losing weight while on a pre-dialysis diet?

[Callie]

Hi!   I'm pretty new here -- I hope this is the right place for questions about diet, even before dialysis?

My husband is the renal patient.   We've been watching his creatinine climb and egfr decline for the past 5 years.  About 2 years ago we modified our diet significantly -- moved to a much more plant-based diet, less protein, and a lot less meat cooked over a hot dry heat.  At that time his kidney function was probably at about 30%.  (I need to get all his record to see the rate of his decline).

This was tough because my husband is a real meat and potatoes, BBQ loving guy.   I also tended to eat a low carb diet.   I thought at the time that we had been eating quite healthily.  A typical dinner for the grownups in the family would be:

1.) a chop, fillet, or fish or meat steak, lightly basted with olive oil and either sauteed or broiled for 8 minutes or so.
2) sauteed or stir fried leafy green veg (spinach, broccoli, Brussels sprouts, etc)
3) a leafy green salad with some veggies
4) some type of starch. generally steamed or fried potatoes, noodles, or rice.

Well the dietitian we consulted with said to eat a lot more meatless meals.   Reduce protein in general, and stop cooking meats over a hot dry heat -- so broiling was out but crockpot was OK.   NO MORE  red meat, period, chicken maybe 1x week, fish 2x per week.  But smaller portions.  And a lot more vegetarian meals.

SO -- we did all that -- and cholesterol and blood pressure went down for both of us.   BUT -- we both gained weight.   I gained 25-30 pounds in 2 years, and this is after a lifetime of never having had to watch my weight.   I am 5' 8" and was always 130- 135 pre pregnancy, about 140-145 post childbearing (younger child is 7).   I'm now 170! My husband also put on a similar amount of weight on this more plant based diet.

So... bring us up to the current time period:  now his egfr is about 16% (will go in for more blood work in a few weeks so we can see if he's declined further.)   We are supposed to go on an even MORE low protein diet.   But he is also supposed to be losing weight to prepare for a possible living donor transplant.   Even if the transplant doesn't happen, I know he should lose weight, and I know I should too.   

Do you have any suggestions for how we can maintain a low protein pre-dialysis diet, while also losing weight?

[MooseMom]

I have to admit that this has me stumped.  I have no idea why you would be gaining weight on a pre-D diet.

My husband is a meat and potatoes guy, too, (I think most guys are) and I know that if were HIM with CKD, there's no way he would change his diet, so I really applaud your husband for being so compliant.

I have heard a few rumblings in the past here on IHD about cooking methods that are more renally friendly, but I am not sure how much of that is based in real science.  It's something to do with how eating the charred bits from grilling foods is bad for you.  I'm going to have to try and find that discussion.  That just seems like a bridge too far.  But maybe there is some new thinking on the subject about which I am unaware.

I am not entirely sure why red meat is worse than other proteins from purely a renal point of view.  Maybe the dietician is trying to protect your husband's heart and feels that red meat is cardiovascularly riskier, but I always thought that fish in particular was higher in both protein and phosphorus than, say, lean ground beef.  But she is right in telling you that the secret really is smaller portions.  And as for eating a lot more vegetarian meals, I hope she was very clear in telling you that many vegetables are just WAY too high in potassium to even look at!

I'm sorry, but for the life of me, I can't begin to guess what is behind your weight gain.  I hate to ask, but could it be age related?  Are you perhaps more sedentary than you realize?

[smcd23]

What kind of grains are you eating? By eating more carbs, you're more likely to gain weight, especially if those carbs are processed - white rice, white bread etc. Whole grains are better for you if you are watching your weight. I know in our house we buy 2 kinds of all grains - the whole grain for me and the white stuff for SO. Eliminating and reducing protein and replacing with carbs can lead to weight gain because your body will have too much fuel in the form of carbohydrates to use, so it will go into storage by turning in to fat. That could be the cause...

[Callie]

I have to admit that this has me stumped.  I have no idea why you would be gaining weight on a pre-D diet.

My husband is a meat and potatoes guy, too, (I think most guys are) and I know that if were HIM with CKD, there's no way he would change his diet, so I really applaud your husband for being so compliant.

I have heard a few rumblings in the past here on IHD about cooking methods that are more renally friendly, but I am not sure how much of that is based in real science.  It's something to do with how eating the charred bits from grilling foods is bad for you.  I'm going to have to try and find that discussion.  That just seems like a bridge too far.  But maybe there is some new thinking on the subject about which I am unaware.

I am not entirely sure why red meat is worse than other proteins from purely a renal point of view.  Maybe the dietician is trying to protect your husband's heart and feels that red meat is cardiovascularly riskier, but I always thought that fish in particular was higher in both protein and phosphorus than, say, lean ground beef.  But she is right in telling you that the secret really is smaller portions.  And as for eating a lot more vegetarian meals, I hope she was very clear in telling you that many vegetables are just WAY too high in potassium to even look at!

