What about Tofu?

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Eating Vegetarian Foods While Living With Kidney Disease

By Joan Brookshyer, RD, CSR

Historically, vegetarianism has been met with skepticism in chronic kidney disease (CKD) patients. However, we now know that with careful planning vegetarianism, or even part-time vegetarian eating is not only safe, but also beneficial to CKD management.1,2 Research shows eating vegetarian proteins can actually slow down the progression of kidney disease and other complications associated with this disease.1,2

Nutrition management focuses on decreasing waste product build up from digested foods, which would normally leave the body as urine. The primary goals of planning a diet with plant-based foods are three fold: 1.) obtaining the appropriate amount of plant protein to meet protein needs while minimizing waste product build up in the blood 2.) maintaining sodium, potassium and phosphorus balance and 3.) maintaining good nutrition. The following information is meant to be an initial guide to those with early kidney disease (30-50 percent of normal kidney function) and not receiving dialysis treatments. More careful follow up is recommended, especially when kidney function decreases below 30 percent or when regular dialysis treatment is required.

Quality Protein

People with CKD should modify the amount of protein they eat.1 Since plant proteins are less demanding on kidney clearance, this restriction does not need to be as severe as with animal protein diets.8 Keeping to .8 gram (g) of protein per kilogram (kg) body weight is recommended, with approximately two-thirds of this protein coming from quality plant protein or animal/plant combination, such as the following:4
Quality Protein     Serving Size = 7 g protein
Egg     1
Meat analogues
(processed soy foods)     2 oz.
Seitan
(Wheat gluten)     1 oz.
Beans, dried cooked     1/2 cup
Tofu     1/4 - 1/2 cup
Tempeh     1/4 cup
Nut Butters     2 tablespoons
Meat, Fish, Poultry     1 oz.

EXAMPLE:

* Your weight: 70 kg
* Your total protein needs: 70 x .8 = 56 grams
* Amount needed from quality protein sources: 56 x 2/3 = 37 grams
(1 pound = 0.4535924 kilogram)

A mixture of these protein sources should be eaten to ensure receiving an adequate balance of all essential amino acids (meat, fish and poultry are optional sources).5-8 Soy protein has been shown to be particularly beneficial in minimizing some complications associated with kidney disease. This includes proteinuria (protein loss in the urine) and minimizing hyper filtration (excess filtering of the kidney causing more kidney damage).9-12 Try to include at least one serving of soy protein per day, such as tofu, tempeh or a milk substitute, soymilk.

Sodium, Potassium, & Phosphorus

Sodium
Though vegetarian foods are healthy in general, some can be very high in sodium. A few foods to avoid for limiting sodium in plant-based foods include:

*Convenience foods such as frozen meals, canned soup, dried soups, miso or packaged vegetable broths
*Soy-based cheese
*Processed dairy cheese
*Meat analogues — this includes such foods as tofu hot dogs, veggie burgers or other canned or frozen soy products
*Salt, soy sauce, tamari sauce or any spices that contain the words sodium or salt

Potassium

In general, potassium does not need to be restricted unless the function of the kidney decreases to less than 20 percent. Routine blood testing is the best way to know your potassium requirements. An estimated two-thirds of diet potassium comes from fruits, vegetables and juices. So initially, the easiest way to limit this mineral will be to minimize fruit and vegetable selections to five servings per day.

A potassium serving size:
1/2 cup fresh fruit, canned fruit or juice
1 cup fresh vegetables
1/2 cup cooked vegetables

If this does not decrease your serum potassium to the normal range, limit these foods:
High Potassium
Limit 1 per day
Textured vegetable protein   1/4 cup
Soy flour   1/4 cup
Nuts and Seeds   1/4 cup
Dried, cooked beans or lentils   1 cup
Dried cooked soybeans   1/2 cup
Tomato products   1/4 cup
Potatoes   1/2 cup
Dried fruit   1/4 cup
Tropical fruit   1/2 cup
Melons   1/2 cup

If you use a lot of beans or textured vegetable protein, alternative protein selections may be needed in order to keep potassium levels from going too high. This will mean using more tofu, tempeh, seitan and eggs or if you prefer some meat, fish or poultry to meet protein needs.

Phosphorus
Some plant proteins are high in phosphorous, but because of the high phytate content (a naturally occurring compound which blocks phosphorous absorption) these foods alone usually do not increase serum phosphorous levels.8 This includes dried cooked beans and nuts. Dairy products are the main source of concentrated phosphorus.14 This will mean decreasing dairy products to one serving or less per day. For the vegan a few other high phosphorus foods are worth noting:
High Phosphorus
Limit 1 per day
Milk   1 cup*
Cottage Cheese   2/3 cup
Cheese   2 ounces
Pudding or custard   8 ounces
Yogurt   8 ounces
Soy cheese   4 ounces
Soy yogurt
(non fortified)   12 ounces

*Non-dairy creamer, rice milk and up to two cups of soymilk per day can be used as a replacement for milk.

