Transcript Weighting for a Kidney

WEIGHTING FOR A
KIDNEY
Stacy Laffin, MS, RD, LD
Lee Memorial Health System
Kidney Transplant Center at
Gulf Coast Medical Center, Fort Myers, FL
THE IMPORTANCE OF HEALTHY WEIGHT FOR THE CKD
POPULATION LEADING UP TO KIDNEY TRANSPLANT.
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Learning Objectives:
Discuss the barriers preventing CKD patients from
making healthier lifestyle modifications
Describe practical strategies useful in helping
motivate behavioral change
Identify & list key resources & tools to help assist
in the improvement of the health of CKD patients
KIDNEY TRANSPLANT STATS
Over 123,000 people are currently waiting for an organ
transplant (as of 9/14/2014)
 Of those ~101,000 people are on the waitlist for a
kidney transplant
 In 2013, 28,955 organ transplants performed
 Of those, 16,896 were kidney transplants
 11,163 from DCD & 5,733 from LD
BMI Characteristics of DCD transplant recipients:
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BMI
National %
n= 11,161
0-20
10.4%
21-25
28.5%
26-30
30.7%
31+
28.4%
Unknown
2.0%
BODY MASS INDEX (BMI) CRITERIA
FOR KIDNEY TRANSPLANT
BMI < 35 in order to receive a transplant- most centers
 Some centers < 40 (current acceptable BMI limits for
transplant candidates vary across transplant centers)
BMI is most common tool used to estimate degree of obesity &
disease risk. It is not a direct measure of body composition, but
for most people it correlates with body fatness.
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BMI
Classification
18.5 to 24.9
Normal Weight
25 to 29.9
Overweight
30+
Obesity
40+
Extreme Obesity
BODY MASS INDEX TABLE
WHO SAYS?
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American Society of Transplant Surgeons
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“Lifestyle alterations that seem reasonable to improve
health outcomes should be encouraged, just as we
require patients with alcoholic liver disease to stop
drinking prior to transplant, it is reasonable to ask
kidney transplant candidates to lose excess body fat
& attempt to increase lean muscle mass by becoming
more physically active &modifying their diet.”
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Betsy Tuttle-Newhall, MD, director of abdominal transplant at
Saint Louis University Transplant
WHAT’S THE BIG DEAL?
Patients with a BMI >30 at the time of transplant
(compared to patients with a lower BMI):
 ~ 40% increased risk of graft failure
 ~ 30% increased risk of death after transplant
 Greater risk for delayed graft function
 Greater risk for surgical wounds that heal poorly or
become severely infected
 Greater risk for cardiac disease
 Longer hospital stay & increased costs
 Poor outcomes
BOTTON LINE: Obesity appears to negatively affect kidney
transplant recipients.
CKD PATIENT BARRIERS TO A HEALTHIER LIFESTYLE
COMMENTS OBTAINED FROM RENAL RD’S & RENALRD LISTSERVE
Lack of motivation
 Depression, feeling of hopelessness
 Lethargy/Lack of energy/Anemic/Out of shape
 Poor compliance history
 Lack of money (to purchase healthier food or gym membership)
 Live in an efficiency (do not have equipment to prepare food)
 Lack of knowledge (how to exercise, eat healthier)
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ADDITIONAL BARRIERS…
Do not know how to cook- turn to frozen, processed &/or
fast food
 Low literacy level and/or language barrier
 Live alone, elderly &/or sedentary
 Disabled -unable to cook, rely on others to cook
 Lack of transportation or live in remote areas
 Medical Setbacks -new dx, sx, access sx/ temp cath
 Extra PD calories -more insulin use & wt gain
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This list could go on & on…
WHAT’S THE NEXT STEP?
How much time do you have to devote to patient
education
 Patients readiness to change
 How do they like to learn
 Do they have sufficient supports (transportation,
finances)
 Do they have any learning barriers (vision, low literacy)
 Do they need Social Worker or other Team Members
to assist with applications & guidance or referrals
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SUGGESTIONS
Refer to local weight loss programs (Weight
Watchers, Jenny Craig, Nutrisystem, Medi Weight
Loss®)
 Refer to local weight loss support groups
(i.e.TOPS)
 Refer to local meet up’s (fitness, wt loss)
www.meetups.com
 Refer to Obesity Action Coalition
www.obesityaction.org
 Discuss & Refer to Bariatric
 Discuss & Refer to MD - pharmacotherapy
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ADDITIONAL SUGGESTIONS
Refer to CDE/Diabetes Self Management (DSME):
The basic component of DSME, taught by a CDE should be
covered, i.e. testing blood sugars, importance of exercise,
coping skills, changing behaviors, complications etc.
