6Nutrition plan and intervention Nutrition for CKDProteinPhosphorusPotassiumSodiumWaterEnergyThere are six main nutrients which play the important role for CKD patients, such as…
7(High biological value protein) Protein is an important nutrient that the body needs for growth and repair. Protein food source is meat, milk, egg, rice, grain, vegetable and fruit. Rice, grain, starch, vegetable and fruit contain low quality protein whereas meat, milk, egg and meat product contain high quality protein called high biological value protein which provide essential amino acids.Protein Digestibility Corrected Amino Acid Score (PDCAAS) is a method of evaluating the protein quality based on both the amino acid requirements of humans and their ability to digest it. High quality protein(High biological value protein)Low quality protein
8High biological value (HBV) protein intake > 50% of total protein intake per dayCKD patients need HBV protein intake at least 50% of total protein intake per day. However, dietitians should suggest patients to select the appropriate protein to prevent complications. For example, patients should avoid dairy products and egg yolk in case of hyperphosphatemia and avoid animal organs in case of hyperlipidemia and hyperuricemia.Remark: Select appropriate protein to prevent complications(Hyperphosphatemia, hyperlipidemia and hyperuricemia)Avoid dairy products and egg yolk HyperphosphatemiaAvoid animal organs Hyperlipidemia and hyperuricemia
9Protein = Meat 1 tablespoon Protein 3.5 grams These figures show food exchange of meat category. Meat 1 tablespoon provides 3.5 g protein. So meat 2 tablespoon equal to 1 egg or 2 eggs (only egg white) or four meat balls or 4 shrimps that provide 7 g protein and kcal.Meat 2 tablespoon = 1 egg = 2 eggs (only egg white)(Protein 7 g and energy kcal)
10Protein free starch====เส้นเซี่ยงไฮ้ 1 ทัพพีแป้งมัน 20 กรัมเส้นซาหริ่ม 1 ทัพพีสาคู 1 ทัพพีวุ้นเส้น 1 ทัพพีProtein restriction Protein free starch (70 kcal)Jelly noodle 1 ladle (40 g) = Rice 1 ladle (55g)Patients with protein restriction are recommended protein free starch which provide 70 kcal such as Salim, Sagu, jelly noodle or wunsen and Shianghai noodle. 1 ladle of these protein free starch products provide calorie equaled to rice 1 ladle.TapiocaThai sweetsShianghai noodle
11Menus from protein free starch These are menus from protein free starch. Spicy jelly noodle with seafood salad, Stirfry Shainghai noodle, Tapioca soup. Tapioca desserts.
12Reduced edema and blood pressure Slow progression of kidney disease SodiumSodium restrictionReduced edema and blood pressureSodium contain in salt and seasonings that have salty taste and also contain in Na compound food additives that have no salty taste. CKD patients need to restrict Na to reduce edema and blood pressure for slow progression of kidney disease.ลดเค็ม จริงๆหมายถึงลดการกินสารโซเดียม ซึ่งการลดการการกินโซเดียมนี้จะทำให้ความดันของเราลดลงและไตเสื่อมช้าลงSlow progression of kidney disease
14Sodium from natural food Control sodium 2,000 mg per dayMost patients need to eat less sodium than they ate before. Aim for less than 2,000 milligrams of sodium per day.2000 mg Na per day can divide into sodium from natural food 800 mg/day and sodium from seasoning 1200 mg per day which equal to 3 teaspoon of fish sauce.2000 เจอได้ที่ไหนบ้างมากจากธรรมชาติ เช่นโซเดียมในข้าว ปลา หมู ผัก ผลไม้ รวมทั้งวันที่เรากินจะได้โซเดียมประมาณ 800 มิลลิกรัมต่อวัน ดังนั้นเหลืออีก 1200 มิลลิกรัมต่อวันจึงเป็นโควต้าสำหรับเครื่องปรุงหรือเทียบเท่ากับน้ำปลา ประมาณ 3 ช้อนชาต่อวันSodium from seasoning1200 mg/daySodium from natural food800 mg/dayFish sauce3 teaspoons
15Sodium from seasoning 1200 mg/day QuantityNa (mg)Salt1 tsp2000Seasoning powder950MSG600Baking powder340Fish sauce, soy sauce,Seasoning sauce400Oyster sauce1 tbspChili sauce,Sweet and sour sauce220From this table, 1 tsp of salt contain 2000 mg sodium that higher than sodium allowance from seasoning. Seasoning powder and MSG also contain high Na. When I ask patients, most of them use these seasoning so we need to teach them how high Na they are and they need to manage sodium from seasoning within 1200 mg per day. For example, when they cook, they should not add any Na seasoning. Then, They measure 1 tsp of fish sauce and put in small bowl. They can dip spoon into fish sauce before they use that spoon to dish out foods to eat.Thai Dietetic Association
16Food Quantity Na (mg) Instant noodle 1 (60 g) 1,500 Instant congee 1,000Rice noodle with soup1 bowl1,800Rice noodle (no soup)785Fried rice/ noodle1 plate1,100Rice and curry1,090Thai Dietetic AssociationProcessed foods such as instant noodle and congee contain very high sodium. Rice noodle with soup contain higher Na than rice noodle without soup.From my work, I am quite surprised when I ask teenager CKD patients about their consumption behavior. Most of them eat very high sodium content per day about 2-3 times higher than recommendation. One of them told me that she ate instant foods every morning before she went to university. If she stay at her room, she eat more instant foods and canned foods because she was lazy to go out.
