Monday, August 14, 2017

Milk and Phosphorus

Milk and Phosphorus

Chronic Kidney Disease (CKD) patients, and especially those on dialysis - referred to as End Stage Renal Disease (ESRD) - are told to limit the intake of milk and dairy products. 

The reason for this is the nutritional contents of milk. One cup of whole milk (8 oz.) contains about 10% of the recommended daily intake (RDI - I know, so many initials to remember), 22% of phosphorus, and 23% of saturated fat. That’s very high for a glass of milk.  Especially because you will find phosphorus in nearly all of the foods we eat. So getting almost one quarter of your RDI in a small glass of milk could  push you over the recommended limit. 

So why is this a problem? People with functioning kidneys can process out excess amounts of nutrients through urination. Have you ever heard the joke about certain vitamins and supplements? It just creates expensive urine. 

That’s right, if you ingest more nutrients that your body needs, you just pee it out. That’s not to say that there isn’t value to those supplements, it means you should listen to your doctor or dietician about what your body is deficient in, and the appropriate amounts needed to supplement. 

For those of us with depleted kidney function, our bodies don’t process out the extra minerals like phosphorus. The result is that those minerals stay in our blood and can do damage to our bodies. The National Kidney Foundation (NKF) website tells us “High phosphorus levels will end up pulling calcium from our bones, making them weak.” This can lead to dangerous calcium deposits in blood vessels and other organs. None of that is good. 

Controlling the phosphorus in CKD patients is left up to diet and binders in pill form, that don’t allow for absorption of all the phosphorus into our system. Of course they also have some unpleasant side effects. and some of those pills are hard to swallow, both figuratively and literally - they are fairly large.

So that’s why high phosphorus is a problem, especially in CDK patients. 

With all this information it’s easy to see why nutritionists and doctors tell their patients to limit their intake. 

But there are some positive sides to these products, especially if you have ESRD and are on dialysis.  They have lot’s of protein and other nutrients which we need like vitamin A and B12. 

To begin with let’s discuss the contents of milk.  One of the big concerns is the fat (we will discuss that issue later and in another section). Let’s look at exactly what we are drinking: 
                         Milk Product           Fat Content

Whole 3.25%
Reduced Fat            2%

Low Fat 1%

Skim 0%

Milk comes out of the cow as whole milk. Making the lower fat products is done using a “separator”, spinning the milk fat out of the whole milk to the desired level of fat content.  But all of these lower fat products contain higher amounts of Phosphorus and Potassium than most nutritionists like to see in a serving for dialysis or CKD patient. In fact, lowering the fat content in milk slightly increases the amount of phosphorus and potassium. 

“Wait a minute. Higher you say?” Yes. Not only do I say it, but so do all of the nutrition data experts, and scientists. The reason for this anomaly is that by removing the fat you are increasing the concentration of the other parts that make up milk, and thats where most of the Phosphorus and Potassium live. 

Milk is made up of about 87% water, 3.5% proteins, 3.7% fat, 4.9% lactose, and .07 % minerals (This is by weight, hence the slight difference in fat by volume.) Separating the milk fat from the rest of the milk increases the concentration of the products left in the lower fat milk. Since we are removing a lower concentration part from the higher concentration part, what’s left will have more of those nutrients by volume.  

In addition, by spinning out the fat molecules, you also remove some of the fat soluble nutrients that milk provides. After the spinning process, Vitamin A and D are usually adding back into the product, making it fortified. 

Speaking of labeling on Milk (weren’t we?), pasteurization is a heating and holding process that destroys organisms that can cause disease, without hurting the nutritional content of the milk or other product. Thanks Louis!

Next the milk is homogenized. Why? I’ll tell you why. Remember the old way of making cream - letting the milk sit for a short while and having all the fat rise to top and skimming it off? Of course you do. Well, homogenization is another spinning process that standardizes all the fat molecules to a small size, thus making it more difficult to separate on the stores refrigerator shelf, or anywhere else for that matter.  

Why is all this important to CDK patients? Understanding. The more we understand about the food we eat the more we will be able to evaluate all foods to help us with a healthier diet for our disease. 

So what about some of those other milk based products? For instance, the cream that in removed from the milk? Good question and I’m glad you asked. 

Let’s look at the phosphorus and potassium content in some of these products in one cup of each product. The RDI is in parenthesis:

Product Phosphorus Potassium Calcium 

Whole Milk    222 mg (23%) 348 mg (10)      276 mg(28%)    

2% milk 245 mg (25%) 397 mg (11%) 314 mg (31%)

1% milk 245 mg (25%)    397 mg (11%) 314 mg (31%)

Skim             276 mg (28%)    448 mg (13%) 352 mg (35%)

1/2 and 1/2 230 mg (23%)      315 mg (9%) 245 mg (25%)

Heavy Cr.    148 mg (15%) 178 mg (5%) 155 mg (15%)

Light Cr.      146 mg (15%) 232 mg (7%) 165 mg (16%)

As you can see, going from whole milk at 3.25% milk fat to skim increases all three minerals in each product. Using heavy cream drops all three of these in half, and diluting the heavy cream to decrease the fat content, starts to bring in back up , but not to levels of of the other milk products. 

