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Using your hand as a guide to estimate portion size  

Using your hand as a guide to estimate portion size  

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Background: The multi-racial and multi-ethnic population of South Africa has significant variation in their nutritional habits with many black South Africans undergoing a nutritional transition to Western type diets. In this review, we describe our practical approaches to the dietary and nutritional management of chronic kidney disease (CKD) patie...

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Background: Chronic kidney disease (CKD) is an emerging health public problem in Brazil. Nutritional counseling with focus on protein restriction is a promising strategy to treatment of nondialysis CKD patients due its effects on slowing renal loss. However, Brazilian people have high protein intake, which is a challenge when low protein diet (LPD...

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... Socioeconomic influences such as financial status may further influence the dietary choices and adequacy in haemodialysis patients. Patients living alone or on a low income may face difficulties preparing appropriate meals and adhering to the renal diet due to limited finances, poor physical strength, and lack of time (due to treatment). is can be a particular problem in developing countries, including sub-Saharan Africa (SSA), where there may be limited access to HBV protein sources which are also normally expensive [17]. Poor literacy and a shortage of renal dietitians/nutritionists pose further challenges for ensuring the adequacy of patients' dietary intakes in many countries in the SSA region. ...
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Malnutrition is common among dialysis patients, but there is insufficient literature on the problem from resource-poor settings of the sub-Saharan region. We conducted a cross-sectional investigation of dietary intake and nutritional status of haemodialysis (HD) patients to inform the current status of this population group in the region. HD patients aged ≥18 years, with dialysis vintage of ≥3 months, at one nephrology unit in Tanzania were assessed for their habitual diet and nutrient intake. Anthropometric measures and biochemistry tests were also performed. The diet was predominantly starchy food based, accompanied by a limited selection of vegetables. Fruits and animal protein were also minimally consumed (1 portion/day each). Fruit consumption was higher in females than males (median (25th, 75th) = 2 (1, 2.3) versus 0.5 (0, 1.7) portions, p = 0.008). More than 70% of participants had suboptimal measures for protein and energy intake, dietary iron, serum albumin, muscle mass, and hand grip strength (HGS). Inadequacies in protein and energy intake and dialysis clearance (URR) increased with the increase in body weight/BMI and other specific components (MAMC and FMI). Consumption of red meats correlated significantly and positively with serum creatinine (r = 0.46, p = 0.01), potassium (r = 0.39, p = 0.03), and HGS (r = 0.43, p = 0.02) and was approaching significance for a correlation with serum iron (r = 0.32, p = 0.07). C-RP correlated negatively with albumin concentration (r = −0.32, p = 0.02), and participants with C-RP within acceptable ranges had significantly higher levels of haemoglobin (p = 0.03, effect size = −0.28). URR correlated negatively with haemoglobin concentration (r = −0.36, p = 0.02). Patients will benefit from improved nutritional services that deliver individually tailored and culturally practical dietary advice to enable them to make informed food choices whilst optimizing disease management.
... 24 Practical approaches should, however, still be developed in the context of various factors including local diets, weather, literacy and cultural practices, to increase awareness and appropriately restrict intake of fluid, salt, phosphate, potassium and protein. 63 Management of Regional CKD Among Agricultural Workers and South Asia (Sri Lanka and India), 65,66 but there are also suggestive reports from Africa (Egypt and Sudan). 67 Although commonly referred to as CKD of unknown origin (CKDu), they are also referred to as "Meso-American nephropathy," "Uddanam nephropathy" and "Sri Lankan nephropathy." ...
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The incidence and prevalence of chronic kidney disease (CKD) and kidney failure continues to increase worldwide, especially in resource-limited countries. Many countries in this category already have a massive burden of communicable diseases, as well as socio-economic and socio-demographic challenges. The rising CKD burden and exorbitant economic cost associated with treatment are mainly responsible for the alarming mortality rate associated with kidney disease in these regions. There is often poor risk factor (diabetes and hypertension) and CKD awareness in these countries and limited availability and affordability of treatment options. Given these observations, early disease detection and preventive measures remain the best options for disease management in resource-limited settings. Primary, secondary and tertiary preventive strategies need to be enhanced and should particularly include measures to increase awareness, regular assessment to detect hypertension, diabetes and albuminuria, options for early referral of identified patients to a nephrologist and options for conservative kidney management where kidney replacement therapies may not be available or indicated. Much is still needed to be done by governments in these regions, especially regarding healthcare funding, improving the primary healthcare systems and enhancing non-communicable disease detection and treatment programs as these will have effects on kidney care in these regions.
