Nutrition interventions to address cardiovascular outcomes in chronic kidney disease

Abstract

The high mortality in chronic kidney disease has been linked to cardiovascular risk and these patients are considered at high risk. Dietary intervention can directly address nutritional risk factors in lipid management, calcium-phorphorus balance, and body composition to reduce risk of cardiovascular disease. Nutrient intake can also indirectly address less overt risks of dental health, nutritional supplements, and compliance issues. The high mortality in chronic kidney disease has been linked to cardiovascular risk and these patients are considered at high risk. Dietary intervention can directly address nutritional risk factors in lipid management, calcium-phorphorus balance, and body composition to reduce risk of cardiovascular disease. Nutrient intake can also indirectly address less overt risks of dental health, nutritional supplements, and compliance issues. The annual mortality in end-stage renal disease (ESRD) exceeds 20% and more than half of these deaths can be linked to cardiovascular disease (CVD).1Levey A.S. Controlling the epidemic of cardiovascular disease to patients with chronic renal disease: Where do we start? Executive summary.Am J Kidney Dis. 1998; 32: S5-S13Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 2U.S. Renal Data SystemsUSRDS 2003 Annual Report, Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar The incidence of CVD is higher in chronic kidney disease (CKD) patients compared with the general population. The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study, a national cross-sectional cohort of over 1,000 dialysis (CKD stage 5) patients, was recently compared with a variable-adjusted data set of participants older than 40 years from the Third National Health and Nutrition Examination Survey (NHANES III). A projected 5-year outcome based on the Framingham Risk Equation, which utilizes traditional CVD risk factors (age, gender, cholesterol, blood pressure, smoking, left ventricular hypertrophy, and glucose intolerance), found dialysis patients to be at significantly higher risk. The mean overall risk differences for the 40–49-year-old age group was 6.5% compared with 2.3% (CHOICE compared with NHANES III) and 20% compared with 13% for those older than 70 years.3Longenecker J.C. Coresh J. Powe N.R. et al.Traditional cardiovascular disease risk factors in dialysis patients compared with the general population The CHOICE study.J Am Soc Nephrol. 2002; 13: 1918-1927Crossref PubMed Scopus (527) Google Scholar The percentage of reported United States Renal Data System cadaver-donor postrenal transplant patients with comorbid CVD and congestive heart failure (CHF) increased from 40% to 50% from 1995 to 2001, and similar increases occurred for living related-donor transplants.2U.S. Renal Data SystemsUSRDS 2003 Annual Report, Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar Patients in all dimensions of CKD (stages 1 to 5) are, therefore, considered to be in the highest CVD risk category and are recommended to be treated accordingly.1Levey A.S. Controlling the epidemic of cardiovascular disease to patients with chronic renal disease: Where do we start? Executive summary.Am J Kidney Dis. 1998; 32: S5-S13Abstract Full Text PDF PubMed Scopus (128) Google Scholar The goal of this review is to outline nutrition interventions that may reduce CVD risk in CKD. Cardiovascular risk management is composed of many facets, all best managed by individualization to patient parameters and attainable goals. Some nonnutritional risk factors cannot be modified (age, ethnicity, and gender), whereas others can be addressed to reduce risk (smoking, physical activity, and blood pressure). Nutrition risk factors are also an important component of CVD risk management. Dietary composition changes can decrease overall risk by affecting lipid management, calcium-phosphorus balance, and body composition.1Levey A.S. Controlling the epidemic of cardiovascular disease to patients with chronic renal disease: Where do we start? Executive summary.Am J Kidney Dis. 1998; 32: S5-S13Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar Nutrient intake can also have an impact on less obvious CVD risk factors influenced by food safety, dental health, nutritional supplements, and behavior modification techniques. The Kidney Disease Outcome Quality Initiative (K/DOQI) dyslipidemia clinical guidelines suggest all CKD