This chart is a little deceiving.  While it is very reasonable to drink or use 8 oz of whole milk or the lesser fat products, you would not be very likely to consume that much heavy cream in a serving. If you are someone who puts milk or cream in your coffee, you are likely to use more of the less fattened up product than with the higher fat products. 

In a recipe I always use heavy cream instead of any other milk product. This may sound counterintuitive based on all the mental beatings we have been through concerning low fat diets, and low fat products. But as you see in the chart, it lowers some of the dangerous minerals in the diet of the CKD patient. 

As for the fat content, there is plenty of new data from current and more professional studies that are telling us that fat is not the problem we have been led to believe it is.  It does not increase the cause of heart disease. It does not increase your bad cholesterol enough to cause problems, unless you are genetically predisposed to high cholesterol. 

In fact, it is not even the cause of obesity. The new studies are showing that sugar, more specifically processed sugars, are linked to obesity, high LDL cholesterol (the bad one), diabetes, and other related issues including heart disease.  I will go into more detail about fats in another section on this site, but the basic principle in some studies is that when we reduce the good fats in our diet, we end up replacing the calories from those fats with something else. That something else is usually sugar, and more specifically processed sugar. This is where we find ourselves consuming products that cause the above mentioned problems.  

This has led me to discount the large concerns about higher saturated fat products concerning my health and diet, for better control over proven risk factors for CKD patients, like phosphorus and potassium. 

In essence, I use Heavy cream for my recipes and I avoid most low fat products. The extra fat in the heavy cream will make you fuller, faster. With the calories coming from foods that I know about, rather than snacks and foods I do not know about, I can help control the dangerous levels of phosphorus in my diet. 

Links to recipes on this topic:

Pasta and Squash in a Cream Sauce

Here are some links to sources I have used for information above:

Sunday, August 13, 2017

Sodium by Example

Cooking for your Kidneys

Sodium by Example
Homemade Hot Sauce and Salt in the diet

Hot sauce you can buy is generally loaded with sodium. This acts both as a flavor enhancer and preservative in foods. That is one reason hot sauce and other bottled items can stay on a shelf in the store without refrigeration. It is also vacuum sealed so that limited or no air gets in the bottle, and hence airborne bacteria can grow inside. 
The problem for most people, especially patients with kidney failure, is the salt. Salt is sodium chloride (NaCl), one part sodium to one part chloride.  Even though Salt is equal parts of each, the chloride ion is heavier and that makes salt approximately 40% sodium and 60% chloride. To be specific, it is 39.3% sodium, 60.7% chloride, by weight.
The human body needs both of these positive charged ions in order to survive, and this is why salt used to be a very high valued commodity.  For a period of time salt was a form of currency. The word “Salary” can be traced back to the word “Sal”, the ancient romans soldiers allowance to buy salt.  
Our bodes need balance in our electrolytes (sodium +, chloride -, potassium +, and phosphorus -, as a component of other negatives).  The electrolytes sodium and chloride reside in the plasma of our blood, and potassium and the phosphorus elements reside the the cells of the body. Our bodies are constantly moving fluid around between blood and cells to regulate the all these electrolyte activities through osmosis - the movement through cell walls to keep the concentration of these elements in balance (I know this is all very “scienecy” but it will make sense in the end.)
O.K., back to the hot sauce for a minute. There are many studies that suggest the active ingredient in hot peppers (capsaicin) is beneficial for the body, and that includes CKD patients. 

It has been shown to have positive effects for pain and swelling reduction. It can increase blood flow which will assist with cardio vascular disease and blood pressure.  It even helps with muscle and joint pain along with increasing the rate of healing. These are all key risk factors in CKD patients. 

Most care providers will tell patients to limit sodium intake in their diet, and to offset the flavor issues, to increase the use of spices and herbs. This includes hot sauce. provided it low in sodium.