I'm sorry, but for the life of me, I can't begin to guess what is behind your weight gain.  I hate to ask, but could it be age related?  Are you perhaps more sedentary than you realize?

Hi MooseMom!  Thank you so much for your response.

Well, certainly I am getting older and I think women tend to change their metabolism as they hit their mid-40s.  I'm definitely not more sedentary than two years ago, but I did just go back to work and I know that has altered my eating habits.  There may well be more stress related eating in there too.

We both completely cut out alcohol 2 months ago and since then I've lost about .5 pounds every week.  Not much but at least it's in the right direction!

My husband is NOT happy about giving up (most) meat but I'm the chef in the family so he basically has to eat what I make.  Am not sure what he eats while at work, though.   

re: the special cooking techniques our dietitian instructed us on:  as I understand them, they are designed to reduce the amount of AGEs in your food -- Advanced Glycation End Products.  She says (if I recall correctly) that they build up in the body and also come from food you eat; they are implicated in causing high blood pressure, diabetes, and kidney damage, and also they are excreted BY the kidneys so if you have reduced kidney function, you will build up more AGEs and cause more damage.   So, she said as much as you can do to reduces AGEs in your diet, the better.  If the kidney is only able to excrete 10% of the AGEs it is supposed to, you have to reduce your AGEs in food content by 90% -- that kind of thing.   Not impossible when you learn that a serving of broiled steak has 5,000 units of AGEs (however it is mentioned) but meatballs cooked in broth soup have 500 units (just an example.... not sure if that's actually true! But the difference in AGE levels between different foods is really that stark, sometimes.)

I don't know how much consensus there is about these things in the scientific community, though -- that's just what she told us.   She is a dietitian who specializes in pre-dialysis renal nutrition, and she said she has had several patients who have done very well on the low AGEs diet in forestalling dialysis and stalling kidney function decline.   My husband seemed to be doing very well but just for 2 years, so I don't know how effective it was.  However, he did not adopt the low-AGEs diet all the way by any means, which at his level of kidney functioning would have meat a mostly vegan diet which we just weren't able to do. 

I understand what you mean about "a bridge too far".   The past 2 years, we did not particularly have to worry about potassium and phosphorus, with the exception of avoiding a few foods, because my husband didn't seem have any problems with those yet.   So it wasn't so hard to think about cooking in a low Advanced Glycation End Product way.   This meant:  more raw foods, more salads, more steamed foods; much less meat, much less cooked meat -- especially red meat (Red meat has something like twice as many AGEs as chicken or fish, I do believe.)   And what meat or fish we did eat -- we marinate in lemon juice first for an hour, then "poach" by wrapping it in aluminum foil tightly and baking it.

The vegetables were not a problem back then -- that was 2 years ago, when I think his kidney function was about 30% -- but a month ago (at 16%) I think his nephrologist did say that his phosphorus levels were slightly elevated and she recommended we reduce intake of that.  So I recognize it is time to start looking at both phosphorus and potassium more.

[Callie]

What kind of grains are you eating? By eating more carbs, you're more likely to gain weight, especially if those carbs are processed - white rice, white bread etc. Whole grains are better for you if you are watching your weight. I know in our house we buy 2 kinds of all grains - the whole grain for me and the white stuff for SO. Eliminating and reducing protein and replacing with carbs can lead to weight gain because your body will have too much fuel in the form of carbohydrates to use, so it will go into storage by turning in to fat. That could be the cause...

Hi smcd23!  Thank you so much for your reply!

Oh, grains we are eating?   Honestly, a TON more pasta, noodles and white rice.   And pizza.  Also more beans and rice and tortillas.   I guess when I think vegetarian meals I go for the easy stuff -- things the kids will also eat.   So spaghetti twice a week, mac and cheese casserole, vegetarian tacos and burritos, pizza, and sometimes a Greek platter with pita bead, hummus, chickpea salad, marinated veggies, and feta.... but heavy on the pita.

Yeah, so it really is no mystery where these extra pounds are coming from ..... CARBS.

In reflecting, I think I have a problem that might be common in families no matter what stage of  renal illness they are dealing with, especially if they have kids -- how to make changes to someone's diet while still providing meals for the rest of the family (that they will eat.) and, oh yeah, hold down a job, and get the kids to soccer practice...etc.  Without serving the kids (or yourself) crap.

