Chronic Kidney Disease
The Foodsmart CKD Nutrition Management Program is an evidence-based comprehensive lifestyle intervention program that incorporates Medical Nutrition Therapy and Motivational Interviewing techniques to promote changes to food intake, exercise, and lifestyle behaviors to reduce the progression of CKD. This 12-session program is delivered by an RDN over three to six months. Upon completion of the 12-session program, patients are encouraged to schedule monthly follow up visits to improve accountability and progress; or enroll in another program (cardiovascular, diabetes, weight management) to further reduce their risk of disease progression and related comorbidities.
Expected outcomes upon completion of this program include maintaining or improvement in GFR, improvements in diet quality in line with a whole-food, plant-based diet, as well as improvements in A1c and blood pressure for those with diabetes and/or hypertension. These results may lead to slowed progression of kidney failure, decreased hospitalizations, and decreased complications related to comorbidities.
Introduction Script
Welcome to Chronic Kidney Disease! My name is <YOUR NAME>, I’m a Registered Dietitian <INCLUDE OTHER RELEVANT CREDENTIALS>. I am so excited to be working with you.
We are pleased you have decided to join the Foodsmart Chronic Kidney Disease Program. Our program focuses on helping you make sustainable lifestyle changes with the help of a Registered Dietitian Nutritionist (RDN). There are no gimmicks or special rules. Your individual and personalized meetings with your RDN will help you make the changes you need to make to meet your health goals by helping you improve your eating habits, health behaviors, and confidence to maintain all of the changes you make.
Healthy lifestyle changes take time; this is why our unique program takes three months to complete. Over this time, you will discover what works for you, and you will get assistance in setting and tracking goals that you can meet.
Many of our participants report that one of the greatest benefits of getting to meet with their dietitian so often is that it helps them stay accountable. During our program, you can expect to see overall improvements in areas such as BUN, creatinine, GFR, blood pressure readings, and other labs. We also teach you strategies for maintaining these improvements and build confidence in choosing a kidney-friendly lifestyle.
At the end of our twelve sessions we’ll talk about ways to give you ongoing support, whether it’s through additional work together or other resources that are helpful for you.
Are you ready to get started? What questions do you have for me about my background, or chronic kidney disease?
Welcome to Chronic Kidney Disease Program!
Congratulations on your decision to work on your health goals!
We are pleased you have decided to join the Foodsmart Chronic Kidney Disease Program. Our program focuses on helping you make sustainable lifestyle changes with the help of a Registered Dietitian Nutritionist (RDN). There are no gimmicks or special rules. Your individual and personalized meetings with your RDN will help you make the changes you need to make to meet your health goals by helping you improve your eating habits, health behaviors, and confidence to maintain all of the changes you make.
Healthy lifestyle changes take time; this is why our unique program takes three months to complete. Over this time, you will discover what works for you, and you will get assistance in setting and tracking goals that you can meet.
Many of our participants report that one of the greatest benefits of getting to meet with their dietitian so often is that it helps them stay accountable. During our program, you can expect to see overall improvements in areas such as BUN, creatinine, GFR, blood pressure readings, and other labs. We also teach you strategies for maintaining these improvements and build confidence in choosing a kidney-friendly lifestyle.
Again, congratulations on your decision to join our program!
Goals & Objectives
Lesson/Visit Objective
After completing this curriculum, participants will
Be able to list nutrients of concern in CKD and sources of these nutrients.
Have improvement in at least 2 nutrition-related metrics within 6 months (BP, potassium, phosphorus, A1c, GFR, creatinine, BUN) thus prevent or slow the progression of their CKD.
Feel confident in their ability to choose kidney-friendly foods and consume a healthy diet.
2. Considerations
What can the participant hope to achieve after completing this curriculum?
Participants will maintain or increase GFR within 6 months as this has been shown to prevent or improve metabolic acidosis, which evidence shows slows the progression from CKD to ESRD. Will assess lab testing done by a nephrologist.
Participants will improve dietary intake quality in line with recommendations for a whole-food plant based diet for kidney disease management which is associated with lower mortality. Overall diet quality will be assessed through NutriQuiz results every 3 months
Participants with hypertension will have a decrease in blood pressure as this slows disease progression and reduces risk of cardiovascular disease. Will assess blood pressure monitoring, decrease in BP medications.
Participants with diabetes will have a decrease in HbA1c within 6 months, which has shown to slow progression of CKD. Lab testing will be done every 3 months; will assess decreases in insulin/other diabetes medications.