patients should be managed similar to existing lipid guidelines for high-risk non-CKD patients. Lipid management should be initially assessed by a fasting lipid profile at baseline screening. If a fasting profile is not possible, a nonfasting serum sample (and before hemodialysis treatment in stage 5 patients) should be used to complete the initial evaluation. Lipid abnormality patterns and corresponding drug management guidelines are individualized by CKD stages. Regardless of treatment modality and concomitant drug therapy, specific changes in dietary lipid composition can be used to reduce risk in all CKD stages.4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar CKD patients may exhibit lipid abnormalities different from the non-CKD population but still represent potential high-risk outcomes. For example, a low-normal serum cholesterol found in chronic stage 5 hemodialysis patients despite high CVD risk may represent confounding variables of underlying protein-energy malnutrition and/or chronic inflammation, whereas an increased body-mass index (BMI) and hypercholesterolemia may actually improve outcome in some patients.5Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in AdultsExecutive Summary of the Third Report of the National Cholesterol Education Program (NCEP).JAMA. 2001; 285: 2486-2497Crossref PubMed Scopus (24129) Google Scholar The K/DOQI clinical practice dyslipidemia guidelines support the use of American Heart Association (AHA) and the National Cholesterol Education Program (NCEP) dietary components when planning diets for patients with CKD.4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar, 6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, 7Kalantar-Zadeh K. Fouque D. Kopple J.D. Outcome research, nutrition, and reverse epidemiology in maintenance dialysis patients.J Renal Nutr. 2004; 14: 64-71Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The emphasis on dietary modification focuses on the degree of saturation of the fat as well as on the total amount of fat in the diet. The daily goals for distribution of dietary fat intake are as follows: monounsaturated fat (MUFA), up to 20% of total kilocalories;polyunsaturated fat (PUFA), up to 10% of total kilocalories; andsaturated fat, less than 7% of total kilocalories. The most beneficial fats with the lowest saturation level are MUFA and PUFA. Olive oil and canola oil are common sources of MUFA, whereas corn oil, soybean oil, and other similar oils contain higher amounts of PUFA. Saturated fat is found primarily in animal sources such as egg yolk (not egg white), animal fat (marbled within meat and visible fat), butter, and full-fat dairy products. With the renewed emphasis on quality of dietary protein to maintain adequate serum albumin, a significant amount of hidden saturated fat can accompany the increased servings of animal protein. Saturated fat can also be found naturally from nonanimal sources such as coconut oil. The majority of dietary nonanimal saturated fat intake comes from commercially modified vegetable fats that have been hydrogenated to contain more saturated hydrogen bonds. For example, the degree of saturation increases with the progressive hydrogenation of corn oil from liquid oil to soft margarine to stick margarine. The trans-fatty acids produced by this modification have been linked with higher serum levels of low-density lipoproteins (LDLs) and lower serum levels of high-density lipoproteins (HDLs), and they are believed to increase the risk of atherosclerotic lesions in vessels over time.8Lichtenstein A.H. Ausman L.M. Jalbert S.M. et al.Effects of different forms of dietary hydrogenated fats on serum lipoprotein cholesterol levels.N Engl J Med. 1999; 340: 1933-1940Crossref PubMed Scopus (305) Google Scholar Soft dietary fats that contain plant sterol esters are now available with no trans-fatty acids. Two tablespoon servings a day, each containing 1.7 g of plant sterol esters, have been shown in clinical studies of non-CKD patients to lower serum lipids, specifically LDL, by 6% to 15%. Commercial brands include Take Control (Unilever Bestfoods, Engelwood Cliffs, NJ) Benecol (Neil Consumer Health-Care, Fort Washington, PA), and Smart Balance (GFA Brand, Heart Beat Foods, Cresskill, NJ).4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar The total amount of dietary fat should be 25% to 35% of total calories a day. A typical 2,000-calorie diet would contain 55 to 65 g of fat. CKD patients must