 Note: CDE providing services can not be a RD-must be
another discipline or it will not be covered. Nutrition will not
be covered because it is bundled under ESRD benefit.
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Counseling/Therapy
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Community Health Centers- low to no cost classes,
information, may cover more remote areas in need of
education & medical care – Florida Association of
Community Health Centers. www.FACHC.org
BARIATRIC SURGERY
NIH criteria for candidacy for bariatric surgery:
Acceptable operative risk
Understands surgery and risks
Absence of drug or alcohol problem
No uncontrolled psychological conditions
Failed attempts at medical weight-loss
(diets, other weight-loss options)
BMI >40, Severe obesity (or weighing more
than 100 pounds over IBW)
BMI 35-40 w/ at least 2 obesity related
conditions (T2DM, HTN, sleep apnea or CAD)
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PHARMACOTHERAPY
BMI > 30
 BMI > 27 with an obesity related condition (HTN,NIDDM,
dyslipidemia)
 Must be medically suitable & monitored by MD
Many weight loss meds are contraindicated when
combined with current meds & preexisting conditions such
as diabetes & kidney failure.
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Currently there are several drugs that are approved by the
FDA for weight-loss:
Phentermine products (Adipex-P® or Suprenza®)
 Orlistat (Xenical® or Alli®)
 Lorcaserin HCI (Belviq®)
 Phentermine- topiramate ER (Qsymia®)
 Contrave- Newly approved
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IF YOU HAVE MORE TIME TO SPEND
WITH THE PATIENT
Suggest food journaling (if they complete this, it is a good
sign they are ready for change)
 Individualize a meal plan
 Suggest cook books or provide recipes
 Evaluate obstacles & distractions, provide alternates
 Set small attainable & realistic goals
 Complete a goal setting contract
 Keep it simple
 Patience
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FOOD JOURNAL
PORTION SIZE & VISUAL AIDS
Weight loss Meal Plan (HD) 1500 calories, 90g protein/day
Grains & Starchy Vegetables
6 Servings
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1 slice white bread
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1 oz. ready-to-eat cereal (½-1 cup, depending on type)
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½ cup cooked white rice or refined pasta, ½ cup cooked cereal
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½ white English muffin, bagel, or hamburger/hotdog bun
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6 saltine crackers or 3 graham cracker squares or 3 cups popcorn
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½ cup mashed (dialyzed) potatoes, green peas, or corn
Vegetables- low to medium potassium
4 Servings
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1 cup raw- lettuce, cucumber, celery, carrots
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½ cup cooked- green beans, mushrooms, broccoli,
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peppers. onions, okra, beets, carrots, cauliflower, squash, water chestnuts, etc.
Fruits- low to medium potassium
2 Servings
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1 small piece of fresh fruit (tennis ball size)- apple, plum, lemon, lime, or 1 watermelon wedge
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½ cup canned fruit- fruit cocktail, mandarin oranges, pineapple chunks, pears, peaches, etc.
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¼ cup dried fruit- apricots, raisins (2 TBSP), dates (3), etc.
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½ cup fresh fruit- strawberries, blueberries, blackberries, raspberries, applesauce, grapes (~15), etc.
Milk
1 Serving
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1/2 cup skim or low-fat milk or 3 oz. yogurt
Meat or Meat Alternatives
10 Ounces
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1 oz.= 1 large egg or ¼ cup egg substitute, meat or cheese
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1 oz.= ¼ cup tuna or cottage cheese or 1 oz.= 2 Tbsp. peanut butter (limit to 1 serving a day)
Fats
5 Servings
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1 tsp. margarine, butter, mayonnaise, or oil
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1 Tbsp. salad dressing- avoid creamy types
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Fluid restriction
4 Servings
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1 cup (8 oz.) water, crystal light, sugar-free Kool-Aid, etc.
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1 cup (8 oz.) fruit juice- light cranberry or diluted apple, grape (dilute- ½ water, ½ juice).
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Limit to 1-serving of juice a day.
GOAL SETTING
My Activity Goals are:
Exercise for ________minutes on:
Mon___ Tue___ Wed___ Thur___ Fri___ Sat___ Sun___
Increase my activity by ______minutes each time until I reach my goal of __________minutes/ day.
Other Suggestions:
Eat three times a day. Do not skip breakfast.
Eat regularly scheduled meals, if not a meal, a healthy snack.
Eat salad or high fiber food before meals. Watch out for high fat, high calorie salad dressing.