3. Outcomes to consider
Anthropometrics: weight change, change in labs (decrease in BUN/Creat, increase in GFR potassium WNL, phosphorus WNL, calcium WNL, Vitamin D WNL, A1c, Trig), improvement in blood pressure
Diet recall: increase in whole food options, decrease in nutrients of concern (potassium, phosphorus, sodium), increase nutrients of concern (protein, calcium)
Subjective/reported symptoms: regular bowel movements, increased appetite, increased energy, improved taste, decreased nausea; decrease in dose of medications (insulin, BP meds, etc)
Quality of life: decreased risk of developing ESRD, increased confidence in chronic disease management and positive outlook on life
Week-by-week (or visit-by-visit) Outline
Week 1: Introduction to CKD
Describe what CKD is, the role healthy kidneys play in your body, and what the curriculum entails. Conduct nutrition assessment, take and review NutriQuiz. Assess patient knowledge of kidney diet. Familiarize patient with the nutrition label and inform them that we will refer to it throughout the program.
Metrics: height, weight, renal labs, blood pressure. Remind pt to upload lab results to the patient portal. Encourage lab draws at a minimum every 3 months. Review medication dose changes (insulin, BP meds, phosphate binders, vitamin D (ergocalciferol and cholecalciferol))
Week 2: Understanding Your Lab Results
Learn what your lab results mean and how your diet can influence the numbers, then work with your RD to prioritize areas of focus. (Utilize KDOQI guidelines for reference ranges or reference ranges provided by patient’s nephrologist if available)
Provide patient with handout explaining goal ranges
Metrics: Review labs, meds, BP, weight
*Week 3: Protein: How Much and What Type
Learn how much protein you need, the roles protein plays in the body, and discuss sources of protein.
Metrics: Review labs, meds, BP, weight
*Week 4: Stabilize Your Potassium
As your kidney function declines, you may also need to limit your potassium intake. Learn about sources and your recommended intake.
Metrics: Review labs, meds, BP, weight
*Week 5: Phosphorus and Your Bones
As your kidney function decreases, you may need to watch phosphorus intake. Learn where to find phosphorus and how to limit your intake. We will discuss organic vs inorganic phosphorus and phosphate binders.
Metrics: Review labs, meds, BP, weight
Week 6: Controlling your Blood Pressure
Learn how to manage your blood pressure to prevent further kidney damage through dietary management. Discuss sodium and fluid, as well as how elevated blood pressure can lead to ESRD.
Metrics: Review labs, meds, BP, weight
Week 7: Managing Heart Disease and Diabetes
This lesson goes more in-depth on carbohydrate, fat and cholesterol intake to help slow your kidney disease progression
Metrics: Review labs, meds, BP, weight
Week 8: Safe Supplementation for CKD
Discuss vitamins, minerals and herbal supplementation- what’s safe and what to avoid; what to look for when shopping.
Metrics: Review labs, meds, BP, weight
Week 9: Physical Activity
Learn how to incorporate movement into your lifestyle without causing further damage to the kidneys.
Metrics: Review labs, meds, BP, weight
Week 10: Shop Smart
Eating healthy for CKD doesn’t have to be stressful- learn how to plan meals and grocery shop using the Foodsmart App; as well as read food labels to identify key nutrients like phosphorus, potassium and sodium.
Metrics: Review labs, meds, BP, weight
Week 11: Eating Out with CKD
Feel confident eating out after you learn what to look for on the menu and simple swaps to fit your needs.
Metrics: Review labs, meds, BP, weight
Week 12: Putting It All Together: Adopting a Whole Food Plant Based Diet
Understand the benefits of a WFPB diet for CKD, what foods are included and potential supplementation.
Metrics: Review labs, meds, BP, weight
CKD is a chronic disease. You’ve learned and put into practice all the steps to slow, or even reverse its progression. What happens next?
Sign up for visits with your RD every 1-3 months for continued accountability and maintenance.
Weeks annotated with a * can be be done in any order based on priority of labs set in week 2
Week 1: Introduction to CKD
Lesson/Visit Objective:
By the end of this lesson:
Participant will be able to state the most common causes of kidney disease.
Participant will set a personal, initial nutrition goal to achieve within 4- 6 months.