be provided with sufficient calories to promote use of the recommended amount of protein calories for maintenance of an adequate serum albumin and lean-body mass. The amount of protein required each day is matched to level of kidney function as determined by stage of CKD, treatment modality, and protein status. Fat calories should be distributed throughout the day to provide essential fatty acids and satiety between meals.4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar, 6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, 7Kalantar-Zadeh K. Fouque D. Kopple J.D. Outcome research, nutrition, and reverse epidemiology in maintenance dialysis patients.J Renal Nutr. 2004; 14: 64-71Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The body of evidence in non-CKD is larger for lipid-lowering strategies. Although substantial research is lacking in the CKD population, these practices may be applicable with close monitoring and individualization in highly motivated patients. The use of omega fatty acids found in fish with higher fat content (tuna and salmon), in shellfish, and in nut meats had low to moderate lipid-lowering effects in short-term studies of both CKD and non-CKD populations.6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, 9VanBeber A.D. Weber C.G. Gorman M.A. et al.The effect of dietary omega-3, -6, and -9 fatty acid supplements on serum fatty acid concentrations in renal dialysis patients Implications for immune response.J Renal Nutr. 1995; 5: 194-203Abstract Full Text PDF Scopus (1) Google Scholar, 10Von Schacky C. Angerer P. Kothny W. et al.The effect of dietary omega-3 fatty acids on coronary atherosclerosis a randomized, double-blind, placebo-controlled trial.Ann Intern Med. 1999; 130: 554-562Crossref PubMed Scopus (421) Google Scholar A recent “portfolio” diet tested in a non-CKD cohort lowered and maintained beneficial levels of serum lipids. Components of the diet include low saturated fat content, small servings of almonds, and an increase in viscous/soluble fiber.11Jenkins D.J.A. Kendall C.W.C. Marchie A. et al.Effects of a dietary portfolio on cholesterol-lowering foods vs Lovastatin on serum lipids and c-reactive protein.JAMA. 2003; 290: 502-510Crossref PubMed Scopus (463) Google Scholar Four tablespoons (1.25 ounces) of almonds contain approximately 220 kilocalories, 9 g of protein, 190 mg of phosphorus, 260 mg of potassium, 4 g of fiber, and 18 g of beneficial nonsaturated fat.12Diet Analysis Plus, Version 6.0, ESHA Research, Belmont, CAGoogle Scholar Substitution of 1 serving of nuts for a comparable protein source may increase kilocalories and protein in patients challenged by nephrotic syndrome or protein-calorie malnutrition. The use of primarily nonanimal protein, however, may lower the biological value of total protein, which may be inadequate to maintain serum albumin, particularly in dialysis patients (CKD stage 5). Good sources of viscous/soluble protein include 0.5 cup of eggplant (123 mg of potassium) or 0.5 cup of okra (365 mg of potassium); these vegetables are often found as part of the “Mediterranean” diet.11Jenkins D.J.A. Kendall C.W.C. Marchie A. et al.Effects of a dietary portfolio on cholesterol-lowering foods vs Lovastatin on serum lipids and c-reactive protein.JAMA. 2003; 290: 502-510Crossref PubMed Scopus (463) Google Scholar Viscous/soluble fiber is preferable to dry fiber sources such as psyillum or powdered fiber tablets or capsules because of fluid restrictions in stage 5 hemodialysis patients. A meta-analysis of 10 controlled trials (n = 1,603 non-CKD patients) addressed the lipid-lowering properties of oat products, specifically 1.5 cups of whole-grain oatmeal a day (3 g of soluble fiber). A modest decrease was seen in serum cholesterol levels of 5 to 6 mg/dL after 6 weeks. Although not detrimental to the CKD population, this recommended oatmeal serving contains 267 mg of phosphorus and 196 mg of potassium, which must be considered when planning chronic intake.13Ripsin C. Keenan J.M. Jacobs D.R. et al.Oat products and lipid-lowering A meta-analysis.JAMA. 1992; 267: 3317-3325Crossref PubMed Scopus (401) Google Scholar The use of viscous or oatmeal fiber sources have not been studied in the CKD population. Research in non-CKD populations has shown some serum lipid reduction with the addition of soy protein and garlic in the diet. A meta-analysis of 38 controlled trials (n = 564 non-CKD patients) found a reduction in serum lipid levels when a