CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction The aim of this chapter is to look into the literature that has already been published on the renal disease 2.2 Renal Dietary Guidelines A person with acute or chronic renal failure needs to follow a renal diet regardless of whether they are on dialysis or not so as to control the amount of waste products to levels the body tolerates. The diet helps prevent the accumulation of waste products which would in turn cause secondary illnesses and further decreases kidney function. Some of the restricted nutrients include Protein, Sodium, Potassium, Phosphorus and Fluids.

2.2.1 Protein Protein requirements differ for different patients and the dietician or doctor can recommend how much is required for each patient. It is important to remember that protein is very important in a renal diet to prevent loss of weight and to maintain health. As cited by Weir (2007), It is important to note that reduction in dietary protein can reduce glomerular filtration rate, hyperfiltration, and proteinuria, which could be helpful in mitigating the progression of kidney disease. According to Convenor, Thomas, Johnson, Nicholls and Gillin (2006), Low protein diets have been recommended as a treatment for retarding renal failure progression for over 50 years. The diet restricts protein at various levels as listed below. Traditionally the regulation of protein was pegged at the following:

 40g per day - for conservative management i.e. patients with chronic renal failure being managed with the diet alone. 60g/protein day for patients on haemodialysis. This is because of accelerated protein catabolism due to the interaction between blood and the membrane in the dialyser. 80g for those on continuous peritoneal dialysis. Owing to the more regular nature of peritoneal dialysis needs are increased because protein diffuses across the membrane into the dialysate. Advancements in protein metabolism have however negated these guidelines and replaced them, as cited by Convenor, Thomas, Johnson, Nicholls and Gillin (2006), with the more moderate restriction of: 0.751.0 g/kg/day, for adults with chronic kidney disease (CKD). The administration of a low protein diet ( 0.6 g/kg/day) to slow renal failure progression is not justified when the reported clinically modest benefit on glomerular filtration rate (GFR) decline is weighed against the concomitant significant declines in clinical and biochemical parameters of nutrition. Protein with a high biological value (HBV) should be used for maximum utilization and these should be distributed through the 3 meals. HBV protein according to Report of a Joint WHO/FAO Expert Consultation on Diet, Nutrition And The Prevention Of Chronic Diseases (2003) is usually of animal origin and good sources include eggs, meat fish, and poultry, milk & milk products. Other sources of protein include vegetables, starch or carbohydrates or staple foods. These foods contribute smaller amounts but they still contribute to total intake. It is important therefore to utilise this other group of protein sources when coming up with snack foods for renal patients with a protein restriction as they give the least amount of protein.

2.2.2 Fluid Patients with advanced kidney disease or on dialysis often need to control the amount of fluids (water and other liquids) that they take. Fluid is restricted in renal patients because they produce small amounts of urine to none. If there is excess build-up of fluid and it is retained in the tissues a condition referred to as hypervolemia. The hypervolemia is characterized by an increase in weight, swelling in the legs and arms (peripheral edema), and/or fluid in the abdomen. Eventually, the fluid enters the air spaces in the lungs, reduces the amount of oxygen that can enter the blood, and causes shortness of breath. Urine output + (500 -600 ml) = __________________ml/day As stated by de Luis and Bustamante (2008) Water balance should be calculated, taking into account the residual urine output of patients. Fluid intake should usually be approximately 500600 mL, added to the residual urine output of patients. As a way of monitoring their intake and to ensure no mistakes are made ensure a patient measures the water they need for the day and place it in a separate container. For ever cup of other liquids they drink remove the same amount from their container and throw it away. Consequentially a restricted fluid diet results in thirst. This according to the National Institute of Diabetes and Digestive and Kidney Diseases (2006) can be helped by: Drinking cold water or sucking ice chips within your fluid retention Eating sour or lemon flavored sweets Avoiding salty foods as they make a person more thirsty Eating cold fruit or fruit slices as they are more refreshing.

2.2.3 Sodium or Salt

There is sufficient evidence in the literature to indicate that dietary salt may be a modifiable risk factor for the progression of kidney disease, (Weir, 2007). A diet high in salt can contribute to raised blood pressure, and fluid retention and for a patient on a fluid restriction, salt can make them thirsty and therefore makes it difficult to stick to their fluid limits. Sodium is commonest in table salt but it is also found in most foods and according to The National Institute of Diabetes and Digestive and Kidney Diseases (2006), too much sodium in your diet can be harmful because it causes your blood to hold fluid. The extra fluid raises your blood pressure and puts a strain on your heart and kidneys. The following are common foods with high sodium levels as stated in the South African Renal Exchange Lists (2005) Table 2.1 Foods with high amounts of Sodium High Sodium levels Starch pizza, salted crackers, pastries, commercial biscuits and cakes, ready to eat cereals e.g. cornflakes, potato crisps, corn chips e.g. zapnaks, lakkernax, Jiggies, corn curls, things tinned especially in brine, salted, or dried meats or fish e.g. biltong Processed Meat, Poultry fish meats e.g. sausage, ham, polony, fish paste, corn beef, viennas e.t.c, Salted peanut butter, Soya products, salted nuts, shellfish e.g. prawns, shrimp, oysters, mussels, Take away meat dishes Vegetables Beverages Gherkins/pickled, cucumber, Pickled onion Milo, Nesquick, Drinking Chocolate, and most chocolate flavoured drinks.

