Nutrition in the Transplant Journey

1. Nutrition in the Transplant Journey TRIO MARYLAND Christine Hare RD CSR LDN Dennis Myers RD CSR LDN 10.8.16

2. Today’s Objectives • Learn about the importance of nutrition throughout the transplant process • Pre-transplant, immediately post-operative, long-term post-transplant nutrition guidelines • Discuss nutrients that need to be focused on or limited • Discuss medication interactions / side-effects • Popular diets- can they be used by transplant patients? • Time for questions!

3. Pre-transplant • Optimize nutrition status • Low sodium diet • Most organ transplant recipients should be limiting sodium • Maintain appropriate protein intake • Lower protein intake for those not on dialysis; higher with dialysis • With liver disease often more protein is needed • Adjust electrolytes as needed • With kidney disease, often limit potassium, phosphorus • Maintain / strive for healthy weight

4. Nutrition and transplant- why is it important? • Post-operative healing • Having a transplant is a big operation! • Proper nutrition helps with healing • Adequate protein intake • Blood sugar management • Electrolyte management • Long-term health • Weight management • Disease specific management • Stabilization of electrolytes

5. Post-operative nutrition • Focus on lean protein • Protein is very important to help heal our bodies • Surgical wound closure • Body in catabolic state, breaks down muscle • Manage blood sugars • If diabetic, important to be on proper medications • Prednisone likely will affect levels • Consistent carbohydrate intake • Balance electrolyte imbalances • Often magnesium and phosphorus are low; potassium variable • Low sodium diet generally is maintained • Drink water! • Big change for anyone that was on hemodialysis

6. Healthy Nutrition Post-Transplant • Maintain / strive for healthy body weight • Manage any health issues (i.e. high blood pressure, DM, high cholesterol) • Keep electrolytes within target range • “Heart healthy” diet = “Transplant healthy” diet too! • Food safety • Cook meats to proper temperature, avoid raw / undercooked meat/seafood; wash fruits / vegetables • Keep hot food hot; cold food cold • Drug-nutrient interactions • Grapefruit / grapefruit juice; also pomegranate juice • Use caution with Fresca™, Sunny Delight ™ as they have small amounts of grapefruit juice

7. Healthy Body Weight • Can be a challenge for everyone, but particularly after a transplant! • Feeling better= increased appetite • Steroids (Prednisone) = increased appetite • Less dietary restrictions = more acceptable choices

8. Decreased use of Prednisone • One big change in transplant over the past 10 years is less steroid usage, and at lower doses • Prednisone affects carbohydrate metabolism in our bodies and fat storage • Weight gain in abdomen and in face “moon face” • Prednisone also is hard on our bones • If on Prednisone, try to limit simple sugars and focus on lean protein and vegetables

9. Working on weight goals • Focus on fiber- fiber helps keep us full; aim for 25-35 grams fiber a day • Whole grains, legumes, vegetables, fruits • Try to choose whole fruits vs. fruit juice, fresh / frozen veggies • Choose lean proteins • At least 93% lean ground beef / turkey • Look for words “loin” and “round” leaner cuts • Take skin off of turkey/chicken choose light meat • Include fish • Beans/legumes/nuts • Low fat dairy • Eggs / Egg-whites • Limit fried foods • When frying use minimal oil and mainly monounsaturated fats such as olive oil, canola oil, sesame oil • Watch portion sizes- this is key! • Focus on REAL FOOD, less processed foods

10. Estimating Portion Sizes Breads, cereals, rice, and pasta • 1 bagel = 1 hockey puck • 1 medium potato = a computer mouse • ½ cup rice = 1 cupcake wrapper • 1 cup dried cereal= a fist Fruit • 1 medium fruit = 1 baseball • 1 cup fruit = 1 tennis ball • 1/3 cup of dried fruit = 1 large egg or a golf ball Meat • 3 ounces of lean meat, chicken or fish = 1 deck of playing cards or a bar of soap • 1 ounce of meat = a match box or a floppy disk • 3 ounces of fish = 1 checkbook Dairy • 1 ½ ounces natural cheese = 3 dominos, or a 9-volt battery • 1 ounce of cheese = 4 dice, 1 small child’s block, or 2 saltine crackers Fats, oils and sweets • ½ cup of ice cream = ½ tennis ball • 2 Tbsp. of margarine, salad dressing, peanut butter, or mayo = 1 ping pong ball • 1 tsp. of margarine, salad dressing, peanut butter, or mayo = 1 die (dice) • 1 ounce of hard candy or nuts = 1 layer covering the palm of your hand (flat layer) • http://blog.myfitnesspal.com/beginners-guide-portion-sizes/

11. Healthy Weight • Try to balance your plate and make ½ of your plate vegetables • Drink mainly non-caloric fluids such as water • Limit fried foods / added fats • Exercise regularly • Try using a pedometer to track your steps- aim for 10,000 a day • MyFitness Pal and Lose It are great apps that track intake and exercise • Keep a food diary to help track your intake • Most of us underestimate what we eat by 1/3 • Be mindful of beverages as well