mean daily intake of 47 g/day of soy protein (range 25 to 50 g/day) was ingested. The feasibility in the CKD population has limitations because the biological value of soy protein may be inferior to other protein sources when dietary protein is limited to slow the progression of kidney disease or when high-quality protein is necessary to maintain or increase serum albumin.14Anderson J.W. Johnston B.M. Cook-Newell M.E. Meta-analysis of the effects of soy protein intake on serum lipids.N Engl J Med. 1995; 333: 276-282Crossref PubMed Scopus (1769) Google Scholar A small study of 15 stable renal transplant patients with moderate hypercholesterolemia showed substitution of 25 g of animal protein daily with 25 g of soy protein for a 5-week period had beneficial effects on LDL cholesterol levels.15Cupisti A. D’Alessandro C. Ghiadoni L. et al.Effect of a soy protein diet on serum lipids in transplant patients.J Renal Nutr. 2004; 14: 31-35Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar A meta-analysis of 5 controlled trials (n = 410 non-CKD patients) examined the effect of garlic on total serum cholesterol during 8-week to 24-week study periods. The amount of garlic ingested varied from 0.5 clove to 1.0 clove per day in the form of a tablet, powder, or aqueous extract. A 9% reduction of serum cholesterol was observed compared with placebo.16Warshafsky S. Karmer R.D. Sivak S.L. Effect of garlic on serum cholesterol A meta-analysis.Ann Intern Med. 1993; 119: 599-605Crossref PubMed Google Scholar The magnitude of risk reduction was linked in all 3 meta-analyses to the initial serum cholesterol level, and the effect was removed when the treatment was ended. Long-term use has not been investigated in the non-CKD population and may not be appropriate for certain levels of CKD. Recent evidence in CKD patients has linked high calcium intake from diet or phosphate binders to increased calcification risk of major blood vessels.17Raggi P. Boulay A. Chasan-Taber S. et al.Cardiac calcification in adult hemodialysis patients A link between end-stage renal disease and cardiovascular disease?.J Am Coll Cardiol. 2002; 39: 695-701Abstract Full Text Full Text PDF PubMed Scopus (991) Google Scholar A study of younger dialysis patients showed calcification was evident even in this age group.18Goodman W.G. Goldin J. Juizon B.D. et al.Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis.N Engl J Med. 2000; 342: 1478-1483Crossref PubMed Scopus (2431) Google Scholar The Kidney Disease Outcome Quality Initiative (KDOQI) clinical practice guidelines for bone metabolism and disease in CKD recommend an oral intake limit of 2,000 mg of calcium a day from diet, phosphate binders, and other medication or supplement sources.19National Kidney FoundationK/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease.Am J Kidney Dis. 2003; 42: S1-S202Crossref PubMed Scopus (665) Google Scholar Many food products are now fortified with calcium because of higher interest in osteoporosis prevention in the non-CKD population. BMI is a mathematical equation of height and weight. BMI of greater than 30 has been associated with obesity and greater cardiovascular risk in non-CKD populations. Men genetically have higher lean-body mass and lower fat mass when compared with women. BMI alone may not accurately predict outcome as protein malnutrition may be present concurrently with obesity.5Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in AdultsExecutive Summary of the Third Report of the National Cholesterol Education Program (NCEP).JAMA. 2001; 285: 2486-2497Crossref PubMed Scopus (24129) Google Scholar Dry weight and lean-body mass, especially in hemodialysis patients, is more complicated to estimate than in non-CKD patients. A recent study has recommended both dual-energy X-ray absorptiometry and air-displacement plethysmography as more reliable methods to estimate lean-body mass in CKD patients compared with bioelectrical impedance.20Flakoll P.J. Kent P. Neyra R. et al.Bioelectrical impedance vs air displacement plethysmography and dual-energy x-ray absorptiometry to determine body composition in patients with end-stage renal disease.JPEN. 2004; 28: 13-21Crossref PubMed Scopus (20) Google Scholar Waist circumference (men <40 inches and women <35 inches) may represent a goal BMI of 25 to 28 kg/m2.21National Kidney FoundationK/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am J Kidney Dis. 2000; 35: S1-S140PubMed Google Scholar Peritoneal dialysis patients typically have lower lean-body mass and higher fat mass because of high chronic glucose load of the dialysate. The onset of obesity after kidney transplantation has been shown to be a significant risk factor.22National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in transplant patients.Am J Trans. 