The Foodsmart ESRD 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.
Week 1: Introduction to ESRD
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:
Welcome patient and begin by asking what their main goal is when it comes to diet and ESRD. Examples may be getting listed for transplant, managing labs, improving quality of life. They may have a variety of reasons.
Conduct initial nutrition assessment as normal. Ask the patient how long they have been on dialysis, and what type of dialysis they are receiving (hemodialysis (HD), peritoneal dialysis (PD), nocturnal hemodialysis or home hemodialysis). HD is the most common type, but PD is also becoming more common. See what knowledge the patient already has of diet and dialysis. 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.
3. Validate your patients’ reasons for seeking nutrition help and give them confidence their goal can be reached. Note: Per CMS guidelines, all dialysis facilities must have a RD on staff. See if your patient is comfortable with you working with their RD to ensure you are both sharing similar information.
4. Discuss kidney disease and 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 dialysis is often working to replace some of these functions. Stress the importance of the patient adhering to their prescribed dialysis treatment. Remind them that healthy kidneys function 24/7 while their kidneys are only receiving help while they are receiving dialysis treatment.
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. (many mentioned in this fact sheet)
5. Have patient take NutriQuiz and review results.
6. 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. If the patient is unsure, you can gently guide them based on what you learned during your intake assessment.
7. 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.
Week 2: Understanding Your Lab Results
Lesson/Visit Objective:
By the end of this lesson:
Participant will become familiar with important labs for ESRD 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.
Ask patient for any new labs. Document results. Patients on dialysis get their labs drawn a minimum of monthly, sometimes every 2 weeks. Your patient should have a nutrition and blood test report that they receive.
Document any changes in kidney disease management (meds, weight,recommendations from doctor).
If needed, review NutriQuiz results with patient.
1. 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.
2. Ask the patient if they have any questions about lab tests or need clarification.
3. 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.
4. Wrap up session. Schedule appointment for session 3 at a one-to- two-week interval.
Week 3: Sodium and Fluid Management
Lesson/Visit Objective:
By the end of this lesson:
Participant will be able to state recommended fluid and sodium intake amounts.
Participant will be able to identify sources of sodium and fluid.
Participant will be able to verbalize consequences of excessive sodium and/or fluid intake.
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 sodium and fluid. When you are on dialysis, your body often can no longer remove enough fluid. This is why it’s important to limit both fluid and sodium intake. I’d first like to get a sense of what you already know about these and if you have a goal intake.
Discuss fluid overload and consequences of bringing in too much fluid. Symptoms of fluid overload include:
Swelling
High blood pressure
Difficulty breathing
Heart problems
Discomfort
Ask patient what their weight gain is between dialysis sessions typically. This should be no more than 3% of their dry weight.
If the patient is having difficulty managing their fluid intake and gaining excessive weight between dialysis treatments, discuss methods to manage fluid intake:
Track your fluid. Some patients use a visual to help them see how much fluid they are taking in. Try measuring with a container or keeping a fluid journal.
Follow the fluid guidelines given to you by your healthcare team. Most dialysis patients need to limit their fluid intake to 32 ounces per day. Ask patient if they know how much fluid they should be consuming a day.
Manage your thirst. Try sugar-free hard candies, ice chips, or frozen grapes/berries, chewing gum. This will help you avoid drinking too much fluid between dialysis treatments.
Take medications without fluids. Try using applesauce or pudding instead.
Remind patient that fluid is anything liquid at room temperature including water, juice, tea, coffee, ice cream, ice chips, jello, soup/broth, etc.
Discuss sodium intake. Sodium, in the form of salt, causes your body to hold on to water. Too much salt in your diet will increase your chances of fluid overload and make it more difficult to remove fluid during dialysis.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. Use this handout for more information on sodium and dialysis.
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.
12. 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.
13. Wrap up session. Schedule appointment for session 4 at a one-to- two-week interval.
Week 4: Potassium and Dialysis
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 excess potassium from the blood. Explain to the patient that at their advanced stage of kidney failure, their kidneys are likely not able to remove enough potassium. Hyperkalemia, or high potassium levels, can lead to serious, even fatal, heart problems.