If you read the label on most bottles of hot sauce you will find a sodium level of anywhere from about 3% to 12% per serving. The problem is what constitutes a serving size.
The Department of Agriculture used two surveys conducted between 1978 and 1988 to determine serving size. The surveys asked citizens about their eating habits to determine the serving size of products that required labeling.  It was important for manufactures to have some kind of standard to use and put nutrition information on the labels. So a serving size is what you (or people of the U.S.) told the researchers they ate in late 70’s and 80’s. 
This really isn’t a problem if we as consumers would read labels and apply the information to our own intake. But I have a suspicion we don’t really do that. 
Hot sauce has a serving size of 1 teaspoon. Go ahead, measure that out the next time you pull that bottle out to spice up your food.  For the very Hot sauces, that might be all you can handle. But as a former restaurant owner and chef,  I can tell you that even an order of six chicken wings is going to have much more hot sauce than 1 teaspoon. A half dozen wings will probably have closer to three tablespoons. That would make your 3% - 12 % RDI jump to 27% to 108% of sodium.  

And keep in mind that this is allowing for a 2300 mg intake of sodium in your diet. 
 1 tsp salt = 2300 mg sodium    

 That’s all you should eat in one day. That’s it. Unless you are in the at risk group. Then less.
(Most chicken wing sauces are made from hot sauces that use jalapeño or fresno chili peppers. Jalapeños turn out a "Mild" chicken wing sauce, about 2500 on the Scoville scale. Fresno peppers will bring you up to at least a medium, as they range from about 2500-10,000 on the same scale. 

To make the hotter varieties, producers  add a hotter sauce to these bases.  The base sauces use the higher sodium content sauces, so keep this in mind when ordering out.)
Today’s nutrition professionals are calling for much less sodium in your diet, and if you are over 50, have hypertension (high blood pressure), kidney disease or a host of other issues, the RDI is 1500mg. If you want to do some math, you will find out that you are consuming a salt lick worth of sodium with those wings. It’s no wonder pubs love to serve them, as they increase fluid purchases (they hope in the form of beer). 

What about all that? The drinking of more fluids when you eat salty food? The thirst? The dry mouth all night long and waking up to gulp down more water? 
Remember all that “sciencey” stuff above? Well, as you increase the sodium and chloride levels in the blood plasma, the body tries to balance out the sudden increase. The body’s cells start pushing water from the cells into the blood stream to balance out the concentration of sodium and chloride to the potassium and phosphorus parts. The concentration of positives and negatives. 
When your cells are depleted of the fluid it tells your body to get more please. So you drink. In a normal body, the excess fluid will travel through your blood stream and into the kidneys. They will filter out the excess electrolytes along with the water and expel them. You pee. It can't clear them all at one pass, so your body carries the excess fluid in the blood plasma through your veins and arteries. This causes your blood pressure to rise, stressing your heart as it pumps harder to get all that water filled blood through your body. In addition, the excess fluid in the arteries and veins causes problems as it accumulates around your bodies other organs, where a high concentration of veins and arteries reside (think congestive heart failure). 
All of this is bad enough for a healthy person, but for someone with limited kidney function, it is very dangerous. The kidneys aren’t  filtering as they should and in some cases not at all.  The excess fluid is either removed  very slowly, increasing the strain on the body, or not until dialysis, if the person has End Stage Renal Disease (ESRD).

For the CKD patient that extra fluid gathers around your major organs and that fluid stresses the body. In addition, dialysis - the removal of those fluids and excess minerals -  also stresses the body. The more fluid you have to remove, the more strain on the body and the worse you feel for the rest of the day All this extra stress on your organs doesn't bode well for the body. 

With the diet for CKD patients being so generalized and restrictive I have noticed that many people get overwhelmed and end up opting out of many of the suggestions. You will see people eating fast food, bags of chips, and other high salt content foods in the dialysis centers, just while they are trying to remove the effects of those very items.
I have found ways to decrease the salt content I consume by altering the recipes of the base ingredients in many foods. A deconstruct and then reconstruct method. 

This is a long way to go to learn about making your own Hot Sauce, but this is how we as patients will learn to eat better and stay healthy. All so that we can live a longer and more enjoyable lives. 

More sodium facts. 
When cooking with salt you should try to use sea salt or large kosher salt. By doing this you will use less salt in your food if you measure the same amounts. It’s not because these products have less sodium or chloride. Remember each piece of salt is one part sodium and one part chloride. Table salt, sea salt, kosher salt: All sodium chloride is the same. There are substitutes out there that claim that have a lower sodium content, but I will get to that. 
The reason there is less sodium in a teaspoon of sea salt or large kosher salt vs your everyday table salt has to do with weight. Yup, weight. If you care to take the time, weigh a teaspoon of each in a kitchen scale and see what you come up with. 

With the larger pieces of salt there is more empty space in the teaspoon between the each piece of salt. Empty space weighs very little when compared to the salt. The smaller the pieces the less empty space, the more the weight. The more weight, the more sodium. Simple stuff. 

Ok, back to those salt substitutes and low sodium products.
We refer to sodium chloride as salt. So does the FDA. If it's not sodium chloride, the label doesn't have to call it salt. 