Baseline data that should have been collected and reviewed prior to first session:
Lab report including GFR, BUN, Creatinine, potassium, A1c, glucose, phosphorus
Handouts to be used for this session
Content discussion and overview:
Gather information from patient regarding their kidney disease and knowledge of the condition. See if they know what stage they are at and if they know the cause of their kidney disease.
Ask patient what their main goal is for the CKD. Do they want to slow progression of CKD, prevent onset of ESRD, pursue kidney transplant? They may have a variety of reasons.
Note: Some patients may have more knowledge of their kidney disease while others may be brand new to it and have little to no understanding of their disease. If a patient has very little understanding, inform them that you will work with them to help them make healthy dietary choices to best manage their condition.
3. Validate your patients’ reasons for seeking nutrition help and give them confidence their goal can be reached. It takes an individualized approach, but the steps in this program touch on a variety of CKD management options.
4. Complete nutrition assessment and health history. Important data to capture include current weight, height, GFR, BUN, Creatinine, glucose, A1c, potassium, sodium, phosphorus, vitamin D, and any other labs the patient has available. .
Document pertinent medications (BP medications, ACE-inhibitors, ARBS, metformin, insulin)
Specifically ask about conditions that put pt at increased risk of CKD/ESRD: diabetes, hypertension, acute kidney injury, cardiovascular disease
Document any symptoms/complaints the patient may have.
*Note: many of these items may have been obtained in your initial assessment
5. Discuss CKD using handout. Explain to the patient that it is important to be aware of the functions of healthy kidneys.
Review the functions of the kidneys and explain that CKD may inhibit some of these functions from performing properly.
Produce urine
Remove waste and excess water from blood
Control the body’s chemical balance
Regulate blood pressure
Keep your bones healthy
Make red blood cells
Explain that Diabetes and Hypertension are the most common causes of CKD but that there are many other potential causes as well.
Explain signs of progressing CKD and importance of going to your doctor if you notice any of these signs: swollen ankles/lower legs, fatigue, decreased appetite, difficulty focusing, foamy urine.
Review the “Golden Rules” to reduce your risk: Keep fit, be active; Eat a healthy diet; Check and control you blood sugar; Check and control your blood pressure; Take appropriate fluid intake; Don’t smoke; Don’t take over-the-counter pain killers/anti-inflammatories regularly; Follow-up with your doctor regularly for testing. Explain to patient that throughout this program, we will cover many of these topics as well as others.
6. Have patient take NutriQuiz and review results. If pt has not registered for the Foodsmart app, you can have the patient take the NutriQuiz as homework and review at the beginning of their next session.
7. Ask the patient to identify one long-term goal that they wish to achieve in the next 4-6 months. This should be related to their kidney health but can be broad to include increasing GFR, improving certain kidney related labs, incorporating more physical activity, improving blood pressure or blood sugar control, or something else. If the patient is unsure, you can gently guide them based on what you learned during your intake assessment.
8. Wrap up session by again congratulating patient on their decision to improve health. Remind patient to bring any new lab results to their next appointment. Schedule session 2 appointment at a one-or-two week interval.
Note: Sessions are recommended to be scheduled every one-to-two weeks apart.
Week 2: Understanding Your Lab Results
Lesson/Visit Objective:
By the end of this lesson:
Participant will become familiar with important labs for CKD and how nutrition can help manage them
Participants will be able to read their lab report and understand the results.
Participants will prioritize dietary areas of focus based on their lab results.
Patient Handouts to be used for this session.
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
2. Ask patient for any new labs. Document results
Document any changes in kidney disease management (meds, weight,recommendations from doctor).
If needed, review NutriQuiz results with patient.
Introduce patient to the Kidney Test Results Handout. Review each lab and potential causes/implications for high/low results. Compare with the patient's labs. Below are some key labs to make sure to touch on. As time allows, you can also review cholesterol, hemoglobin, bicarbonate and albumin.
eGFR: use this handout to explain what eGFR means and how to determine the stage of kidney failure. Explain to patient that symptoms of kidney failure are likely not noticeable in the early stages of kidney disease. As kidney disease gets worse, eGFR decreases. Make sure to verify with patient which stage of kidney failure they are in. If their doctor has not told them, use the eGFR chart to determine.
Creatinine: as kidney failure worsens, creatinine increases. Creatinine is a normal waste product that builds up in the blood from using muscles. This test is used to tell how well your kidneys are working. Normal range is 0.6-1.2 mg/dL in males and 0.5-1.1 mg/dL in females; 2-15 mg/dL in CKD depending on eGFR and muscle mass.