2004; 4: 11-53Google Scholar Any recommendation of reduction of CVD by diet should also include recommendations for increased physical activity. The term functional activity has been used to emphasize energy expended in daily functions such as vacuuming, gardening, cleaning, and other common tasks. The American Heart Association recommends even a moderate activity of 30 minutes a day can decrease risk and that such activity can be completed through the day or at 1 time period for similar benefits. A simple guideline of 10,000 steps a day is attainable in many dialysis patients over time and can be measured by the use of pedometers.6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, 23Beto J.A. Bansal V.K. Interventions for other risk factors tobacco use, physical inactivity, menopause, and homosysteine.Am J Kidney Dis. 1998; 32: S172-S184Abstract Full Text PDF PubMed Scopus (19) Google Scholar Newer models are available that are easier to use, record only steps, and are relatively inexpensive (<$15.00). A cohort of 60 chronic hemodialysis patients in an observational pilot study wore a pedometer for 7 consecutive days (3 dialysis days and 4 nondialysis days) and was instructed to complete normal activities without changing typical activity patterns. The majority of patients found the pedometer simple to use but logged less than 2,500 steps a day; they logged more steps on dialysis days than nondialysis days. Response was positive, and most patients expressed interest in using the pedometer for longer periods of time, with the goal of increasing the number of daily steps. One patient was able to log more than 9,000 steps and participated in a local kidney foundation walk.24McGaffigan L. Relationship of daily activity levels estimated by pedometer to kidney disease quality of life questionnaire in chronic hemodialysis patients. Unpublished data, 2002Google Scholar To be most effective, physical activity must be undertaken in conjunction with multiple CVD risk factor reduction. A recent study in kidney transplant recipients found exercise training alone did not reduce CVD risk during the first year after transplantation.25Painter P.L. Hector L. Ray K. et al.Effects of exercise training on coronary heart disease risk factors in renal transplant recipients.Am J Kidney Dis. 2003; 42: 362-369Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Carbohydrate intolerance and insulin resistance are often present in the CKD population. More than 50% of the patients who start dialysis have diabetes.2U.S. Renal Data SystemsUSRDS 2003 Annual Report, Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2003Google Scholar Tight glycemic control has been shown to slow the progression of nephropathy and neuropathy in early CKD stages, but few studies are available that assess lipid impact. The value of strict glucose control in stage 5 CKD is less clear, needs to be assessed on an individual basis, and may be more difficult to achieve. Peritoneal dialysis patients are particularly challenged by dialysate glucose load and hyperlipidemia patterns that may be resistant to conservative therapy.4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar Kidney transplant patients may face glycemic control challenges from immunosuppressive medications and body weight increases over time.22National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in transplant patients.Am J Trans. 2004; 4: 11-53Google Scholar, 26Manske C.L. Hyperglycemia and intensive glycemic control in diabetic patients with chronic renal disease.Am J Kidney Dis. 1998; 32: S157-S171Abstract Full Text PDF PubMed Scopus (35) Google Scholar Studies in non-CKD patients have linked the incidence of infection to increased CVD risk and C-reactive protein levels.27Maupome G. Gullion C.M. White B.A. et al.Oral disorders and chronic systemic diseases in very old adults living in institutions.Spec Care Dentist. 2003; 23: 199-208Crossref PubMed Scopus (19) Google Scholar, 28Ajwani S. Mattila K.F. Narhi T.O. et al.Oral health status, c-reactive protein and mortality—a 10-year follow-up study.Gerodontology. 