Good Nutrition
A plant-based diet is often lower in calories and higher in fiber than an animal-based diet. As a result, you need to be careful you do not lose weight. Here are some ideas to help add healthy calories to your eating plan:

*

Soy shakes: Make shakes with soymilk, tofu, rice milk and non-dairy frozen dessert.
*

Adding fats: Use more oils such as olive oil, peanut oil or canola oil in cooking. Drizzle flaxseed oil on food after it is cooked, or mixed with salad dressing over lettuce.
*

Snacks: Eat small frequent meals if you fill up quickly.
*

Sweets: Even though a high sugar diet is not the best choice for food, on occasion these calories can be beneficial to avoid weight loss. Good choices are jellybeans, hard candy, sherbets or sorbet.

Vitamins and Minerals
Supplementation of vitamins and minerals in kidney disease needs to be treated on an individual basis. Most people will require a water-soluble vitamin without fat-soluble vitamins or minerals. Mineral levels will need to be checked individually to determine if a supplement is needed. High dosages of any vitamin and or mineral in kidney disease are discouraged since the poor clearance from you kidney can cause toxic levels in the blood.15

Where To Turn For Further Help

It is best to be guided by a nephrologist and a registered dietitian that is familiar with vegetarianism for the optimum nutrition planning. Together these professionals can help manage kidney disease while assisting in appropriate vegetarian food selections. The following organizations can help in locating a dietitian who works with vegetarians:

*

American Dietetic Association-Vegetarian Practice Group www.eatright.org
*

• Seventh Day Adventist Dietetic Associationwww.sdada.org

Joan Brookhyser is a registered dietitian, board certified in renal nutrition, for St. Joseph Medical Center Nephrology Services in Tacoma , Washington . A renal dietitian for over 20 years, Ms. Brookhyser frequently speaks and writes on vegetarianism and kidney disease. She is a vegetarian herself and recently wrote the book, “The Vegetarian Diet for Kidney Disease Treatment.”

References:

1. Barsotti, Giuliano, Morelli, Ester, Cupisiti, Adamasco, et al, A Low-Nitorgen Low-Phosphorus Vegan Diet for Patients with Chronic Renal Failure. Nephron 1996;74: 390-394
2. Walser, M, Hill, S, Tomalis, E., Treatment of Nephrotic Adults with a Supplemented Very Low Protein Diet. Amer J Kid Ds Vol 28, No 3(Sept), 1996; 354-364
3. Pagenkemper, Joni, The Impact of Vegetarianisn Diets on Renal Disease. Top Clin Nutr 1995;10(2): 22-26
4. ADA, Vegetarian Practice Group, Fact Sheet: Vegetarian Diet in Renal Disease, 1998
5. Pagenkemper, Joni, Planning a Vegetarian Renal Diet. J Renal Nutr, Vol 5, No 4(Oct), 1995; 234-238
6. Pellett, Peter, Protein Requirements in Humans, Amer J Clin Nutr, 51:723-37, vol 339: 1990;1131-1134
7. Young, Vernon and Pellett, Peter, Plant Proteins in relation to Human Protein and Amino Acid Nutrition. Amer J Clin Nutr, 1994; 59(supp):1203S-12S
8. Patel, Chhaya, Vegetarian Renal Diet and Practical Applications, Renal Nutrition Forum ADA. Vol 19, No.3, Summer 2000
9. Anderson, James, Soy Protein Decreases Risk for Heart Disease and Kidney Disease. Health Benefit of Soy Products through the Life Span. Lecture October 6, 2000
10. ADA, Vegetarian Diets, Position Paper of American Dietetic Association 1997;1317-1321
11. Anderson, James,Blake, Jill, Turner, Jan, Smith, Belinda, Effects of soy protein on Renal function and proteinuria in patients with Type 2 Diabetes. Amer J Clin Nutr 1998;68(suppl):1347-53S
12. Soroka, N., Silverberg, D.S., Greemland, M. et al, Comparison of a Vegetable-Based (soya) Based and an Animal-Based Low-Protein Diet in Predialysis Chronic Renal Failure Patients. Nephron 1998; 79:173-180
13. D-Amico, G, Gentile, M, Manna, G, Et al, Effect of Vegetarian Soy Diet on Hyperlipidemia in Nephrotic Syndrome. LanceT Ltd, Vol 339, May 9, 1992; 1131-1134
14. Brookhyser, J, Pahre, S, Dietary and Pharmacotherapeutic Consideration in the Management of Renal Osteodystrophy. Adv in Renal Replacement Therapy, Vol 2, No 1 (January) 1995;5-13
15. Wiggins, Kerri, Guidelines for Nutrition Care of Renal Patients, 3rd Ed. 2002

The information contained herein is intended for educational purposes only. It is not intended and should not be construed as the delivery of medical care. Persons requiring diagnosis or treatment, or those with specific questions, are urged to contact their local healthcare provider for appropriate care.

This article originally appeared in the March/April 2004 issue of Kidney Beginnings: The Magazine, Vol. 3, No. 1.