Moderate stepwise restriction of potassium intake to reduce risk of hyperkalemia in chronic kidney disease: A literature review

Table 4 Strategies to gradually introduce a mild potassium-restrictive dietary plan

Strategy	Steps
Ensure care is patient centered	(1) Involve dietitians, nurses, psychologists, pharmacists, and social workers if resources allow to ensure patient understanding. Clarify roles and responsibilities of each regarding dietary education to reduce conflicting information and deliver nutrition training to non-dietetic staff to promote consistency of message; (2) Individualize the plan according to patient’s lifestyle, and personal, religious, and sociocultural background. Train staff, particularly dietitians, to ensure expertise on culturally important foods and dietary patterns; (3) Explain the plan’s benefits and limitations and give the patient ample time to accept, to change dietary habits, and to adhere. Plant-based diets can be eco-friendly and economically advantageous. These arguments may promote adherence; (4) Adapt to all levels of education. Health literacy improves patient access and use of health information. Many patients have low health literacy, which may hinder communication, comprehension, and use of digital technology, prolonging the time to convey the message; (5) Identify vulnerable patients (young, socially isolated) who may need more nutritional education and support; and (6) Provide early and continuous access to the renal dietitian for collaboration on plan design and implementation
Instruct patients to identify potassium content of foods to avoid potassium-rich food. Food with > 200 mg of potassium/serving is defined as a potassium-rich food by the National Kidney Foundation	(1) Check serving size/weight. A large low-potassium food serving may have more potassium than a small high-potassium food serving; (2) Spread potassium-rich food items throughout the day to avoid acute postprandial hyperkalemia; (3) Increase the intake of low-potassium to fiber ratio fruits (apple, apricot, berries) and vegetables (green beans, peas, asparagus, lettuce, onions) and reduce the intake of high-potassium to fiber ratio food (processed juice and sauces); (4) Avoid food items that are very rich in potassium, such as edamame, molasses, and white and black beans; (5) Switch to soy-, rice-, and almond-based milk and yogurt because they may have less potassium and phosphorus than dairy; and (6) Avoid 93% lean ground beef since it has substantially more protein, phosphorus, and potassium than 70% lean ground beef
Describe food preparation methods and cooking procedures that may help reduce the potassium content of food	See Table 5
Apply dietary plan to real life	(1) Invite and engage both patients and family members responsible for buying and preparing food (spouse, relative) in the appointments with the dietitian to translate dietary recommendations into accessible plans; (2) Adopt a stepwise approach allowing patients to adapt to dietary recommendations gradually. Patients do not eat calories, protein, or carbohydrates; they eat food, therefore, translate information about nutrients into food using food models, pictures, and recipes to make dietary counseling real and achievable; (3) Simplify nutrition education/advice particularly for those with multiple dietary needs. Avoid weighing or counting servings if possible so it is more practical for most patients. Use the hand to estimate serving size; (4) Explore unrestricted food. Discussion should focus less on what is not allowed and more about what is. Counseling based on food habits highlights foods that should be avoided with alternatives for replacement. For example, animal-based food (cow’s milk) may be replaced by plant-based food (vegetable milk such as soy, almond, and coconut); (5) Nothing should be “forever.” Social life is shared around a table; more restaurants have plant-based options, but the main courses in family meetings are often animal-based. Patients will not easily give up food they love. Allowing occasional freedom can improve long-term adherence; (6) Suggest cooking classes for recipes desired by patients to stimulate emotional involvement. Explore seasonal fruits and vegetables; (7) Offer positive feedback for the patient/caregiver during visits to motivate the patient to continue with the plan. Show how it affects laboratory values, intradialytic weight over time, or even number of pills patient is taking; (8) Meal delivery service may benefit patients who live alone or have difficulty shopping and preparing meals; and (9) Utilize the internet and social media: (a) Smartphones and tablets help interactive sessions (sharing pictures of dishes, describing sizes and preparation methods); (b) Telehealth/virtual nutrition counseling supports patients who need frequent reinforcement that outpatient clinic timing does not allow for or for those who have difficulty attending in-person clinical settings. They are cost effective in communities where long distances represent a barrier to face-to-face nutritional education; (c) Dietitian-facilitated and -supervised online peer support programs can promote healthful dietary behaviors. Age and cultural appropriateness of group participants should be considered; and (d) Online resources and technology-based interventions using smart phones (E-learning) can be used as platform for teaching and workshops reinforcing nutrition education and self-management plans

Information compiled from references[1,2,5,12,15,16,19,20,31,45-50,52].