Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.

Do beans and tofu have the same effect on the kidney as mean?
How to cope with all of the dietary restrictions in diabetics with kidney problems?

Dr. Fine's answers
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Do beans and tofu have the same effect on the kidney as mean?
Dr. Fine:
The biologic value is not quite as high as the protein in meat. Another issue is, that tofu contains soybeans, and there are some data that soybeans have anti-atherosclerotic properties, due partially to their content of isoflavones, or natural plant estrogens. A soy diet has been shown to protect the kidney in some animal models.

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The problem I have is my father is a borderline dialysis patient. He is getting a fistula put in. So he is on a low protein diet, low phosphorus... I have four charts on my fridge. Two say what he can and two say what he can't. And then of what he can eat, I have to factor in that he is a diabetic. So your corn is really a quarter of an ear of corn. I noticed that the diet you had on the board had potatoes and tomatoes. We have eliminated them in our household. We have eliminated tomatoes. We don't have pasta with tomato sauce any more. A concern that I have is we are very limited in the group of foods we eat.
Dr. Fine:
You need to meet on a regular basis with a good dietitian. Who goes to Weight Watchers? No one is going to put up their hand for that one, are they? Weight Watchers has a system of trade-offs. "So, today I won't eat a potato, but I will eat this food, instead." For Weight Watchers, all they are interested in is total calories at the end. As nephrologists, we are interested in calories, and protein to make sure that you get the basics, as well as sodium, potassium, and phosphorus for many patients with more advanced kidney problems. One also has to be concerned about the type of fats one eats, and for diabetics, of course, the amount of refined carbohydrates.

So there are trade-offs. It is important not to restrict the diet too much, as for many people, eating is one of their few pleasures. Also, it is of key importance to maintain an adequate intake of protein and calories. Often it is difficult to change a diet when food preparation is not under patient control. Getting back to the potato and tomato: A potato, if this is really important to your father, should not be completely eliminated from his diet. To me, you've got to adapt the diet to something that your father can live with for 10 years. Otherwise you are going to have a miserable patient or more miserable than he otherwise might be. Very restrictive diets can also be restrictive in a social sense. So you need to discuss this matter with a good dietitian, and you can do trade-offs. You go through and say, "These are the foods he really likes. He likes that more than the beans you're saying he should eat. Can we do a trade?" Your dietitian will give you the protein and calorie exchange values. Remember my very first statement? It is very difficult to balance a diet and have someone like his food. There's no question about this.

Audience member:
Well, in his case because his pre-admission results came back, he is a borderline diabetic. To prolong the time he is not on dialysis so they don't do an emergency start, they have almost a zero tolerance to trade-offs in his diet.

Dr. Fine:
One of the difficulties in giving a talk like this is one does not want to enter in any way or interfere with, the relationship between patients and their current caregivers, who in this case know your father much better than I can. I will just tell you the way we operate as doctors in general. If someone were a borderline diabetic, that is not to say they have not had diabetic kidney disease for 10, 20 years, and it is borderline. Then I would just put a question mark, especially if he is very close to needing dialysis, as to how strict the diabetic part of his diet should really be. But I don't know the numbers. You have to look at each individual patient. I would just put a question mark there.

Maybe they could reconsider this if his diet is really miserable. There has to be some compromise somewhere in many patients. Imposing the ideal diet becomes slightly less ideal if the patient is unhappy and this interferes with quality of life. Of course you must monitor the patient closely and make sure that there is no harm being done by reducing the restrictions. That would be my query. Someone who is a borderline diabetic about to go onto dialysis, I am personally not sure how strict the diabetic control should be. You certainly shouldn't go out and buy 10 pounds of candy because frankly then his diabetes may run out of control and over the long run, tight glucose control has been shown to reduce many diabetic complications.