Increase vegetable intake by consuming at least ____servings per day.
Increase fruit intake by consuming at least _____ servings per day.
Avoid juices and regular sodas.
Include ONE servings of dairy in your day.
Read labels of packaged food to limit fat and sugar.
Choose low fat foods (Less than 3 grams of fat / serving).
Measure out food. Use a measuring cup for accurate portions.
Change snacks to foods less than 150 Calories.
Limit snacks to ___________daily. Limit the number of times I eat out to________/ week/ month.
Use only sugar free beverages.
Other_________________________________
Signature: ____________________________________ Date: _______
MOBILE APPS FOR IPHONE & ANDROIDS
Your phone & apps are always with you. They are a constant
reminder to check in on progress, stay the course & keep up
motivation.
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Myfitnesspal: (free) A great tool to help set weight-loss goals &
monitor progress. The app also tracks calories.
Pocketdietitian: (free) Provides meal plans & recommendations for
people who have some combination of CKD, HTN & DM.
Fooducate: (free) This app scans UPC code of your favorite foods &
provides the nutritional information including calories, saturated fat
and sodium levels.
Kidneydiet: (~$1.99) Great for ESRD.
AAKP myHealth Nutrition Guide app (free)
JEFIT – (free- yet can upgrade & $)- This app helps you find
exercises for every part of your body and keeps track of your
workouts.
FREE ONLINE WEIGHT LOSS PLANS
Sparkpeople.com- The tools include weight tracking, water intake, daily
meal plans, fitness plans & tracking reports. You can modify the meal plan
by adding, deleting or substituting foods in the suggested plan. Similarly,
you can modify the exercise plan by adding strength training or cardio
exercises. Also has an app.
Fitday.com- This site & app tracks weight, activities & foods. In addition with
the free account you can access their detailed nutritional information & food
database. You can customize foods as well as view various reports for
activities, weight & nutrition. It does not give you meal plans or fitness plans
but you can record what you eat and which exercises you do and for how
long. Can be upgraded or purchase software for home computer.
Fitclick.com -Once registered, pick diet plan which includes low carb,
vegetarian, diabetic diets, etc. Once selected, a daily meal plan is provided
with recipes. You can add, swap, delete & save foods to your favorites. In
addition, a weekly workout plan may be created, from beginner to
advanced.
Lose It! & Fitbit – pay a fee
National Kidney Foundation- My Food Coach(also has app)www.kidney.org
SUPPORT GROUPS
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Obesity Action Coalition www.obesityaction.org
Bariatric Support Centers International
www.bariatricsupportcenter.com
Binge Eating Disorder Association www.bedaonline.com
Children’s International Obesity Foundation
www.ciofoundation.org
Eating Disorder Hope www.eatingdisorderhope.com
Food Addicts in Recovery Anonymous www.foodaddicts.org
Obesity Help www.obesityhelp.com
Overeaters Anonymous www.oa.org
Take off pounds sensibly (TOPS): www.TOPS.org
BLOGS
Weight loss can be a lonely and confusing adventure.
Blogs may provide inspiration & valuable information
to help achieve goals safely.
 Canyoustayfordinner blog
 OAC blog
 Many websites previously mentioned have blogs
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A word of caution…
AVAILABILITY OF FOOD: RESOURCES & WEBSITES
MYFLORIDA.com Food Assistance
 Florida Dept. of Children & Families
www.myflfamilies.com (WIC, SNAP)
 TANF (temporary assistance for needy families/welfare)
 Food Pantries/ Food Banks websites: Foodpantries.org
 Feedingamerica.org
 UnitedWay.org
 US Dept. of Agriculture
 US Dept. of Health
 Meals on Wheels/Senior Nutrition Programs –may have
same information as United Way for food distribution
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EXERCISE
Walking, biking, weights, pool, gym, stat. bike, pedals,
resistance bands, dancing, stretching, hula hoop, jump
rope, chair exercises, internet videos, dvd’s.
 Consignment, Thrift Stores & Tag Sales for equipment
 Silver sneakers – need to qualify
 YMCA/YWCA, JCC, Rec centers, Senior centers, gyms
(many centers have scholarships for reduced
membership dues- sliding scale)
 Walking groups
 Physical therapy, Occupational Therapy, Cardiac rehab
 Exercise logs- write it down.
 Make it FUN!
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EXERCISE JOURNAL
SUMMARY
Understand your patient
 Identify barriers
 Address confusion
 Develop simple yet actionable strategies
 Provide resources & tools
 Positive reinforcement goes a long way
 Be Patient
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THANK YOU.