2003; 20: 32-40Crossref PubMed Scopus (82) Google Scholar A small survey of stage 5 CKD (n = 45) patients on dialysis were found to have a 100% incidence of some form of periodontal disease; 64% had severe gingivitis and 36% had periodontitis.29Naugle K. Darby M.L. Bauman D.B. et al.The oral health of individuals on renal dialysis.Ann Periodontol. 1998; 3: 197-205Crossref PubMed Scopus (106) Google Scholar Patients should be encouraged to maintain good dental health and decrease risk of untreated bacterial and gum infections. Many CKD patients have elevated C-reactive protein, which may be a marker of depressed immunity to subsequent infection. Diabetic CKD patients may have undiagnosed foot ulcers or infections. Common gastrointestinal disturbances caused by medications or other problems seen in this population may mask symptoms of infections. Good food safety and sanitation practices can decrease the risk of introducing bacteria into the gastrointestinal tract. Because of a lack of well-designed clinical trials to determine proper indication for use in the CKD population, evidence is lacking for the use of nutritional supplements to reduce CVD risk. A common over-the-counter calcium supplement also contains vitamin K, which may affect blood-clotting time. Some food products are now being fortified with folic acid, which may reduce risk by lowering serum homocysteine. The use of alcohol and red wine to reduce risk has not been studied in the CKD population. In a recent survey of 216 chronic dialysis patients, 14% reported taking 16 different herbal products at some time, which is lower than reported in the general population. However, potential adverse effects may be more pronounced in the CKD population.30Hermann D.D. Naturoceutical agents in the management of cardiovascular diseae.Am J Cardiovasc Drugs. 2002; 2: 173-196Crossref PubMed Scopus (19) Google Scholar, 31Kleshinski J.F. Crews C. Fry E. et al.A survey of herbal product use in a dialysis population of Northwest Ohio.J Renal Nutr. 2003; 13: 93-97Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Many of the CVD risk reduction recommendations are also applicable to non-CKD patients. The application of CVD risk activities to the entire family or caregiver unit could enhance compliance. Patient-focused education in this area has direct benefits to others living in the same home or environment.32Kaveh K. Kimmel P.L. Compliance in hemodialysis patients Multidimensional measures in search of a gold standard.Am J Kidney Dis. 2001; 37: 244-266Abstract Full Text PDF PubMed Scopus (139) Google Scholar A shelf inventory survey can be adapted to gather information on the fat content of specific items in the home, such as type of milk (whole, reduced fat, or skim) or type of egg products (in shell or egg substitutes). Local restaurant menus can be gathered and used to face the reality of eating-out choices. Cooking workshops can be planned to address lower fat methods, innovative recipes, and motivation to try new dietary pathways. The epidemic of obesity in America has been reported to be escalating and now includes overweight patterns in children. The reduction of fat mass in dialysis patients and their families can reduce risk of cardiovascular disease and provide a more unified approach to one of many important aspects of nutrition education. Health-care professionals working within the CKD population can recognize this opportunity to “practice what we preach” by reflecting on our own cardiovascular risk. Walking meters can be used by both patients and staff. Group participation in local kidney walks and other visible means to reinforce goals provide a continuous education opportunity for interaction with patients and their families. The changes we make in our own lives can be used to help others make similar changes as well. Recommended interventions to decrease cardiovascular risk in CKD patients are summarized in Table 1.Table 1Summary of Interventions Recommended to Reduce Cardiovascular Risk in the Chronic Kidney Disease PopulationInterventionPractical ModificationAnticipated OutcomeLipidChange type of dietary fatDecrease dietary intake of trans-fatty acids, animal fat, saturated fats (coconut oil, hard fats). Increase dietary intake of MUFA, PUFA, plant sterol esters, omega-3 fatty acidsDecreased level of plasma lipids and/or change in profile distributionReduce amount of dietary fatDecrease total fat calories to 25%-35% of total calories while maintaining sufficient total calories and protein calories to