17Processed foods Dried foods Fermented foods CKD patietns should avoid to eat high Na food sources such as…Fermented foods
18Tips for lowering sodium intake Avoid to add salt seasoning2. Buy fresh foods and cook foods instead of eating processed/prepared foodsAvoid to add seasoningBuy fresh foods and cook foods instead of eating processed/prepared foods that are higher in sodiumอาหารที่ผ่านกระบวนการแปรรูปจะมีโซเดียมเพิ่มขึ้นจากเดิม 5-10 เท่า ดังนั้นเมื่อกินก็จะเสี่ยงต่อการได้รับสารโซเดียมเกิน
19Tips for lowering sodium intake Avoid to eat soupReduce to add sauceUse spices in place of salt3. Avoid to eat soup that is high in Na. If eat rice with curry, should separate curry in a bowl.4. Reduce to add sauce. For example, steamed chicken or red pork with rice always served with tasty sauce that high in Na.5. Use spices in place of salt to enhance flavorUse spices in place of saltหากรับประทานอาหารประเภทข้าวราดแกง แนะนำให้แยกแกงใส่ถ้วยเล็ก ไม่ราดบนข้าว และรับประทานน้ำซุปหรือน้ำแกงเพียงเล็กน้อย
20Potassium Fruit and vegetable K source Normal values of blood K 3.5 – 5.0 mEq/LHigh blood K level Irregular heart beat or heart attackK mainly found in fruit and vegetable. Normal values … If blood K level becomes higher than normal, it can cause irregular heart beat or heart attack.
21Stronger color Ripe and sweet Tuber crop High K source of fruit and vegetableStronger colorRipe and sweetTuber cropWe can notice high K source of Fruit and vegetable such as …
22Vegetable Low K Medium K High K (< 100 mg/100 g) (100-200 mg/100 g)
23Fruit Low K Medium K High K (< 100 mg/100 g) (100-200 mg/100 g) แอบเปิ้ล 1 ผลชมพู่เขียว 2 ผลกลางลิ้นจี่ 3 ผลใหญ่เงาะ 4 ผลกลาง
24Consumption of fruit and vegetable Normal K( mEq/L)Rotated fruit and vegetable consumption3-4 serving/dayHigh K( mEq/L)No consumption of high Kfruit and vegetableConsumption low/medium KPatient with normal blood K can rotate …Very high K(> 5.5 mEq/L)No consumption of fruitConsumption of low K vegetable
25Phosphorus Normal values of phosphorus 2.5-4.5 mg/dL High blood P Increased risk of osteoporosis and combined with Ca to form deposits in soft tissueP intake 800 – 1,200 mg/dayNormal values of phosphorus in blood is mg/dL. Extra P pull calcium out of bones increased risk of osteoporosis and combined with Ca to form deposits in soft tissue. P intake should be mg/day.
27High P food sources (cont.) 2. Egg yolk and egg york products
28High P food sources (cont.) 3. Bean, nut, grain and products
29High P food sources (cont.) Baking powder and yeast- added products 4. Proceed foodsBaking powder and yeast- added products
30High P food sources (cont.) Frozen foods and processed meat 4. Proceed foods (cont.)Frozen foods and processed meat
31High P food sources (cont.) Coffee, cocoa and soft drinks 4. Proceed foods (cont.)Coffee, cocoa and soft drinks
32P-to-Protein Ratio (mg/g) Phosphorus and protein content of food:FoodServing amountPhosphorus (mg)Protein (g)P-to-Protein Ratio (mg/g)Egg white1 large53.61.4Pork1 oz (28.35g)626.69.3Fish636.59.7Whole egg846.313.3Soybeans½ cup21114.314.7Soymilk240 ml1186.817.4Egg yolk652.622.8Milk2298.128.3Kalantar-Zadeh et.al. Clin J Am Soc Nephrol 5: , 2010
33Water Water intake (ml/day) No edema = ml (Insensible loss) + Urine volume 24 hrEdema = ml/dayVery edema = 300 ml/dayPt with no edema can have water intake from food and beverages calculated by 500 ml from insensible loss plus urine volume 24 hours. For pt with edema, physician will restrict water intake.