Spices and stock cubes, gravy powder, ready to make soup packets, usavi mix, tomato sauce, Condiments chutney, soy sauce, meat and vegetable extracts (e.g. Marmite), pickles, salt substitutes, meat tenderizers, foods containing Monosodium Glutamate (MSG).

General guidelines on lowering food potassium content include alternative seasonings like lemon juice, salt-free seasoning mixes, or hot pepper sauce. But it is advised to avoid salt substitutes that use potassium, The National Institute of Diabetes and Digestive and Kidney Diseases (2006).

2.2.4 Potassium The main route for eliminating potassium in the body is through the kidneys and hence advanced forms of kidney failure such as CRF or ARF cause elevations in the blood potassium level (hyperkalemia). The following is a table summarising Potassium levels in common foods as stated in the South African Renal Exchange Lists (2005) Table 2.2 Categorisation of food stuffs by Potassium quantities High Potassium levels Apricots, Banana, Mango, Fruit salad with fruits to be avoided, Fruits Naartijie, Oranges, Peaches, Grape fruit, Grapes, Guava, Paw Paw, Watermelon, Pineapples, Melon, Raisins Potatoes, Salted popcorn, Starch Pancakes, Sweet Rice, Sadza/porridge, Samp, Pasta, Oats, Moderate Potassium levels Low Potassium levels Apples, Avocado, Cherries, Fruit salad with fruits low in potassium, Granadilla, Lemon, Pears, Plums, Mulberries, Strawberries, Litchi Kumquat, Prickly pears

potatoes, Muffins, Pudding/cakes/pies/tarts Starch made with milk and eggs, Savoury snacks, Hot cross buns, egg noodles, All Bran Flakes, Crude Bran wheat, Sponge cakes/Swiss roll.

Scones, Apple tart, Butter cake, White or brown or whole wheat bread or rolls, Gingerbread, Madeira, Corn flakes, Chocolate clairs with cream filling, Plain doughnuts, Sugar coated popcorn, Mealierice, Noodles, Pearl barley cooked

Madhumbe, Spinach, Vegetables Okra, Beetroot, Green beans, Mushrooms, Carrots

Asparagus, cooked (green) Cauliflower, cooked Mushroom, raw, sliced Tomato, raw Beetroot, cooked

Cabbage, Lettuce, Onion, Cauliflower, Broccoli, Pepper (all types), Peas, Cucumber, Celery, Asparagus, Corn, Sweet corn, Carrots, Pumpkin/butternut/gem squash/baby marrows Tomato,

All nuts, Other Foods Sunflower seeds Assorted chocolates Peanut butter

The following recommendations are given by National Institute of Diabetes and Digestive and Kidney Diseases (2006) for the reduction of potassium in foods: Cut vegetables and starces with a high potassium content into small pieces and soak them in water before consumption. Boil the food in large amounts of water, discard the water and do not use it to make sauces or gravy Use canned vegetables or fruits but do not use the syrup

2.2.5 Phosphorus At physiologic levels of serum phosphorus and during a normal dietary phosphorus intake, approximately 6 to 7 g/d of phosphorous is filtered by the kidney. Of that amount, 80% to 90% is reabsorbed by the renal tubules and the rest is excreted in the urine, (Levi and Popovtzer, 2003). If the amount of phosphorus that is supposed to be excreted is not excreted this results in an increase in serum phosphate levels, a condition known as hyperphosphatemia Too much phosphorus in your blood pulls calcium from your bones. Short term effects of this are itchy skin while the major long term complication is weakened bones which are likely to break.

As the kidney disease progresses, there will be need to take a phosphate binder like calcium acetate, or calcium carbonate to control the phosphorus in the blood, (National Institute of Diabetes and Digestive and Kidney Diseases 2006). Because it is bound, the phosphorus does not get into the blood. Instead, it is passed out of the body in the stool. As stated by Levi and Popovtzer, (2003) hyperphosphatemia in patients with end-stage renal disease is managed from a

dietary perspective by phosphate restriction and phosphate binders to decrease gastrointestinal phosphate reabsorption.

The following is a table summarising Phosphate levels in common foods as stated in the South African Renal Exchange Lists (2005)

Table 2.3 Categorisation of food stuffs by Phosphate quantities

High Phosphate levels Dairy milk, cheese, yoghurts, eggs, ice cream, Baked custard

Moderate Phosphate levels

Low Phosphate levels double cream & water, low fat milk and milk products such as yoghurt, powdered milk etc.