sustain serum albuminDecreased level of plasma lipids and/or change in profile distributionMineralControl serum phosphorus 3.5–5.5 mg/dLControl dietary intake of phosphorus to 800–1,500 mg/day; use phosphate binders to maintain serum P range; use calcimimetics, vitamin D to maintain Ca-P product ≤55Reduction of soft-tissue calcificationControl serum calcium 8.5–9.4 mg/dlControl dietary intake of calcium to 1,500–2,000 mg/day including phosphate binders; use calcimimetics, vitamin D to maintain Ca-P product ≤55Reduction of soft-tissue calcificationBody CompositionPhysical ActivityMaintain functional level of activity; maintain waist circumference and body-mass; index within levels for CKD stageCardiovascular health; Increase lean-body massAbbreviations: CKD, chronic kidney disease; MUFA, monounsaturate fatty acid; PUFA, polyunsaturated fatty acid.Data from the National Kidney Foundation4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar, 19National Kidney FoundationK/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease.Am J Kidney Dis. 2003; 42: S1-S202Crossref PubMed Scopus (665) Google Scholar, 21National Kidney FoundationK/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am J Kidney Dis. 2000; 35: S1-S140PubMed Google Scholar, 22National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in transplant patients.Am J Trans. 2004; 4: 11-53Google Scholar, Krauss et al6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, Kalantar-Zaden et al7Kalantar-Zadeh K. Fouque D. Kopple J.D. Outcome research, nutrition, and reverse epidemiology in maintenance dialysis patients.J Renal Nutr. 2004; 14: 64-71Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, Van Beber et al9VanBeber A.D. Weber C.G. Gorman M.A. et al.The effect of dietary omega-3, -6, and -9 fatty acid supplements on serum fatty acid concentrations in renal dialysis patients Implications for immune response.J Renal Nutr. 1995; 5: 194-203Abstract Full Text PDF Scopus (1) Google Scholar, Flakoll et al20Flakoll P.J. Kent P. Neyra R. et al.Bioelectrical impedance vs air displacement plethysmography and dual-energy x-ray absorptiometry to determine body composition in patients with end-stage renal disease.JPEN. 2004; 28: 13-21Crossref PubMed Scopus (20) Google Scholar, and Painter et al25Painter P.L. Hector L. Ray K. et al.Effects of exercise training on coronary heart disease risk factors in renal transplant recipients.Am J Kidney Dis. 2003; 42: 362-369Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar. Open table in a new tab Abbreviations: CKD, chronic kidney disease; MUFA, monounsaturate fatty acid; PUFA, polyunsaturated fatty acid. Data from the National Kidney Foundation4National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar, 19National Kidney FoundationK/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease.Am J Kidney Dis. 2003; 42: S1-S202Crossref PubMed Scopus (665) Google Scholar, 21National Kidney FoundationK/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am J Kidney Dis. 2000; 35: S1-S140PubMed Google Scholar, 22National Kidney FoundationK/DOQI clinical practice guidelines for managing dyslipidemias in transplant patients.Am J Trans. 2004; 4: 11-53Google Scholar, Krauss et al6Krauss R.M. Eckel R.H. Howard B. et al.AHA dietary guidelines: Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association.Circulation. 2000; 102: 2296-2311Crossref Scopus (1401) Google Scholar, Kalantar-Zaden et al7Kalantar-Zadeh K. Fouque D. Kopple J.D. Outcome research, nutrition, and reverse epidemiology in maintenance dialysis patients.J Renal Nutr. 2004; 14: 64-71Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, Van Beber et al9VanBeber A.D. Weber C.G. Gorman M.A. et al.The effect of dietary omega-3, -6, and -9 fatty acid supplements on serum fatty acid concentrations in renal dialysis patients Implications for immune response.J Renal Nutr. 1995; 5: 194-203Abstract Full Text PDF Scopus (1) Google Scholar, Flakoll et al20Flakoll P.J. Kent P. Neyra R. et al.Bioelectrical impedance vs air displacement plethysmography and dual-energy x-ray absorptiometry to determine body composition in patients with end-stage renal disease.JPEN. 2004; 28: 13-21Crossref PubMed Scopus (20) Google Scholar, and Painter et al25Painter P.L. Hector L. Ray K. et al.Effects of exercise training on coronary heart disease risk factors in renal transplant recipients.Am J Kidney Dis. 2003; 42: 362-369Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar.