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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 4
| Issue : 2 | Page : 23-25 |
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How to provide very low protein diet
Zamurudin Patel
Department of Dietetics, Global Hospitals, Mumbai, Maharashtra, India
| Date of Web Publication | 6-Dec-2018 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2395-1540.246996
How to cite this article:
Patel Z. How to provide very low protein diet. J Renal Nutr Metab 2018;4:23-5 |
| Introduction | |  |
A very low protein diet can be of 2 types: i) Very low protein diet (vLPD)-0.3 g/kg ideal body weight/day supplemented with essential amino acids (EAA), ii) Very low protein diet (vLPD)-0.3 g/kg ideal body weight/day supplemented with mixture of EAA and ketoanalogues (KA) of EAA.
| Rationale of Supplemented Very Low Protein Diet | | |
- Supplementation with essential amino acids and their ketoanalogues (KA) allows prescribing a protein intake below the minimum daily requirement (0.6 g/kg/day) because requirements are met by the supplements.
- KA do not contain nitrogen and do not generate nitrogenous by-products. At the same time KA are acceptors for amino groups and can be rebuilt to corresponding amino acids. In the transamination reaction which leads to this formation, urea-generating non-essential amino acids like glutamine and alanine, are used as amino group donators.
| Indian Experience with Supplemented Very Low Protein Diet | | |
We studied efficacy and safety of KA supplemented very low protein diet in patients with CKD. The study included 29 stable stage V (non-diabetic) patients with slowly progressive CKD. Fourteen agreed to treatment with KA (treatment group) and 15 did not agree (control group). The patients in both groups were comparable as regards age, sex, dietary habits, degree of renal dysfunction and degree of proteinuria. Patients in the treatment group were prescribed 0.3g/kg/day mixed protein supplemented with KA (ketosteril 1 tablet/5 kg body weight [Table 1]) while patients in the control group were allowed to continue regular diet. Renal function was monitored from 24 hour urinary creatinine clearance and protein intake was monitored from urea nitrogen appearance (UNA) i. e. 6.25 (24 hour urinary urea nitrogen + 0.031 × weight in kg). All were followed monthly for 6 months. The rate of decline in creatinine clearance was 0.09 ml/min/month in the treatment group while it was 0.3 ml/min/month in the control group [Figure 1]. | Figure 1: Rate of decline in creatinine clearance in the treatment and control groups
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Prakash et al.[1] conducted a randomized. Double-blind, placebo controlled trial to evaluate efficacy of VLPD supplemented with KA in patients with CKD. Thirty-four patients were randomized to 2 comparable groups in terms of age, sex distribution, etiology of CKD, blood pressure control, use of angiotensin converting enzyme inhibitors, GFR and body mass index (BMI). Subjects randomly received either 0.6 gm/kg/day protein plus placebo (n = 16) or 0.3 gm/kg/day protein plus 1 tablet/5 5 kg of KA (Ketosteril; Fresenius Kabi, Germany) for 9 months. The mean GFR at baseline in the KA group and control group was 28.1 + 8.8 and 28.6 + 17.6 ml/min/1.73 m2 respectively. At the end of the study it was 27.6 + 10.1 and 22.5 + 15.9 ml/min/1.73 m2 respectively. Thus there was a significant drop in GFR in the control group compared to KA group. In both groups there was no significant change in the BMI after the study.
A study assessed the effect of very low protein diet supplemented with one KA tablet for every 5 kg BW in 56 patients. The blood urea level which was 98.38 ± 42.97 mg/dl at baseline was 102.74 ± 45.98 mg/dL at the end of 1 year. The CrCl which was 17.25 ± 9.25 ml/minute at baseline was 18.24 ± 12.12 mL/minute at the end of 1 year.[2] There was a decrease in urinary protein excretion. Thus there was significant stabilization of renal function [Figure 2]. | Figure 2: Follow-up of a patient showing stabilization of renal function
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| What Does Very Low Protein Diet Look Like? | | |
Restrict use of proteins of animal origin (meat, fish, eggs, milk and milk products, cheese, shellfish, fish eggs etc.) as well as Proteins of vegetable origin containing more than 3-5 g protein for 100 g cooked foods. Unlimited intake of food poor in protein (Fresh fruits and vegetables, Sugar, honey, jaggery, Cooking oil and ghee, potato, sago, arrowroot, rice in limited amounts) is allowed. Use of starch will provide for adequate calories and also provide variety. [Table 2] shows standard vegetarian diet.
Following are some recipes:
- Chapati/Khakra/Bhakri/Thepla
- Ingredients:
- Rice Flour – 10 gm
- Arroot Flour – 20 gm
- Boil Potato – 25 gm.
Above recipes provide 126 Kcal and 1 gm protein:- Snack Recipes (Sev/Puri/Shakarpara/Jeera Stick)
- Ingredients:
- Rice Flour – 10 gm
- Arroot Flour – 30 gm
- Oil for frying.
Above recipes provide 230 Kcal and 0.6 gm protein:- Non-Veg Recipes (Chicken Keema Aloo/Chicken Potato Gravy/Fish in Aloo Gravy/Veg Egg Bhurji).
- Ingredients:
- Non-Veg – 25 gm/½ Egg
- Vegetable – 100 gm
- Boiled Potato – 100 gm
- Oil for cooking.
Above recipes provide 200 Kcal and 6 gm protein:
| Conclusion | | |
- Dietary protein restriction retards progression of CKD. But it should be used only in those who are nutritionally adequate. It should not induce malnutrition
- Restricting protein intake below 0.6 g/kg/day is possible by supplementing EAA or their KA
- By restricting N2 intake there is reduced generation of uremic toxins and thus improvement in symptoms
- When closely monitored, nutritional status can be maintained
- In patients without active underlying disease, KA supplemented diets significantly delay the need for renal replacement therapy (RRT).
| References | | |
| 1. | Prakash S, Pande DP, Sharma S, Sharma D, Bal CS, Kulkarni H. Randomized, double-blind, placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure. J Ren Nutr 2004;14:89-96.  |
| 2. | Chang JH, Kim DK, Park JT. Influence of ketoanalogs supplementation on the progression in chronic kidney disease patients who had training on low-protein diet. Nephrology 2009;14:750-7. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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