Questions?
REFERENCES
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Weight control (n.d.). Medline Plus. Accessed Sept. 14, 2014. Web Site:
http://www.nlm.nih.gov/medlineplus/weightcontrol.html
Overweight and obesity statistics (2014, April 1). Weight-Control Information Network. Accessed
September 14, 2014 from http://win.niddk.nih.gov/statistics/.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and
treatment of overweight and obesity in adults: The evidence report. National Heart, Lung, and
Blood Institute; September 1998. NIH Publication No. 98–4083. Accessed Sept. 14, 2014 from
http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm .
Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution
of body mass index among US adults, 1999–2010. Journal of the American Medical Association.
2012; 307(5):491–97. Accessed Sept. 14, 2014 from
http://jama.jamanetwork.com/article.aspx?articleid=1104933 .
Ogden CL, Carroll MD. Prevalence of overweight, obesity, and extreme obesity among adults:
United States, trends 1960–1962 through 2007–2008. NCHS Health E-Stat. Hyattsville, MD:
National Center for Health Statistics; 2010. Accessed Sept. 14, 2014 from :
http://www.cdc.gov/nchs/data/hestat/obesity_adult_07_08/ obesity_adult_07_08.pdf
Z. Molnar, E. Streja, et al.American Journal of Transplantation. 2011;11(4):725-736. Associations
of Body Mass Index and Weight Loss with Mortality in Transplant-waitlisted Maintenance
Hemodialysis Patients Accessed Sept. 2, 2014.
Am J Nephrol. 2012;36(6):575-586.Epub 2012 Dec 5. Obesity and kidney transplant
candidates: how big is too big for transplantation?. Lentine KL1, Delos Santos R, Axelrod D,
Schnitzler MA, Brennan DC, Tuttle-Newhall JE. Accessed Sept. 2. 2014.
Johansen KL, Painter P. Exercise in individuals with CKD. Am J Kidney Dis. 2012, 59(1): 126134. Accessed Sept. 9, 2014.
Marketdata Enterprises Inc. The U.S. weight loss & control market. 11th ed. Market Research Web
site: http://www.marketresearch.com/Marketdata-Enterprises-Inc-v416/Weight-Loss-Diet-Control11th-6314539/. Released May 1, 2011. Accessed Sept., 29, 2014.
WWW.UNOS.org OPTN data September 19, 2014 . Scientific Registry of Transplant Recipients
[http://optn.transplant.hrsa.gov/converge/latestData/rptData.asp]. Accessed Sept. 29, 2014.
REFERENCES
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Centers for Medicare and Medicaid Services www.cms.gov Accessed Sept. 4, 2014.
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National Heart, Lung and Blood Institute www.nhlbi.nih.gov Accessed Sept. 2, 2014.
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National Institute of Diabetes & Digestive and Kidney Diseases www.niddk.nih.gov Accessed
Sept. 4, 2014.
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National Institute of Health www.nih.gov Accessed Sept. 2, 2014.
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U.S. Department of Health & Human Services www.hhs.gov Accessed Sept. 2, 2014.
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Social Security Administration www.ssa.gov Accessed Sept. 4, 2014.
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State Obesity and Health &Nutrition Programs www.obesityaction.org Accessed Sept. 8, 2014.
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American College of Sports Medicine www.acsm.org Accessed Sept. 8, 2014
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US Dept. of Health and Human Services www.hhs.gov Accessed Sept. 8, 2014.
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National Kidney Foundation www.kidney.org Accessed Sept 2, 2014.
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American Association of Kidney Patients www.aakp.org Accessed Sept. 4, 2014.
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Fresenius Medical Care www.kidneyschool.org Accessed Sept. 2, 2014.
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Davita www.davita.com Accessed Sept. 8, 2014.
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The State of Florida www.MYFLORIDA.com Accessed Sept. 9, 2014.
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Florida Dept. of Children & Families www.myflfamilies.com Accessed Sept. 8, 2014.
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Food Pantries www.Foodpantries.org Accessed Sept. 9, 2014.
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Feeding America www.Feedingamerica.org Accessed Sept. 8, 2014.
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United Way www.UnitedWay.org Accessed Sept. 4, 2014.
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US Dept. of Agriculture & Consumer Services www.freshfromflorida.com Accessed Sept. 2,
2014.
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Florida Dept. of Health www.floridahealth.gov Accessed Sept. 4, 2014.
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Preventive Cardiovascular Nurses Association www.PCNA.net Accessed Sept. 4, 2014.