BUN or Blood Urea Nitrogen: BUN is a waste product from digestive processes and tells how well your kidneys are removing waste. Higher levels mean your kidneys are not removing enough waste. Normal range is 10-20 mg/dL, typically elevated in CKD.
Potassium: 3.5-5.0 mEq/L
Phosphorus: 3.0-4.5 mg/dL
Calcium: 9.0-10.5 mg/dL, avoid sustained levels above normal
PTH or Parathyroid Hormone: KDIGO recommends 2-9 times the upper normal limit (10-65 pg/mL is normal)
Vitamin D: measured as 25-Hydroxy-cholecalciferol, >20 ng/mL
A1c: ~7% or less
Other tests your provider may conduct include urine tests. Specifically, they may be looking for protein in the urine. If you have high amounts of protein in your urine, this may indicate that you need a protein restricted diet.
Ask the patient if they have any questions about lab tests or need clarification.
Encourage patient to set a new goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
Wrap up session. Schedule appointment for session 4 at a one-to- two-week interval.
Week 3: Protein: How Much and What Type
Lesson/Visit Objective:
By the end of this lesson:
Participant will understand the difference between plant and animal protein sources
Participant will understand the roles protein play in the body and why protein restriction may be necessary.
Participant will be able to verbalize their recommended daily protein intake and methods to meet their goal.
Patient Handouts to be used for this session.
https://www.jrnjournal.org/article/S1051-2276(20)30082-0/pdf (handout at end of article)
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
2. Ask patient for any new labs. Document results
3. Document any changes in kidney disease management (meds, weight,recommendations from doctor).
4. New topic introduction: Today’s focus is on protein. I’d first like to get a sense of what you already know about protein and CKD. Has your doctor given you any recommendations? Are you familiar with sources of protein?
5. Why is protein important? Protein provides the building blocks to build and repair muscles, organs, and other parts of the body. However, when we eat protein, it produces waste. One of the kidneys jobs is to remove excess waste. When we eat high amounts of protein when we have CKD, our bodies have to work harder to remove the excess waste.
6. Plant sources need to be combined to provide all the building blocks your body needs. Calculate your patient’s daily protein needs. Per the KDOQI Guidelines:
CKD stage 3-5 w/o diabetes: 0.55-0.6 g/kg BW
CKD stage 3-5 w/ diabetes: 0.6-0.8 g/kg BW*Note: Patients on a low protein diet are at risk for protein-calorie malnutrition. Make sure you continue to monitor their weight, and total intake, make adjustments to calories and protein as appropriate.
7. Explain the difference between plant and animal sources.
Animal sources provide all of the amino acids, or building blocks, your body needs.
Plant sources of protein need to be combined to provide all of the building blocks our bodies need.
8. Explain how a whole-food, plant-based diet is shown to reduce progression of kidney disease to kidney failure compared to a diet that includes animal protein sources. Handout
Plant protein sources are naturally lower in protein, making it easier to reduce your protein intake.
Eating more plants decreases inflammation due to the high levels of antioxidants and phytochemicals.
Plant protein creates less toxins than animal protein, allowing your kidneys to rest some.
Switching animal protein out for plant protein reduces protein in the urine (proteinuria)
Plant protein has less absorbable phosphorus compared to animal protein.
9. Discuss foods to limit/avoid when choosing plant-based foods: imitation meats, vegan meats, overly processed meats like deli meat, hotdogs, sausages, cured meats, etc.
10. Review portion sizes of protein with patients using this handout
11. Encourage patient to set a new goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
12. Wrap up session. Schedule appointment for session 4 at a one-to- two-week interval.
Week 4: Stabilize Your Potassium
Lesson/Visit Objective:
By the end of this lesson:
Participant will become familiar with dietary sources of potassium
Participant will be able to list risk of high potassium levels
Patient Handouts to be used for this session:
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Ask patient for any new labs. Document results
Document any changes in kidney disease management (meds, weight,recommendations from doctor).
New topic introduction: Today’s focus is on potassium. Open the discussion by having the patient identify their current potassium level and if it is high, low or within range (3.5-5.0 mEq/L). Praise patient for being aware of their lab results.
Discuss the importance of maintaining normal potassium levels. Healthy kidneys are responsible for removing potassium from the blood. Explain to the patient that their kidneys are not working at full capacity so they may not be able to remove all excess potassium. Too high or too low of potassium levels can cause heart and muscle problems, potentially as serious as a heart attack.