... Alternatively, some patients adopt advice that they can easily integrate in their lifestyle [16]. The apparent contradictory information observed in our study could partly be attributed to the fact that although certain elements of the renal diet remain applicable to all patients, the alterations of the diets of patients with CKD often need to be individualized, taking into account comorbidities and individual body composition [44]. Lack of consistency in delivery of information by different nutritionists decried by participants in our study suggested a gap in the competency of some nutritionists working in renal units. ...
... The dietary recommendations in CKD may indeed make food less appetizing resulting in diminished intake and compromised nutritional status [47]. In the initial phase of CKD diagnosis, the basis for the required dietary adjustments is not well understood by patients and many of them get intimidated and feel overwhelmed by heavy restrictions placed on their diets not to mention the sudden disruption of their longstanding individual routine life [44,48]. Patients have been reported as being angry about having to take on a new food regimen in addition to changes to their daily schedules and recreational activities imposed by CKD. ...
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Diet is one of the modifiable lifestyle factors in management of kidney disease. We explored perceptions on adherence to dietary prescriptions for adults with chronic kidney disease on hemodialysis. This was a qualitative descriptive study. Participants were purposively selected at renal clinics/dialysis units at national referral hospitals in Kenya. Data were collected using in-depth interviews, note-taking and voice-recording. The data were managed and analyzed thematically in NVIV0-12 computer software. Study participants were 52 patients and 40 family caregivers (42 males and 50 females) aged 20 to 69 years. Six sub-themes emerged in this study: “perceived health benefits”; “ease in implementing prescribed diets”; “cost of prescribed renal diets”; “nutrition information and messages”; “transition to new diets” and “fear of complications/severity of disease”. Both patients and caregivers acknowledged the health benefits of adherence to diet prescriptions. However, there are mixed messages to the patients and caregivers who have challenges with management and acceptability of the prescriptions. Most of them make un-informed dietary decisions that lead to consumption of unhealthy foods with negative outcomes such as metabolic waste accumulation in the patients’ bodies negating the effects of dialysis and undermining the efforts of healthcare system in management of patients with chronic kidney disease.
... 35 Therefore, awareness of the value of dietetic consultation at appropriate frequency (every 4-6 months 9,36 ) should be raised amongst medical aids, patients and/or caregivers, nephrologists, nurses and social workers who treat patients on MHD. 9 The suggested dietitian to patient ratio of 1:100 should be mandated by policy-makers to improve the quality of care, as staff shortages could result in insufficient and infrequent dietetic visits. 9,12,15,37 Limitations ...
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Introduction: In sub-Saharan Africa, a paucity of data exists in respect of the knowledge, attitudes and practices (KAP) of patients on maintenance haemodialysis (MHD) regarding the dietary adaptations they should make. Methods: In a descriptive, cross-sectional study, conducted in 2017, questionnaires were administered during structured interviews with 75 participants in five MHD-units in Bloemfontein to assess socio-demographics and KAP regarding the ‘renal’ diet. Results: The median age was 50.5 years; 70.7% of participants were male. Overall, 49.4% scored low (< 50%) on knowledge regarding restricted foods, food content of restricted minerals, and phosphate binders; 60.0% reported negative attitudes towards the diet, and 61.4% reported poor adherence practices. Participants with tertiary education (28.0%) had significantly higher knowledge scores than participants with only primary school education (6.7%) (95% CI 3.9%; 73.5%), or those who had only partially completed secondary school (17.3%) (95% CI 6.3%; 64.0%). Only 21.0% reported having received written, and 30.7% verbal, nutrition education in their home language, while 24.0% reported never receiving nutrition education in either their home or second language. Having received nutrition education in a home language and/or second language was associated with significantly higher knowledge scores (95% CI 3.7%; 49.5%). Most (77.3%) reported zero to one consultation with a dietitian per MHD year (NKF-K/DOQI recommends at least three/MHD year). Conclusion: This population on MHD presented with poor KAP regarding the ‘renal’ diet, and inadequate involvement of dietitians in their treatment. Receiving nutritional education in a first or second language significantly increased knowledge of, and insight into, the required dietary adaptations.
... 6 Unemployment and a low level of education affect patients' understanding of their prescribed diet for CKD, limiting their purchasing power and ultimately adherence to their prescribed diet. 7 Recent studies exploring dietary patterns and its relationship to renal outcomes show some promising results which suggest that CKD diets do not need to be so restrictive. 4,8,9 Are We Overcomplicating Dietary Advice? ...