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).
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.
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 5 at a one-to- two-week interval.
Week 5: Mineral Bone Disorder
Lesson/Visit Objective:
By the end of this lesson:
Participant will be able to state how kidney disease impacts bone health
Participant will be able to identify specific labs that impact bone health and ways to maintain normal 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.
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’s focus is on mineral bone disorder. Healthy kidneys keep bones strong by managing the amount of minerals in the blood. This is a common problem in kidney failure and affects almost all patients on dialysis. Specifically, mineral bone disorder is when there is an imbalance of calcium and phosphorus in your blood. Your bones, heart and blood vessels can all be impacted.
As kidney function declines, a few things happen. One is that the ability to filter out extra phosphorus from our diet decreases. Phosphorus then builds up in the blood. Second, healthy kidneys also change vitamin D from sunlight and the foods you eat into active vitamin D that your body can use. When kidneys fail there is a short supply of active vitamin D. This causes calcium and phosphorus to get out of balance. When the blood phosphorus level goes up and blood vitamin D level goes down, your body makes too much parathyroid hormone (PTH). High PTH levels cause calcium to move from your bones into your blood. As calcium leaves your bones they become weaker, more brittle, and are more likely to break. Some calcium may also end up in the heart and blood vessels. This may lead to calcification that can cause or worsen heart disease.
Review signs and symptoms of mineral bone disorder
Itchy skin
Bone pain
Weak bones that break easily
Blocked blood vessels
Heart problems
Anemia
Nerve problems
Difficulty fighting off germs
How do you know if you have mineral bone disease? Check your phosphorus, calcium, vitamin D, and PTH levels. (refer to reference ranges from week 2).
How can you manage mineral bone disorder?
Lower your phosphorus levels. We will go more in-depth on this topic next session.
Improve your Vitamin D level: Your body needs the active form of vitamin D. Often times your nephrologist will prescribe active vitamin D. (Typically the patient’s renal dietitian will manage vitamin D. Dietary intake does not improve blood levels due to the kidneys decreased ability to convert it to the active form).
Calcimimetics: Calcimimetcs are medicines often used when blood PTH, calcium and phosphorus levels are too high in people on dialysis. This medication is typically called Sensipar or Cinacalcet. It is often recommended to be taken with food as it can cause GI upset, especially in larger doses.
Calcium supplements: Speak to your nephrologist before taking a calcium supplement. The results of your blood tests will help show if you need to take extra calcium.
Surgery: Some people with high PTH levels need surgery to remove some or all of the parathyroid gland.
Exercise: The exercises that may be most helpful are strengthening and weight-bearing exercise. Make sure you talk with your nephrologist before starting an exercise program. We will discuss exercise further in week 8.
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.
Wrap up session. Schedule appointment for session 6 at a two-week interval.
Week 6: Deep Dive into Phosphorus
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.
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 kidney failure, 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.
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
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
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.
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.
Wrap up session. Schedule appointment for session 7 at a two-week interval.
Week 7: Albumin, Protein, Infection and Inflammation
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:
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’s topic is albumin, protein, infection and inflammation.
Albumin is the most common protein found in the blood. It provides the body with the protein needed to both maintain growth and repair tissues. During a dialysis treatment, the albumin in your blood also helps with fluid removal. It helps "pull" extra fluid from swollen tissues back into the blood, where it can then be removed by the dialyzer. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, from the National Kidney Foundation, recommend that a blood albumin level be 4.0 g/dl. or higher
We can help our albumin level by making sure we are eating enough protein. Foods from animals (e.g., beef, pork, fish, chicken, eggs, milk) contain the best sources of high quality protein. Lower quality protein comes from foods such as nuts, beans, vegetables and grain products. However, some of these protein-containing foods may be limited in the dialysis diet because the potassium and phosphorus levels are too high for most dialysis patients to eat them on a regular basis or in normal portions.
Protein intake is not the only thing that impacts albumin levels.
Inflammation and infection will cause an albumin level to drop. Possible causes of infections include:
An infected access site
An infected foot or other wound
Decayed teeth or infected gums
Bladder infection
Long-term inflammations include arthritis and lupus.