12. Potassium and portion control… • Potassium is a mineral that is usually very healthy, but for some of us due to kidney dysfunction or medication we have to be careful with it. Even “low potassium” choices such as strawberries can become “high potassium” if the portion is large • 5 berries: 92 mg LOW POTASSIUM • 8 berries: 147 mg MEDIUM POTASSIUM • 15 berries: 275 mg HIGH POTASSIUM • 25 berries: 450 mg VERY HIGH POTASSIUM

13. Limit sodium intake • Aim for less than 2,000 mg of sodium per day • One teaspoon of table salt has 2,300 mg of sodium • Read food labels • Choose more fresh / frozen, less canned • If canned, opt for lower sodium choices; rinse off. • Keep in mind “Low Sodium” on label means 30% less, not necessarily low in sodium • Eating out usually has much more sodium • Prepare and look at menu in advance if possible ° Watch the “extras”- things like cheese, sauces, and dressing can add a lot of extra sodium ° Look at the serving size

14. Phosphorus and Magnesium • Phosphorus may be low post-transplant • Good dietary sources include dairy products, whole grains, beans, nuts / nut butters, dark sodas, and protein foods • Supplement may be needed • Magnesium also may be low post-transplant • Good sources include dairy products, whole grains, nuts / seeds, dark leafy greens • Supplements often required • Mag-ox, Slo-Mag • Magnesium supplements may cause diarrhea; monitor

15. Medication Side Effects- Prednisone • Use / Side Effects • Maintenance / rejection • Increased appetite • Retain fluids • Weight gain • “moon-face”, abdominal weight • Increased blood sugars • Can lead to bone breakdown • Managing Side Effects • Keep food diary to track • Try eating 6 small meals • Drink mainly non-caloric fluids (water especially) • Limit sodium intake • Limit simple carbohydrates • Focus on lean proteins, vegetables, complex carbs • Weight bearing exercise • Adequate calcium / Vitamin D

16. Medication Side Effects Cellcept / Myfortic • Gastrointestinal issues • Nausea / Vomiting • Diarrhea • Talk to your doctor / transplant coordinator about any side effects you are having • Small, frequent meals of easier to tolerate foods may help Prograf • May have elevated potassium • Low magnesium • Hair loss • Biotin may help Cyclosporine • Elevated Cholesterol Rapamune • Elevated lipids / TG • Impaired wound healing

17. New Onset Diabetes After Transplant • Medications • More prevalent in overweight / obese / older patients • In kidney transplant patients, there is improved kidney function, insulin moves more quickly through body • Goal of maintaining healthy weight • Losing 5-10% of body weight may be effective in decreasing insulin resistance • Consistent carbohydrate diet • Whole grains • Choose carbs with fiber • Fruit, vegetables • Follow up with diabetes doctor

18. Elevated Cholesterol • More common with certain medications • Diet may be less restrictive than pre-transplant • Post-kidney transplant foods like cheese, chocolate may be introduced • Focus on lean protein choices • Make ½ plate vegetables and fruit • Choose whole grains • Limit sweetened beverages • Limit fried foods • Choose monounsaturated / polyunsaturated fats • Exercise

19. Review • Overall post-transplant the focus is on a “heart healthy diet” • Strive for a healthy weight • Stay active • Focus on Food Safety • Avoid foods that interact with medications • Drink plenty of water • Communicate with your healthcare team

20. Popular Diets- What Works with Transplant? • Gluten Free • Medifast • Shakeology • Paleo

21. Gluten Free • Best for Celiac disease and people with wheat/gluten allergies / intolerances • Celebrity Endorsements • Better athletic performance? • Feeling of well being? • Remember gluten free does not mean calorie, carbohydrate, or sodium free

22. Medifast Diet • Shakes / bars for meal substitutes • One meal: “Lean and Green” • Focus on lean protein, fiber • May be appropriate if kidney function adequate • Important to learn how to make good choices for long-term weight management • Can get tiresome of same shakes / bars

23. Shakeology Type Diets • Substitute protein shake for meal • Read all ingredients • Be careful with additives (herbs, grapefruit juice, etc.) • Count total protein and carbohydrate in portion consumed • Important to learn about healthy eating overall; difficult to stay on shakes forever

24. Paleo Diet • Hunter –Gatherer diet • Like Atkins diet-low carbohydrate • Advocates meat and plants. • Restricts entire food group • Heart disease • Cost

25. Recommended diets • Mediterranean Diet • Dash diet • Weight Watchers

26. Mediterranean Diet • Predominant foods of countries surrounding the Mediterranean Sea • Includes plenty of fish, vegetables, fruits and olive oil • Meat and sugars occasionally

27. Dash Diet • High Potassium-Low Sodium • “Dietary Approach to Stop Hypertension” • Monitor potassium levels • Lots of fruits and vegetables • WWW.NHLBI.NIH.GOV (for more information and sample meal plan)

28. Weight Watchers • Points Plus Program(more than 40,000 foods on their website) • Balanced approach • Learn how to make healthy choices long-term • Community support (online, or meetings) • Can do online (3months-$65.00)