Explain that what we eat and drink impacts our potassium levels. We can maintain normal potassium levels by watching what we eat. Review dietary sources of potassium (handout) and non-dietary sources (constipation, medications, seasonings like salt substitutes).
Have patient identify if they need to reduce or increase their potassium intake based on their lab results. Remember, normal lab ranges for potassium in CKD are 3.5-5.0 mEq/L.
If the patient needs to reduce their potassium intake, ask them to identify sources of potassium they regularly consume. Once the patient has identified these foods, ask them if there are any they would like to switch out. Remind the patient that we will re-evaluate their potassium intake with any new lab results they receive.
If the patient needs to increase their potassium, ask the patient to list 3-5 high potassium foods they enjoy. Once the patient identifies these foods, remind them to start slow, with 1-2 servings of high potassium foods a day. Remind them we will re-evaluate their potassium intake with any new lab results they receive.
Encourage patient to set a new goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
9. Wrap up session. Schedule appointment for session 5 at a one-to- two-week interval.
Week 5: Phosphorus and your Bones
Lesson/Visit Objective:
By the end of this lesson:
Participant will be able to identify sources of phosphorus
Participant will be able to find sources of phosphorus on the food label
Participant will be able to state the difference between organic and inorganic phosphorus.
Patient Handouts to be used for this session:
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today’s focus is on phosphorus. Explain that similarly to potassium, phosphorus is normally removed from the blood by healthy kidneys. Remember that normal phosphorus lab ranges are 3.0-4.5 mg/dL. Phosphorus is important for bone health, as well as keeping blood vessels and muscles working correctly. Because of your CKD, the kidneys can have difficulty removing phosphorus from the blood. Too much phosphorus in our blood can weaken the bones, causing them to be brittle and break. Too much phosphorus can also lead to bone and joint pain, and itchy skin.
6. Discuss sources of phosphorus. Phosphorus comes in two forms- organic, or naturally occurring, and inorganic. Organic sources are not as easily absorbed by our bodies, especially if it’s coming from plant sources. Sources of organic phosphorus include whole grains, meats, dairy products, nuts, seeds, beans. Inorganic phosphorus is typically found in the form of phosphate additives in food and is much more easily absorbed by the body. Common sources of inorganic phosphorus are processed foods, fast food and convenience foods.
*Emphasize that organic phosphorus will not be found on the food label, while inorganic phosphorus can likely be found on the food label under the ingredients section.
*Review handout with phosphorus containing foods
7. Review common sources of phosphorus additives to look for on the food label.
Dicalcium phosphate
Disodium phosphate
Monosodium phosphate
Phosphoric acid
Sodium hexameta-phosphate
Sodium tripolyphosphate
Tetrasodium pyrophosphate
Trisodium phosphate
8. Discuss Phosphate binders. Ask the patient if they are taking a phosphate binder. Common binders include calcium acetate, Renvela, Renagel, Sevelamer, Auryxia, Velphoro, and sometimes Tums. Not all patients will need to be on one.
If the patient is not on a binder, you can briefly explain that binders are a medication that is taken with meals to help absorb excess phosphorus in the diet. These are only needed if your phosphorus lab level is elevated.
Explain that binders work like a sponge in the stomach. When taken with food, they soak up, or absorb, the phosphorus. That excess phosphorus is then excreted through the stool.
9. Encourage patient to set a new behavioral goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
10. Wrap up session. Schedule appointment for session 6 at a two-week interval.
Week 6: Controlling Your Blood Pressure
Lesson/Visit Objective:
By the end of this lesson:
1. Participant will be able to state recommended daily sodium intake
2. Participant will be able to identify dietary sources of sodium
3. Participant will be able to identify methods to decrease sodium intake in their diet.
Patient Handouts to be used for this session:
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
New topic introduction: Today I would like to talk about blood pressure management and sodium. Tell me a little about your blood pressure management. NOTE: Patient may or may not have hypertension. Answers may vary from regularly checking blood pressure, taking blood pressure medications, working on dietary and lifestyle changes, or no current intervention plan.
Explain that hypertension is one of the leading causes of kidney disease. Controlling blood pressure now is important in slowing the progression to kidney failure. Limiting sodium intake is an important part of blood pressure management. When you consume high amounts of sodium, your body holds on to excess fluid. Retaining fluid leads to high blood pressure and swelling, which puts stress on your kidneys and heart.