Other non-dietary causes of a low albumin level include:
Liver problems, such as from alcohol or from other liver diseases (albumin is synthesized in the liver)
Metabolic acidosis
With peritoneal dialysis (PD), protein loss across the peritoneal membrane
Fluid overload
What can you do to help keep an adequate albumin level?
Know what foods are good sources of protein and eat the amount recommended in your diet plan. Your dietitian is an excellent source of information.
Help prevent infections (e.g., avoid scratching, keep your access clean).
If you notice an area on your body that looks or feels infected (red, swollen, sore, possibly drainage), let your medical team know so that treatment can begin.
Keep track of your albumin level. Know what your monthly blood levels are. If your albumin level has a significant decrease, work with your medical team to determine the cause and come up with a solution.
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.
Wrap up session. Schedule appointment for session 8 at a two-week interval.
Week 8: Staying Active on Dialysis
Lesson/Visit Objective:
By the end of this lesson:
1. Participant will be able to identify benefits of physical activity for kidney disease
2. Participant will be able to identify different types of physical activity to incorporate into their lifestyle.
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.
New topic introduction: Today we will talk about staying fit on dialysis. We know that being physically active is important for everyone, and that’s no different when you’re on dialysis.
Review benefits of regular exercise with patient. Regular exercise will help your muscle strength, your energy levels, and your overall ability to do the things you need to do in your life. Regular exercise has the following benefits for people with kidney disease:
Improved heart function
Better blood pressure control
Reduce the risk of diabetes
Helps to control blood sugar in those with diabetes
Improves muscle strength
Helps with anxiety and depression
May help with weight management
Before you start, make sure you talk with your nephrologist, especially if you have had problems with your heart (such as a heart attack, bypass surgery, angioplasty, or chest pain) or if you experience excessive shortness of breath. You should also talk to your doctor first if you are interested in more vigorous exercise, such as sports like basketball, tennis, or other activities. You can ask your doctor for a referral to physical therapy for an evaluation and to help get started with your exercise program. If you have a new dialysis access, it’s important to follow exercise recommendations from your surgeon.
Discuss choosing an exercise program. When starting out, it is important to start slowly and gradually work your way up.
Stretching or flexibility exercises improve the movement of joints, help in reaching above your head, and reduce stiffness in muscles.
Strengthening or resistance exercises will increase strength of muscles.
Cardiovascular or endurance exercise (also called “aerobic” exercise) such as walking or cycling improves the function of the heart and circulation, and results in improved endurance and energy levels.
When to Exercise: Exercise at the time during the day when you feel best. For some people, it is first thing in the morning. For others, it is in the afternoon or evening. If you are on hemodialysis, you may feel best exercising on your non-dialysis days, or before your treatment. Exercise after hemodialysis may not be best because your blood pressure may be too low. If you miss a dialysis treatment and have excessive fluid in your system, it may not be best to exercise that day. If you are on peritoneal dialysis (CAPD), you may feel more comfortable if you exercise with an “empty” abdomen. It is most important to do your exercise regularly, and it is best to plan a specific time every day for your exercise session. This will help keep it part of your regular routine.
It is important to listen to your body during your exercise. You should slow down if:
The exercise feels “hard” or “very hard”
The exercise causes muscle or joint discomfort or pain that may prevent you from exercising the next day
You are breathing too hard to carry on a conversation with someone else
You feel your heart racing
You do not feel fully recovered within one hour after your exercise session
Remember, you will have good days and bad days. On those days you are low on energy, try doing your exercise at a level that is slower, and you may find that the exercise actually perks you up.
Stop the exercise and contact your health provider if you feel any of the following:
Excessive shortness of breath
Pain or pressure in your chest, neck or jaw
Irregular or racing heartbeat
Nausea, dizziness or lightheadedness
Excessive fatigue during your exercise or that lasts all day
Blurred vision
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.
Wrap up session. Schedule appointment for session 9 at a two-week interval.