... Sodium intake and dietary patterns vary enormously worldwide, and therefore, the strategies need to be based on the local reality. Some practical strategies developed in Brazil, South Africa, Japan and Italy are published; they can serve as examples of implementation at the local level taking into account local patterns and peculiarities [52][53][54][55]. ...
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Background: Hypertension affects almost all chronic kidney disease patients and is related to poor outcomes. Sodium intake is closely related to blood pressure (BP) levels in this population and decreasing its intake consistently improves the BP control particularly in short-term controlled trials. However, most patients struggle in following a controlled diet on sodium according to the guidelines recommendation due to several factors and barriers discussed in this article. Summary: This review article summarizes the current knowledge related to the associations between sodium consumption, BP, and the risk of cardiovascular disease and chronic kidney disease (CKD); it also provides recommendations of how to achieve sodium intake lowering. Key Messages: Evidences support the benefits in decreasing sodium intake on markers of cardiovascular and renal outcomes in CKD. Trials had shorter follow-up and to maintain long-term sodium intake control is a major challenge. Larger studies with longer follow-up looking at hard endpoints will be important to drive future recommendations.
... Other papers deal with this important question. The African experience shows that a well-balanced diet, with a restricted protein content, can be proposed in many contexts, including low-income, low-literacy settings [15,16]. Given the "silent epidemic" of illiteracy in developed countries, the strategies developed in Africa can be used in Europe, as an Italian case report explains [17]. ...
... In countries such as Australia or the US, in which the normal protein intake is well above 1.2 g of protein per kg of body weight per day, a feasible dietary protein reduction would probably be a protein intake of 0.8 g/kg/day. A similar intake may be needed in poorer countries, for balancing malnutrition [16,32,33]. ...
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In this editorial we present the special issue dedicated to low-protein diets (LPDs) in chronic kidney disease, from a global perspective. The experiences gathered from several countries across all continents have created an issue which we hope you will find insightful, and lead to further discussion on this interesting topic. We discover that LPDs are feasible in both developed and low income countries, in patients where literacy is an issue, and are also safe, including during pregnancy and in old age. Patients prescribed a low protein diet are more inclined to follow and adhere to this change in lifestyle, provided the diet has been adapted to meet their own individual needs. With an increasing list of different menu options and better medical advice being offered we no longer need to identify low protein diets with a specific menu, ingredient or supplement, or with a specific level of protein restriction. Evidence shows how the best diet is often the one chosen by the patients, which doesn’t drastically affect their day-to-day life, and delays the start of dialysis for as long as is safe under careful clinical control. The colourful menus gathered from all over the world remind us that a low protein diet does not necessarily mean that the pleasure of preparing a delicious meal is lost. The final comment is therefore dedicated to our patients: low protein diets can be beautiful.
... Chronic kidney disease (CKD) is highly prevalent in South Africa, a country in which there is a double burden of under-and over-nutrition [1][2][3][4]. One in four households still experience hunger, while in one in five households the diet is monotonous and low in nutrient diversity, low in proteins with high biological value, and contains high quantity, low quality food, with excessive amounts of cheap starches, fats, and sugars, causing obesity, a known risk factor for CKD [5,6]. ...
... One in four households still experience hunger, while in one in five households the diet is monotonous and low in nutrient diversity, low in proteins with high biological value, and contains high quantity, low quality food, with excessive amounts of cheap starches, fats, and sugars, causing obesity, a known risk factor for CKD [5,6]. Hypertension, often combined with obesity, is the major cause of CKD in South Africa; salt-sensitive primary hypertension often presents at an early age in the native African population [1][2][3][4]7]. Type 2 diabetes, often combined with hypertension and obesity, is the second cause of CKD in South Africa. HIV affects 6% of the population and contributes to HIV-associated nephropathy, another leading cause of CKD [2,8,9]. ...
... Simple visual aids may be of great help not only in recalling diet-related concepts, but also in reassuring patients, thus ensuring empowerment and compliance even in difficult settings [4,36]. ...