What should your blood pressure goal be? The National Kidney Foundation recommends that individuals with diabetes and hypertension keep their blood pressure below 130/80. Have patient ask their doctor for a specific blood pressure goal if they have not already provided you with one. https://www.kidney.org/news/newsroom/factsheets/Diabetes-And-CKD
How much sodium do you need? Explain that the U.S Food and Drug Administration recommends adults limit daily intake to no more than 2,300mg a day. As a clinician, use your professional judgment to determine if the patient requires a greater restriction.
Discuss sources of sodium. Sodium is found in many canned foods like vegetables and soups; some frozen foods, especially frozen dinners; snack foods like chips and crackers; processed meats; and seasonings and sauces.
Discuss dietary interventions to lower sodium intake.
When possible choose fresh, frozen or canned produce with no added salt or low sodium.
If choosing canned foods with sodium, drain and rinse them to remove excess sodium.
Choose unprocessed meat rather than processed
Cook from scratch more frequently
Use spices and herbs for seasoning rather than salt. Mrs DASH is a great low sodium seasoning.
Explore other alternatives to seasoning like lemon juice, peppers, onions.
Read labels and look for “low sodium” or “no added salt” or “salt free”
Limit the amount of packaged, processed and fast foods you eat.
*NOTE: Avoid salt substitutes as many replace salt with potassium.
11. Encourage patient to set a new behavioral goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
12. Wrap up session. Schedule appointment for session 7 at a two-week interval.
Week 7: Managing Chronic Conditions with CKD: Heart Disease and Diabetes
Lesson/Visit Objective:
By the end of this lesson:
1. Participant will be able to identify at least one thing they can do to better control their blood sugar.
2. Participant will be able to identify sources of fats to include in their diet.
Patient Handouts to be used for this session:
Sources of complex carbs
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today’s topic is heart disease and diabetes management. As we discussed earlier in the program, diabetes is the number one cause of kidney disease. Heart disease is one of the leading causes of death for individuals with kidney disease. Learning how to manage these conditions with diet is extremely important.
6. Explain to patient that diabetes and heart disease are complex diseases and we will not be able to fully cover them in just one session. Foodsmart does have 12 week programs on diabetes and cardiovascular disease. Recommend that patient pursue these programs upon finishing the CKD program if they would like more in-depth information.
7. Review three main things the patient can do to better control their diabetes.
Check their blood sugar consistently. Ask patient how often they currently check their blood sugar levels.
Take prescribed diabetes medications as ordered. Stress the importance of not skipping out on doses or taking a smaller dose to make your medication last longer.
Choose complex carbs and try to not eat carbs alone (pair them with protein or healthy fats). Explain that by eating carbs with other food you are slowing the absorption of glucose, thus lowering the rise in blood sugar.
8. Talk about how fats are an essential part of a healthy diet, and are important for blood pressure regulation and vitamin absorption. However, because people with CKD are at greater risk for heart disease, the amount and type of fat you consume makes a big difference. Aim to choose monounsaturated and polyunsaturated fats over saturated and trans fats. Review handout on choosing fats. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/4-ways-to-get-good-fats-infographic
9. Encourage patient to set a new behavioral goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
10. Wrap up session. Schedule appointment for session 8 at a two-week interval.
Week 8: Safe Supplementation for CKD
Lesson/Visit Objective:
By the end of this lesson:
1. Participant will be able to identify potential nutrients that may need to be supplemented.
2. Pt will be able to identify types of supplements/nutrients to limit or avoid.
Patient Handouts
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today we will talk about supplements and CKD. Almost all vitamins and minerals that the body needs can be found in the foods we eat. If you are eating a diet that includes a variety of foods from all food groups, you are likely meeting your vitamin and mineral needs. However, if you have a chronic health condition, like kidney disease, you may need to limit certain foods or groups in your diet. In these cases, supplementation may be necessary.
6. Review supplements with patient based on this resource.
B Complex: B complex vitamins are grouped together, but each has a different job to do.
One of the important functions of vitamin B6, B12 and folic acid is to work together with iron to prevent anemia. If you have anemia, it means you do not have enough red blood cells. Red blood cells carry oxygen from your lungs to all parts of your body. Anemia is very common in kidney disease because the kidneys are responsible for producing red blood cells.
Additional B vitamins, called thiamine, riboflavin, pantothenic acid and niacin, can also be given as a supplement. These vitamins help to change the foods you eat into energy your body can use.