The problem is that there are other items that are under the salt family but have a different chemical make up. Potassium chloride has a similar to taste to salt, and is often labeled as salt free, meaning there is barely any sodium. That's true. But the replacement of sodium with Potassium can have devastating effects on people with CKD. 

Potassium is a mineral that CKD patients don't process out, and the dangers for high levels in the body are quick and servere. Heart attack. Yup, that's a real problem, especially for those with high blood pressure, or those with lots of excess fluid. I would avoid potassium chloride, even if you generally have low potassium levels. The risks don't seem to outweigh the rewards. 

Other lower salt products are either a combination of sodium chloride and potassium chloride, giving you both risks at once. A few other products attempt to confuse you with statements like "33% less sodium per teaspoon" and still be real salt. This is usually by altering the size and shape creating more empty space per teaspoon. This works to your benefit is you are a measuring type of person, just like the above reference to sea salt and kosher salt. If you still use the "to taste" method, you will probably just add more of whatever you are using. 

I hope all of this helped, and didn't send you into fuzzy wonderland. It is my belief that the more we learn about the food we eat, the better we can participate in our own health with this difficult disease. 

**Please remember to check with your Doctor about how this information may effect your personal health issues. **

Articles about Capsaicin, Chilis, and Kidney Disease

Other Low sodium recipes

Thursday, August 10, 2017

Homemade Pepper Sauce - Print

  • About 18 Fresno, cayenne, or jalapeño peppers. (The color of the pepper=color of hot sauce).
  • 2 Additional Hotter peppers. ( If you like HOT) 
  • 1 3/4 to 2 cups white wine vinegar or cider vinegar (Not that distilled stuff) 
  • Juice of one whole lime - about 2 tablespoons
  • 3 garlic cloves
  • 1 shredded carrot
  • 1 tsp salt

Total Time: 45 minutes.

Equipment: Blender, Immersion blender, or Food Processor 

Yield: About 1 pint if you remove the seeds. Up to about a pint and half without straining. 

Start by cutting off the stems of all the peppers. Next cut each pepper into about 4 to 6 pieces. 
Cut the garlic cloves into a few smaller pieces each.

Combine the vinegar, lime juice, garlic, and all the peppers (seeds included) into a pot. Bring to a boil and reduce the heat to a simmer. Let simmer for 20 minutes. 
After 20 minutes remove from the stove and let cool, or place in the refrigerator for 15 minutes. Hot food in blenders and food processors can be very dangerous.
When the pepper mixture has cooled to room temperature, fill your blender or food processor to just under the half way mark. You will need room for the mixture to combine and spin.
Mix very well, until all the peppers have combined with the vinegar and you don’t see any chunks. The seed will not get reduced.
Remove pepper sauce, and repeat with the rest of the peppers. 
At this point you will have a choice to make. You can either leave the seeds in the pepper sauce or strain them out with fine mesh strainer. It’s really a personal choice. 
Straining will make the hot sauce look like many of the typical ones you see on store shelves. Still others like the appearance of the seeds and the extra heat that comes with leaving them. 
You can use the sauce as soon as you are finished, but a few days in the fridge will enhance the flavor. In addition the hot sauce will last for months if kept in the fridge as it is a vinegar based product. 
You will notice that I did not use any salt when preparing. You will notice that the end result will have a very peppery taste, but no salty taste at all. I will add just a little sea salt to whatever I am putting the hot sauce on at the end to enhance flavor in needed.  By doing this I will know exactly how much sodium is going in my food. 

Amount Ingredients Sodium (mg) Phosphorus (mg) Potassium (mg)
18 Fresno Peppers
2 cups White wine vinegar
1 Lime
1  Carrot
3 Garlic cloves
2 Chile peppers - hot
1 tsp Table salt


1/4 cup 

32 Total for whole recipe

Recommended daily intake (Non CKD)
1 Tbsp Portion size

% RDA per portion


Sodium (mg) Sodium %
1 tsp (5 ml) Tabasco
1 tsp (5 ml) Sriracha
1 tsp (5 ml) Cholula
1 tsp (5 ml) Red Hot
1 tsp (5 ml) John’s homemade hot Sacue

Sodium (mg) Sodium %
1 Tbsp (15 ml) Tabasco
1 Tbsp (15 ml) Sriracha
1 Tbsp (15 ml) Cholula
1 Tbsp (15 ml) Red Hot
1 Tbsp (15 ml) John’s homemade hot Sacue

Some bottles were even mislabeled. claiming 1 tbsp was 5 ml. And that 220 mg was only 3% of the RDI

 Capsaicin - Found in the ribs and the internal part that holds the seeds. Some health benefits include: improved blood circulation, reduced inflammation, pain relief for muscles and joints. protection from high blood pressure and heart disease. - Source

Articles about Capsaicin, Hot Sauce, & CDK.

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