[Callie]

MooseMom -

This is a link to the text of an article published in the Journal of the American Dietetic Association in 2010 that lists the AGE levels of many different types of foods and explains some of the current thinking about the effect of AGEs on different conditions.

http://marshfieldceliac.weebly.com/uploads/2/5/5/7/2557865/ada_ages_in_food_reduction1.pdf

[MooseMom]

Thank you, Callie, for that link!  I remember it now.  Yes, I can see the wisdom in reducing AGEs in the diets of kidney patients.  That makes a lot of sense.  It's just one more thing that makes us feel like food is the enemy.  The authors of this study didn't take into account the problems with potassium that renal patients are prone to.  Whenever anyone says that a more plant based diet is best, well, that is probably true for most people, but not for us.  And so what happens?  You end up with exactly the problem you and your husband are facing right now...overconsumption of carbs because whole grain foods are too high in phosphorus (so, no more multigrain breads or brown rice) and beans of all kinds (except for green beans) are too high in both phos and potassium.  AND if you are pre-dialysis, there is the added restriction on protein intake.

Unless you have access to organic produce, our foods are so heavily processed that for us renal patients, it really does feel like food is the enemy.

Anyway, thanks for that info.  I don't think I've ever poached chicken or fish before, so I'm going to try it.

[Callie]

Well, the dietitian told US to eat a plant based diet, mostly, but again at the time my husband had no problems with phosphorus or potassium.

But if you look at the AGE listings at the end of the study, you can see that some types of meat prepared certain ways have as few AGEs as many vegetables, at least cooked ones.

For example, a 90g serving of corned beef brisket has 179 kU of AGEs.  The same amount of beef, stir fried, with oil, has 8,570 k/U of AGEs.
90 g of skinless, broiled chicken breast = 5,245
90 g of poached chicken breast = 991

OK now corned beef brisket has a lot of salt so it isn't good for anyone anyhow.   But that's just one example of how huge the variations in AGEs can be, depending on how you cook the food.   And I would think that by choosing more on the low end for cooking, for each type of food, one should be able to make a significant reduction in intake of AGEs.

Whether it is scientifically proven to make a difference, is of course another question.   Anecdotally since we adopted this low AGEs diet -- as I said, my husband still experienced kidney decline, however his blood pressure and cholesterol both went way down (good cholesterol went up).   I never had a problem with either, but my good cholesterol went way up and LDL went way down, too-- doctor was very impressed.

Anyhow that has nothing to do with weight loss!   But I did want to explain.

[MooseMom]

Oh, I agree, Callie; a more plant based, less processed diet is unquestionably better for all of us.  And to further complicate matters, there is a difference between inorganic phosphates (what you see in colas and processed meats) and the organic phosphorus you see in beans.  I personally could live on beans, but beans give a double whammy by being also high in potassium.  I will eat beans occasionally, but usually as a salad topping.  And whenever I go back down south, I have to have at least one meal that includes black-eyes peas.

I can understand doing just about anything to stay off of dialysis as long as possible!  Has your husband been back to the renal dietician since his egfr has dropped below 20%, and if so, what has she had to say about potassium?  If he has not seen her recently, does he plan to do so?

[smcd23]

Callie, I have been guilty of grabbing some McDonalds on the way home for work for me and the little guy after a busy day. It's tough but luckily my little guy eats everything we eat so it hasn't been a big change for him, but it has been a big change for me. I miss having things with cheese and making quick things like bagel pizzas and such for dinner.

It's interesting that the pre dialysis diet differs so much from the dialysis diet. We have to have protein at every meal now, which is a challenge, because there is only so much chicken and pork I can eat!

[Callie]

Oh, I agree, Callie; a more plant based, less processed diet is unquestionably better for all of us.  And to further complicate matters, there is a difference between inorganic phosphates (what you see in colas and processed meats) and the organic phosphorus you see in beans.  I personally could live on beans, but beans give a double whammy by being also high in potassium.  I will eat beans occasionally, but usually as a salad topping.  And whenever I go back down south, I have to have at least one meal that includes black-eyes peas.

I can understand doing just about anything to stay off of dialysis as long as possible!  Has your husband been back to the renal dietician since his egfr has dropped below 20%, and if so, what has she had to say about potassium?  If he has not seen her recently, does he plan to do so?

I did not know that there was a potassium difference.   SO does it make a difference in how your body processes inorganic versus organic, or does it all need to be limited the same amount?

Yes, my husband and I will be going back to the dietitian.  He hasn't made an appointment yet.   Since we got this new diagnosis he's had a laundry list of dr.'s to go see to get a checkup or clearance in order to be approved (we hope) for a transplant.   That has been about 2 appointments per week .  It's hard right now for him to take time off of work.   But we should go back soon... mid June I should hope.

[Abdiel]

Yeah this is possible,Let me tell you what i am feeling right now.The diet he is taking is alright according to me but you need to follow what the nutritionist have said.Prefer having vegetables in your meal because that is the finest for losing your fats.I have personally had it for a long time and results are very good i mean i have lost my fats and achieved my goal in a healthy way without any side-effects.