Iron: If you are taking medicine to treat anemia, you may also need to take an iron pill or have injectable iron. You should only take iron if your doctor prescribed it. Encourage patient to discuss this with their doctor if you believe iron supplementation may be beneficial.
Vitamin D: Vitamin D is important to maintain healthy bones. There are different types of vitamin D. Your healthcare provider will tell you the type and amount you should be taking. You should only take vitamin D if your healthcare provider prescribes it for you. *Based on labs, RD may use clinical judgment to recommend that the patient talk to their doctor regarding vitamin D supplementation. Vitamin D deficiency is typically identified as serum 25(OH)D level <30. Typically patients not on dialysis are recommended oral Vit D2 or Vit D3 supplements and research shows that adequate dosing is 50,000 IU/month.
Calcium: Calcium along with vitamin D helps to keep your bones healthy. It is important to take only the amount of calcium prescribed by your healthcare provider. Too much calcium can clump together with phosphorus and deposit in places such as your heart, blood vessels, lungs and other body tissues. If your blood phosphorus level is too high, you may need to take a medicine used to bind the phosphorus from your food. Some phosphorus binder medications contain calcium. They can give you extra calcium if you need it.
7. Next discuss vitamins and supplements to avoid.
Vitamins A, E and K should be limited. When the kidneys are not working correctly, these vitamins can build up in the body and cause toxicity. Typically you do not need to restrict dietary intake of these, just supplementation.
Vitamin C may need to be supplemented in low doses for some people, but only if prescribed by a doctor for a specific purpose like wound healing. Large doses of supplementation can cause oxalates to build up in people with kidney disease, which can cause pain and other health issues.
8. What about herbal supplements? You may have heard many healing properties about herbs and kidney disease. These are not true. Most herbal supplements should be avoided in people with kidney disease. Many herbs can interact with other medications you are taking and cause unwanted side effects. There are also many herbs that can cause further kidney damage.
9. Encourage patient to set new behavioral goal around today’s topic or review previous goals and ask what they would like to continue or build upon.
10. Wrap up session. Schedule appointment for session 9 at a two-week interval.
Week 9: Physical Activity
Lesson/Visit Objective:
By the end of this lesson:
1. Participants will be able to identify how to incorporate physical activity into their lifestyle
Patient Handouts for this session:
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today’s focus is on physical activity. Being physically active is very important in maintaining your strength and energy. It is always important to discuss a new activity program with your physician. Today we will review some general things to look for when starting to exercise.
6. Type of Exercise: Choose continuous activity (like walking, swimming, bicycling, dancing, etc) where you use large muscle groups continuously; or choose low-level strength exercises. Think low weight and high repetitions for weight training; while avoiding heaving lifting unless okayed by your doctor.
7. How Long and How Often to Exercise: There is no rule on how long you should exercise but try to work your way up to 30 minutes at least 3 times a week. By spreading out your workouts, you will get the most benefits from them so try to do them on non-consecutive days.
8. How Hard Should I Exert Myself? Everyone is different but if you are new to exercising, or just getting back into it, we don’t want to overdo it. Your breathing should not be so hard that you can’t carry on a conversation. You also don’t want to push yourself so much that you become too sore to complete your next workout. The intensity should be a comfortable push level. Allow your body to start slowly and gradually adapt to the increase in activity.
9. Encourage patient to set new behavioral goal around today’s topic. If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon.
10. Wrap up session. Schedule appointment for session 10 at a two-week interval.
Week 10: Shop Smart
Lesson/Visit Objective:
By the end of this lesson:
1. Participants will have confidence in buying groceries for a kidney-friendly diet.
Resources for this session:
https://www.jrnjournal.org/article/S1051-2276(20)30082-0/pdf (see pages 3 and 4)
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today we will discuss grocery shopping for kidney disease. Having a well stocked kitchen with kidney-friendly foods will be important in helping you stay on track. NOTE: Depending on your patient’s stage of kidney disease, their recommended foods may differ. Stage 4 through Dialysis typically need a lower potassium diet.
6. Fruits: fresh, frozen or canned are all acceptable. When choosing canned fruits, look for those canned in water or light syrup to avoid added sugars. Specific recommendations include:
Stage 1-3: strawberries, blueberries, blackberries, raspberries, cranberries, oranges, grapefruit, lemons, limes, kiwi, bananas, cantaloupe, melons, mango, papaya, apples, grapes, cherries, plums, pineapple, pears, peaches
Stage 4-5, Dialysis: strawberries, blueberries, blackberries, raspberries, cranberries, cherries, pineapple, pears, peaches, watermelon
7. Vegetables:
Stage 1-3: spinach, broccoli, cabbage, lettuce, asparagus, brussel sprouts, green beans, green peas, kale, cabbage, mustard greens, turnip greens, cucumber, leeks, celery, carrots, squash, cauliflower, corn, eggplant, pumpkin, peppers, mushroom, potatoes, yams, beans, peas, lentils, onions, radishes
Stage 4-5, Dialysis: broccoli, cabbage, lettuce, asparagus, green beans, green peas, mustard greens, turnip greens, leeks, carrots, celery, cauliflower, corn, eggplant, onions, peppers, radishes
8. Whole Grains
All stages: oatmeal, quinoa, brown rice, couscous, bread, pasta
Nuts and Seeds:
Stage 1-3: Almonds, pistachios, sunflower seeds, walnuts, pecans, chia seeds, flax seeds, brazil nuts
Due to the need for low potassium and low protein, Stage 4-5, Dialysis should limit nut and seed intake.
9. Encourage patient to set new behavioral goal around today’s topic. If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon.
10. Wrap up session. Schedule appointment for session 11 at a two-week interval.
Week 11: Eating Out With CKD
Lesson/Visit Objective:
By the end of this lesson:
1. Participants will be able to apply strategies for choosing kidney-friendly meals when eating out.
Patient Handouts for this session:
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today’s topic is eating out with kidney disease. Start by asking the patient which meals, if any, they typically eat out. Ask the patient to elaborate with where they normally choose to eat, what they like to order and adapt the conversation to their lifestyle.
6. While it is best to choose home cooked meals as often as possible, it is not realistic to never eat out. Being prepared when going out to eat is key.
Know where you’re going in advance. Look at the menu before you arrive at the restaurant to have an idea of what options are served. Begin planning what you are going to order before you sit down.
Don’t be afraid to order with special requests. Explain to your server that you have a medical condition before you order. Special requests can include “no salt”, “dressing/sauce/gravy on the side”, “without cheese”.
If you have a protein restriction, try splitting a meal with a friend/family member or ask for a to-go box right away and only serve yourself a small portion of your protein. (Don’t forget that protein isn’t just in meat/fish/poultry but also in dishes prepared with milk, cheese and nuts.)
7. Review the Dining Out with Confidence Guide for better options to choose, and items to stay away from regarding specific meals/beverages.
8. Encourage patient to set new behavioral goal around today’s topic. If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon.
9. Wrap up session. Schedule appointment for session 12 at a two-week interval. If patient is unable to meet in two weeks.
Week 12: Adapting a Whole Food, Plant-Based Diet
Lesson/Visit Objective:
By the end of this lesson:
Participant will be able to state the benefits of a whole food, plant based diet for CKD
Participant will identify strategies for maintaining motivation to maintain newly formed habits.
Content discussion and overview:
Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
Check in with patient on lab updates.
Ask patient for current weight and document.
Check in with patient on the goal they set last week. Did they achieve the goal?
If patient was not successful in completing their goal, ask them what got in the way? Briefly help them problem-solve ways to remove barriers that prevented them from achieving their goal.
5. New topic introduction: Today we will discuss putting together everything we have learned to adapt your eating patterns to a Whole Food, Plant Based Diet. What does this mean? This type of eating style has shown to be nutritionally adequate, while also slowing the progression of kidney disease.
6. A Whole Food Plant Based Diet is naturally low in protein. We previously discussed limiting protein intake. By decreasing protein intake, you are decreasing uremic, nitrogenous waste. The build-up of these toxins in your body can cause decreased appetite and increased workload of your kidneys.
7. Plant- based foods, specifically fruits, vegetables and legumes, are high in antioxidants. Antioxidants are important because they help fight inflammation, and chronic inflammation can worsen kidney disease.
8. Phosphorus absorption from plant-based sources is less. These food choices are organic sources of phosphorus.
Plant-based diets have benefits for comorbidities related to CKD: diabetes, cardiovascular disease and hypertension. As we previously discussed, these conditions can make your kidney disease progress faster if not controlled.
Discuss any concerns patient may have about staying motivated. See if patient has any questions or concerns that have not been addressed throughout the program.
9. Encourage patient to schedule a one month follow up/check-in appointment for accountability and encouragement or enroll in another program if there is one that interests them. (The Diabetes or Heart Healthy programs may be good choices if the patient has either condition).