Week 9: Shop Smart
Lesson/Visit Objective:
By the end of this lesson:
1. Participants will have confidence in buying groceries for a kidney-friendly diet.
2. Participants will be able to reach nutrition facts labels to help choose healthy options while grocery shopping
Patient Handouts for this session:
Meal Planning for a Kidney Disease Diet | Recipes and Tips -section on label reading
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 we are going to talk about how to Shop Smart for kidney disease. Eating healthy on dialysis doesn’t mean you have to stop enjoying the foods you love. Many recommended foods are part of a balanced, healthy, family-friendly diet.
Making dietary changes can be daunting but setting yourself up for success makes things much easier!
Plan your favorite meals. Use the Foodsmart app to help you find renal-friendly recipes. Other great resources for dialysis-friendly recipes are davita.com and freseniuskidneycare.com
Avoid impulse purchases. Have a list of what you plan to buy and stick to it. If you struggle in the grocery store, try ordering online for pick-up or delivery.
Grocery Shopping Tips:
If you’re not sure what to buy, read labels. Compare products to find those low in sodium and potassium. Use the section on this link for label reading tips: Meal Planning for a Kidney Disease Diet | Recipes and Tips
Shop the perimeter of the store first. You’re more likely to find the freshest produce along the outside. It’s important to limit processed and packed foods as these are often higher in sodium, potassium and phosphorus.
Discuss this grocery list with participant:
Remind patient that this list is a general place to start. If they have specific questions that you are not able to answer, encourage the patient to speak with their RD at dialysis.
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.
Wrap up session. Schedule appointment for session 10 at a two-week interval.
Week 10: Managing Blood Glucose Levels
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.
Resources 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 we will discuss the diabetes dialysis diet. The diabetes dialysis diet is specifically for patients who have stage 5 chronic kidney disease (CKD), also called end stage renal disease (ESRD), in addition to diabetes. The diet’s goal is to manage blood glucose levels and help you feel your best. We’ve already covered many of the main components of the dialysis diet: low phosphorus, low potassium, low sodium, and high protein. But with diabetes it is also important to balance your carbohydrate intake to control your blood glucose levels.
All carbohydrate-containing foods raise blood glucose levels. These foods include bread, cereal, pasta, rice, starchy vegetables, fruits, juices, and many sugar-free desserts. It is ok to include these foods in moderation but the key is to watch portion size and balance them with kidney-friendly protein and fat sources.
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.
If your patient is on PD (peritoneal dialysis), they are receiving glucose everytime they receive dialysis. It is especially important for these patients to make sure they are watching their carbohydrate intake.
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.
Wrap up session. Schedule appointment for session 8 at a two-week interval.
Week 11: Safe Supplementation for ESRD
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 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 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.
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.
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.
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.
Protein supplements: It is important to get adequate protein in the diet, especially when you have kidney failure. Many dialysis patients take protein shakes, bars, powders or gels to help meet protein needs.
Nepro or Novasource Renal are high calorie, high protein shakes that are specially formulated for dialysis patients. They are low in phosphorus and potassium. Use this form for Nepro assistance or this one for NovaSource.
Liquacel from Global Health is a gel that can be taken on it’s own or mixed with other beverages.
Zone Perfect Bars have some flavors lower in phosphorus and/or potassium that are appropriate for renal patients. Strawberry yogurt or cinnamon roll are a few flavors.
Check labels of other supplements for phosphorus and potassium content. Some patients may be able to take in higher amounts so they may be able to try a larger variety of supplements.
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.
Wrap up session. Schedule appointment for session 9 at a two-week interval.
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 ESRD
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.
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 decreasing the amount of additives in the diet.
A Whole Food Plant Based Diet is naturally low in protein. We previously discussed the importance of adequate protein intake once on dialysis. Try incorporating minimally processed protein options when able, and more plant based sources.
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.
Phosphorus absorption from plant-based sources is less. These food choices are organic sources of phosphorus meaning they are less absorbed.
Plant-based diets have benefits for comorbidities related to kidney disease: diabetes, cardiovascular disease and hypertension.
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.
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).
Patient may wish to continue to follow up with RDN on monthly basis. Follow up sessions should be used for encouragement, problem-solving, and goal-setting as needed.