restaurant or going to a social event with food, be careful to follow your diet before the event, so you'll know what you can eat when you're there. Or, before you go, ask your dietitian for advice on what to eat and what to avoid.
Choose the restaurant with care. Call ahead to find out what's on the menu, and whether or not the chef can handle special requests.
When you arrive at the restaurant, study the menu while waiting to be seated, so you'll have plenty of time to make the right choice.
Before ordering, ask your waitress or waiter how the foods you're interested in are prepared. See if changes can be made in a dish to meet your special needs (such as salad dressing gravies or sauces on the side, food cooked without salt or monosodium glutamate), sandwiches or burgers without cheese and mustard or catsup on the side.
Watch portion sizes. If your specific diet includes a protein restriction, you may want to request half portions of main dishes that contain meat, poultry, fish or cheese. You could share a main dish with a dinner companion or take part of your main dish home in a doggy bag.
Be aware that three ounces of cooked meat, fish or poultry is about the size of a deck of cards. Or, if you weigh meat portions at home, measure them against your hand to use as a guide when eating out.
Remember that protein is found in cheese and cream sauces; food prepared with milk, nuts and eggs; and in vegetarian dishes containing dried beans or lentils. Don’t forget to count this as part of your daily protein allowance.
Consider using a high-protein appetizer as a main course (e.g., chicken, pork or steak tostadas; crab cakes or steamed clams.)
Ask for substitutes. If the menu says French fries, and you're trying to keep potassium low, ask for rice or noodles instead. If the cooked vegetable is not a good choice for you, order a salad, or ask for a substitute vegetable.
Save your fluids throughout the day to allow more when you are eating out. Watch out for beverages with a high potassium and/or phosphorus content. The meal itself may contain more of these minerals than the food you normally eat at home.
Ask the waiter or waitress not to refill your water glass. Have the person remove it when you're done, to avoid temptation. If you still feel thirsty, ask for some lemon wedges or crushed ice to suck on. After the meal, have a stick of gum or a piece of hard candy if you are thirsty.
Choose salad. A salad bar is an excellent place to find vitamins, fiber, color and variety for your meal. Some good choices are: lettuce (all types), carrots, celery, cucumbers, onions, green peas, corn, beets, asparagus, green beans, radishes and gelatin salad with allowed fruits.
Ask for your salad dressing on the side, so you can use it sparingly. Or, bring your own low-sodium dressing. If all else fails, mix your own dressing using oil, vinegar or lemon juice and black pepper.
Remember to take your phosphate binder. Put the pills at your place when you sit down for the meal, or ask a companion to help you remember. You can also carry a pill box with an alarm to remind you. Or, place your medication in your wallet--so you'll see it when you pay.
For more tips, see “Dining Out With Confidence: A Guide for Kidney Patients,” available from the National Kidney Foundation.

WHAT'S ON THE MENU--FOR YOU?
To give you an idea of the many choices available to kidney patients who eat out, here are some sample menus to help you make the best choices. Your final selections, of course, must always be in line with your diet.

Breakfast

BETTER CHOICES:
___ eggs, cooked to order
___ omelets with low-potassium vegetables
___ toast, bagels, English muffins, croissants and plain or blueberry muffins
___ pancakes, waffles, French toast
___ margarine, jelly, honey , cinnamon, sugar and syrup
___ low-potassium fruits or juices such as applesauce or apple juice
___ hot or cold cereals
___ donuts, Danish pastry, sweet rolls and coffee cake

POOR CHOICES:
___ cured or salted meats or fish, ham, sausage, lox and Canadian bacon (Limit bacon to two strips occasionally.)
___ omelets with cheese or any of the above meats, fast-food breakfast sandwiches, breakfast burritos
___ biscuits and bran muffins
___ home fries or hash brown potatoes
___ real maple syrup or gravy
___ fruits and juices such as orange juice or a fresh grapefruit half
___ bran cereals and granola with nuts, seeds or wheat germ
___ pastries containing chocolate, nuts, coconut or caramel

Lunch and Dinner

BETTER CHOICES:
___ beef (broiled or grilled steaks, burgers without cheese, prime rib roast, hot roast beef sandwiches), chicken (baked, fried, grilled or roasted), leg of lamb, lamb chops, veal, meatloaf
___ fish or seafood (grilled, steamed or poached)
___ seafood or meat kabobs
___ fajitas, meat or chicken tacos (no cheese or tomatoes)
___ omelets with allowed vegetables and sauce served on the side
___ sandwiches (request no cheese), roast beef, chicken, egg, turkey, hot roast beef or turkey, fresh seafood sandwich

POOR CHOICES:
___ mixed dishes, beef or lamb stew, liver and onions, cured or salted meats (ham, corned beef, sausage, prosciutto, chorizo)
___ bouillabaisse, oysters, lobster Newburg, lox
___ sauces (especially cheese or tomato), gravies
___ bean dishes, chili beans, chili con carne
___ omelets with bacon, cheese, ham, sausage
___ submarine sandwiches, toasted cheese, BLT, bacon hamburger, Reuben, tuna (canned) salad

