Many times, people with chronic kidney disease (CKD) have a decreased energy level, which can primarily be attributed to anemia and/or decreased caloric intake. 

The kidneys regulate red blood cell production, thus as a person’s kidney function decreases, so can the production of red blood cells. This reduces the amount of oxygen delivered to all body tissues, such as the brain, muscle, heart or skin. In return, a person develops anemia and their energy level diminishes.¹ Your doctor may recommend a blood transfusion and/or medication to increase red blood cell production.1 If the anemia is due to a vitamin or iron deficiency, a diet modification can be beneficial. 

Decreased caloric intake can be caused by restricted diets, increased blood toxins and decreased appetite. As more restrictions are put on a kidney patient’s diet, the more difficult it becomes to increase total calories. Additionally, as CKD progresses and a person’s kidney function continues to worsen, waste products build up in the blood leading to nausea, vomiting and, inevitably, lack of appetite.²

Carbohydrates, proteins and fats provide fuel for you each day. You need to eat enough calories to maintain your weight and energy level.³

Carbohydrates

Carbohydrates, such as starches, fruits, milk products, vegetables and sugars, are the primary energy source of one’s diet, especially when protein is restricted. Without adequate carbohydrate intake, the body starts to break down protein and fat for fuel.⁴ Carbohydrates are classified as simple or complex. Complex carbohydrates provide vitamins and minerals along with calories. Complex carbohydrates include pasta, rice, grains, bread, legumes (beans) and starchy vegetables.

Simple carbohydrates are considered “empty calories,” because they do not provide any vitamins or minerals. Simple carbohydrates include candy, syrups, table sugar and regular carbonated soft drinks. People without diabetes can increase their caloric intake by adding more simple carbohydrates to their diet. Individuals who have diabetes should eat more complex carbohydrates and vegetables and keep simple carbohydrates to a minimum.

Protein

Low protein diets (0.6 grams of protein per kg of body weight) are usually recommended for people with CKD, because they may slow the progression of kidney disease.⁵ However, if you eat too little protein, you may lose muscle and weight, lack energy and have difficulty fighting infections.² In order to get the essential amino acids your body needs, 50 to 60 percent of the protein you eat should be of high biological value (HBV), which includes meat, fish, poultry, eggs and tuna. Since most of HBV proteins come from animal products, vegetarians need to eat a variety of vegetable proteins in combination at a meal.⁶ Examples of complementary proteins are grains and milk or grains and legumes. It is important to remember that if a person is on dialysis, their protein needs actually increase (1.1 to 1.4 grams of protein per kg of body weight). 

Fat

Another way to increase total calories without compromising your renal diet is to add more fat.  It is important to try to eat more unsaturated fats than saturated fats, especially if you have high cholesterol. Unsaturated fats consist of vegetable oils, avocados, nuts, soft margarine and mayonnaise. Some saturated fats are bacon, butter, cream cheese and lard.

Nutritional Supplements

Nutritional supplements are packed with calories and vitamins and can be a great way to boost your calories. Be sure to read the labels, because some can contain large amounts of protein and potassium. 

If you are not on dialysis and are strictly restricting protein, it may be beneficial to choose a supplement that is very low in protein, like Suplena®. Some supplements that are formulated for people on dialysis include Nepro®, Magnacal Renal® and Novasource®. Basic supplements for people with minimal kidney damage include Ensure®, Boost® and Choice®. Glucerna® and Choice DM® are examples of supplements formulated for people with diabetes. By adding just one nutritional supplement a day or possibly two to three per week, should help to increase your weight and energy level. 

Vitamins/Minerals

Normally, well-balanced diets supply you with the vitamins and minerals you need. However, with kidney problems, you may need additional vitamins. Since your kidneys are unable to excrete waste products as efficiently, some over-the-counter (OTC) vitamins and minerals may be harmful.⁴  Therefore, it is important that your doctor prescribes any vitamin and mineral supplements that you may need. Vitamin supplementation is very individualized. If a person has iron deficiency anemia, then, of course, an iron supplement would be prescribed. Your intake of B vitamins and vitamin C are typically adequate in your diet unless you are on dialysis.⁵ You generally get sufficient amounts of fat-soluble vitamins (A, E and K) in your diet.⁵ 

Energy Savers

Another way to increase energy is by using less energy. Try to find the most efficient ways to do everyday tasks. For instance, prepare meals ahead of time or have someone else cook your meals. Additionally, use paper goods instead of china to decrease the amount of cleaning after a meal.

Tips to Increase Calories⁷

• Eat more bland, starchy foods.

• Eat small portions of protein foods at a cold temperature, such as egg salad, tuna salad or a  cold chicken sandwich.

• Graze all day – eat several small meals instead of one large meal.

• Watch cooking shows to increase your appetite.

• Add margarine to hot bread, pasta or rice.

• To boost protein, add egg whites or protein  powders to cooked cereals.

• Instead of milk, use half-and-half or cream.

Summary

Even though it can be difficult to eat an appropriate amount of calories on a restricted diet, you can do it. Be creative and try to increase the amount of calories you eat by eating dense foods. Plan meals ahead of time and schedule three meals per day. If your appetite is decreased, you do not want to wait until you are hungry to prepare a meal. You will need to continue to increase your calories until you reach your normal healthy weight.

Kimberly McKinney, MS, RD currently works in the diabetes center at Touro Infirmary in New Orleans, La.

References:

1. www.anemiainstitute.org/layout/set/print/content

2. www.kidney.ca/english/publications/brochures

3. National Kidney Foundation, How to Increase Your Calories in Your Renal Diet, Brochure, 1998

4. Living With Kidney Disease. 3rd Edition. The Kidney Foundation of Canada. 1999; 5-5 to 5-10.

5. www.nlm.nih.gov/medlineplus/print/ency/article/002442.htm

6. www.nutrition.org.uk/information/energyandnutrients/protein.html

7. www.davita.com/education/kidney_disease/about_chronic_kidney_disease

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 September/October 2004 issue of Kidney Beginnings: The Magazine, Vol. 3, No. 3.

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