Meat

liver, kidney, pate, game, shell fish, kippers, whitebait, roe

Beef, lamb, pork, chicken, turkey, Rabbit, White fish, fish fingers/cakes, tuna, salmon

Starch

Cereals containing bran, nuts or chocolate, chocolate biscuits, oatcakes, scones, rye crisp bread

All other cereals without bran. Cream crackers, water biscuits, digestives, rich tea, shortbread, crumpet, pancake,

doughnuts, jaffa cakes, pastries milk chocolate, Other Foods nuts, baking powder, cocoa, marzipan, Marmite Plain chocolate, boiled sweets, jelly sweets, mints, chewing gum

2.2.6 Energy According to Bull (1980), some patients with advanced renal failure do not eat well. It is important to have a nourishing diet, with enough protein and calories. As a result such renal cases have a less than average weight for their height. It may be possible to relax dietary restrictions for a short period until their appetite improves. Patients on haemodialysis sometimes seem to burn calories faster than usual, so the recommendation for calorie intake is usually slightly increased, to prevent unintentional weight loss, (National Institute of Diabetes and Digestive and Kidney Diseases 2006). Energy requirements may be calculated by formulas used for nutritional evaluation in general patients (with no renal failure), such as the Harris-Benedict formula or other special formulas. However, various authors use approximations to facilitate daily practice ranging from 35-40 calories per kg and day in chronic kidney disease.

Table 2.4 Human Energy Requirements Formulae Equation Harris Benedict Male Female Sex Formula (EE- Energy Expenditure) EE = 66 + (13.7 x weight) + (5 x height) - (6.8 x age) EE = 655.1 + (9.6 x weight) + (1.8 x height) - (4.7 x age)

formula De Luis Male Female Males(18-30yrs) Males(30-60 yrs) Males> 60 yrs Schofield Females(18-30yrs) Females(30-60 yrs) Females> 60 yrs
Source: (de Luis and Bustamante, 2008)

EE = 58.6 + (6.2 x weight) + (1,023 x height) - (9.5 x age) EE = 1,272.5 + (9.8 x weight) - (61.6 x height) - (8.2 x age) EE = 15.3 x weight + 679 EE = 11.6 x weight + 879 EE = 13.5 x weight + 487 EE = 14.7 x weight + 496 EE = 8.7 x weight + 829 EE = 10.5 x weight + 596

2.3

Nutraceutical

2.3.1 Definition According to DeFelice (1989), nutraceutical can be defined as, a food (or part of a food) that provides medical or health benefits, including the prevention and/or treatment of a disease. Nutraceuticals though intricately inter-twined with functional foods, they are not to be confused. Kalra (2003), Defines functional foods as foods cooked or prepared using "scientific intelligence" with or without knowledge of how or why it is being used. The distinction between the two is elaborated by the more recent definition coined by Kalra (2003) that When functional food aids in the prevention and/or treatment of disease(s) and/or disorder(s) other than anemia, it is called a nutraceutical. Thus a functional food can be said to be a subset of a nutraceutical.

2.3.2 Concept of Nutraceuticals

2.3.2.1 Food & Nutrition As Medicine Food can be utilized to retain, maintain or attain good health depending on its nutritional composition. This however to be effective is dependent on the health and nutritional needs of the individual consuming the food. The nutrition related needs of individuals, population segments can be viewed as a hierarchy of, foundation, condition specific and enhancement needs, (Ernst & Young, 2009). The diagram below is an illustration of the hierarchy.

Enhencement Needs

T fu

Condition specific needs

Foundation needs

Source: (Ernst & Young, 2008)

This hierarchy of nutritional needs is complemented by various nutraceutical product segments that exist across the need hierarchy. These products aim to fulfill different consumer needs based on which they can be classified as Enhancement segments, Condition specific segments and

Foundation segments. Below is a diagram showing the complementary products for the nutritional hierarchy.

High protein supplements Energy drinks Sports drinks Glucose drinks

Antioxidants Vitamin supplements Mineral supplements

Macronutrient supplements Nutrition fortified foods, e.g., (fortified flour) Probiotic foods, e.g., (yogurt) Extracts

According to report published by Indias Ernst & Young (200X) as a concept nutraceuticals is in its stage of infancy with several developed countries having defined it only in the last 15 years though it is globally a USD117 billion dollar industry, and still growing. The presence of nutraceuticals in the global market of therapies and therapeutic agents has been solidified by the following, as enumerated by Kalra (2003): 1. The high cost of prescription pharmaceuticals and reluctance of some insurance companies to cover the costs of drugs,

2. A ray of "cure preference" in the mind of common patients revolves around nutraceuticals because of their false perception that "all natural medicines are good." 3. Nutraceuticals accomplish desirable therapeutic outcomes with reduced side effects, as compared with other therapeutic agents. Nutraceuticals are represented for use as a conventional food or as the sole item of meal or diet. Nutraceuticals must not only supplement the diet but should also aid in the prevention and/or treatment of disease and/or disorder. 1. However, with all of the aforementioned positive points, nutraceuticals still need support of an extensive scientific study to prove "their effects with reduced side effects."