Dessert

BETTER CHOICES:
___ angel food, apple, lemon, pound, spice, white or yellow cake may be topped with whipped cream and low-potassium fruit
___ sugar cookies, Lorna Doones, vanilla wafers, lemon creme and butter cookies
___ fruit ice, sherbet, sorbet
___ Lower potassium fruit desserts (like berries, strawberry shortcake, gelatin desserts)
___ pies, tarts or cobblers made with apple, blueberry, cherry, lemon meringue, strawberry

POOR CHOICES:
___cakes rich in chocolate, coconut, dried fruit or nuts, such as carrot, chocolate mousse, devil’s food, fruit or German chocolate cake
___ brownies, chocolate, coconut macaroons, snickerdoodles
___ ice cream or frozen yogurt
___ fruits higher in potassium like bananas, oranges, kiwi
___ pies like banana cream, chocolate cream, coconut, minced meat, pecan, pumpkin, sweet potato or cheesecake

HINT #9: HELP YOURSELF RESIST TEMPTATION
You may have a strong urge to overeat or eat foods that aren't good for you when you're just easing into your special diet, or coping with depression over your kidney condition. But giving in can have serious consequences. Too much sodium from salty and processed foods can lead to thirst and fluid overload, for example. And eating too much of certain fruits and vegetables can raise your potassium levels higher than they should be.

The good news is, you can learn ways to resist. Here are a few:

Rather than reach for food when you're feeling depressed, reach for the phone instead. Call a friend or family member who can help you talk through your troubles.
If your life feels out of control because of your chronic kidney disease, remind yourself that you do have control over what you eat. Reward yourself for sticking with your diet.
Ask your dietitian to work with you to spot problem foods (the "bad-for-you" foods that you reach for when you need comfort)--and how to avoid them.
Don't bring foods you shouldn't eat into the house, the car or your work space.
Stock up on healthy snacks that fit into your diet. Keep a few acceptable "splurge" items in the house, like Mallow Bars or Seasoned Snack Mix. (See APPENDIX A for recipes.)
Talk yourself out of cheating. When you have an urge to eat something that is bad for you, ask yourself: Am I really hungry, or is something else bothering me?
Before you reach for forbidden food, try doing something else: Take a walk for 10 minutes, or pick up a book or current project.
Get involved in an exercise program that will improve your physical health, but check with your doctor first.
Remember, temptation is like a wave: It builds and builds to a crest, and then breaks and subsides. The better you get at riding the wave, the better you'll feel.

HINT #10: MODIFY RECIPES
Rather than try to change your eating habits overnight, focus on finding ways to keep your favorite foods on the “yes” list. For instance:

If the recipe calls for:	Use this instead:
Canned vegetables	Fresh or frozen vegetables; Low-sodium canned vegetables
High-potassium fresh fruits	Low-potassium fresh fruit, Lower potassium canned fruit with liquid drained before serving
Milk	Non-dairy substitutes (some are low in phosphorus)
Salt	Spices and herbs
Ice Cream	Sherbet or sorbet made from allowed fruits

HINT #11: READ FOOD LABELS

This is extremely important, since many foods aren't what they seem at first glance. Sometimes, labels may be incomplete or misleading. Labels will give you information on calories, fat, carbohydrate, protein and sodium. Most labels do not list potassium or phosphorus content. Ask your dietitian to explain the food label. Here are some tips to help you shop right. In general, look for food items with:

Nutrient:	Percent Daily Value:
Total fat	Under 20%
Saturated fats	Under 10%
Cholesterol	Less than 7%
Fiber	More than 10%
Sodium	Less than 6-10%
Potassium (if listed)	Less than 6%
Phosphorus (if listed)	Less than 5-15%

Look at certain foods and choose:

Food:	Look for:
Meats; lean and extra lean	Total fat 7.5-15%
Frozen meals	Sodium under 20%; total fat under 15%
Margarine and vegetable oils	Saturated fat under 10%
Deli meats	Total fat under 15%; sodium under 20%
Vegetables	Sodium under 6%

Ingredients to Avoid:
Banana, cheese, chocolate, cocoa, coconut, cream, dried fruit, dried peas and beans, lentils, melon, milk, molasses, nuts, orange, peanut butter, potassium chloride (KCl), potato, raisins, dark rye flour, frozen vegetables packed with sauce, spinach, tomato, wheat or oat bran, whole wheat. "Your Guide to the New Nutrition Food Label"

HINT #12: CONSULT OTHER RESOURCES
You may be surprised to learn that a number of really good cookbooks, meal planning guides, and even guides to dining out are available for kidney patients. These are great places to look for new recipes and other useful information, but they don't replace the advice of your dietitian. If you find some recipes that look interesting, ask your dietitian first, to make sure they fit your dietary goals. See APPENDIX D at the back of this book for a list of other resources.

Back to the previous Section

Back to the Table of Contents

Continue on to next Section