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Providing nutritional education for chronic kidney disease (CKD) patients in South Africa is complicated by several conditions: the population is composed of diverse ethnic groups, each with its own culture and food preferences; eleven languages are spoken and illiteracy is common in the lower socio-economic groups. Food preparation and storage are affected by the lack of electricity and refrigeration, and this contributes to a monotonous diet. In traditional African culture, two meals per day are often shared “from the pot”, making portion control difficult. There is both under- and over-nutrition; late referral of CKD is common. Good quality protein intake is often insufficient and there are several misconceptions about protein sources. There is a low intake of vegetables and fruit, while daily sodium intake is high, averaging 10 g/day, mostly from discretionary sources. On this background, we would like to describe the development of a simplified, visual approach to the “renal diet”, principally addressed to illiterate/non-English speaking CKD patients in Southern Africa, using illustrations to replace writing. This tool “Five steps to improve renal diet compliance”, also called “Eating like a Rainbow”, was developed to try to increase patients’ understanding, and has so far only been informally validated by feedback from users. The interest of this study is based on underlining the feasibility of dietary education even in difficult populations, focusing attention on this fundamental issue of CKD care in particular in countries with limited access to chronic dialysis.
... Since the beginning of "renal medicine", low-protein diets (LPDs) have been adopted to correct the metabolic alterations of kidney failure, sometimes interpreted as "protein intoxication" [1][2][3]. To date, the limited availability of dialysis in developing countries and the grim prognosis of patients who start dialysis in developed countries make prolonging dialysis-free survival a major achievement for developed as well as developing countries [4][5][6][7][8][9][10][11][12]. ...
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The indications for delaying the start of dialysis have revived interest in low-protein diets (LPDs). In this observational prospective study, we enrolled all patients with chronic kidney disease (CKD) who followed a moderately restricted LPD in 2007–2015 in a nephrology unit in Italy: 449 patients, 847 years of observation. At the start of the diet, the median glomerular filtration rate (GFR) was 20 mL/min, the median age was 70, the median Charlson Index was 7. Standardized mortality rates for the “on-diet” population were significantly lower than for patients on dialysis (United States Renal Data System (USRDS): 0.44 (0.36–0.54); Italian Dialysis Registry: 0.73 (0.59–0.88); French Dialysis Registry 0.70 (0.57–0.85)). Considering only the follow-up at low GFR (≤15 mL/min), survival remained significantly higher than in the USRDS, and was equivalent to the Italian and French registries, with an advantage in younger patients. Below the e-GFR of 15 mL/min, 50% of the patients reached a dialysis-free follow-up of ≥2 years; 25% have been dialysis-free for five years. Considering an average yearly cost of about 50,000 Euros for dialysis and 1200 Euros for the diet, and different hypotheses of “spared” dialysis years, treating 100 patients on a moderately restricted LPD would allow saving one to four million Euros. Therefore, our study suggests that in patients with advanced CKD, moderately restricted LPDs may allow prolonging dialysis-free follow-up with comparable survival to dialysis at a lower cost.
... Finally, it is important to provide practical advice: no more structured dietary plans, nutritionally sound but complex to realize, or long lists of foods to exclude (potassium, phosphorus, sodium, protein lists), but useful and simplified basic information on how to change habits and help patients combine ingredients to create enjoyable meals that fit recommendations for CKD (47)(48)(49). ...
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This is a case report on a patient with non-dialysis chronic kidney disease (CKD) in whom several nutritional issues are briefly discussed from a practical point of view. The article is accompanied by an editorial published in this Journal in relation to the 2 nd International Conference of the European Renal Nutrition working group at ERA-EDTA—“Retarding CKD progression: readily available through comprehensive nutritional management?”— and focuses on several practical topics associated with the nutritional approach for the conservative treatment of non-dialysis CKD. The article is divided into 3 sections—basic nutritional assessment, nutritional targets, and nutritional follow-up in non-dialysis CKD—linked to 3 consecutive steps of the clinical follow-up of the patient and the related nutritional concerns and intervention. First visit: Baseline nutritional assessment and basic nutritional considerations in non-dialysis chronic kidney disease (CKD) • What nutritional assessment/monitoring for protein-energy wasting (PEW) should be employed? • Is a body mass index (BMI) of 21 kg/m ² adequate? • What phosphate target should be pursued? • What are the nutritional habits in patients with incident CKD? • What protein needs and amount of dietary protein should be pursued? • Does the quality of protein matter? • What amount of dietary salt should be employed? How should this be obtained? • How should normal serum phosphate be achieved? • What diet should be recommended? Is a vegetarian diet an option? Second visit: Major nutritional targets in non-dialysis CKD • Consequences of unintentional weight loss • What is the role of the renal dietitian in helping the patient adhere to a renal diet? Intermediate visits: Nutritional follow-up in non-dialysis CKD • What treatment for calcium/parathyroid hormone (PTH) will affect CKD progression? Final visits: • Would a dietary recall/intensive dietary education improve adherence with the diet? • Would a very-low-protein diet (VLPD)/ketodiet be indicated for this patient?