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CHAPTER PART 7 OF 9

Worked day plans, and the counselling protocol

Three plans built on a 60 kg reference weight in ordinary Hyderabadi food, with the tally shown so staff can rebuild them for any other weight, and then the order the counselling visit runs in.

Section 7

Worked day plans

Built on a 60 kg reference weight, in ordinary Hyderabadi food, with the tally shown so staff can rebuild them for any other weight.

36 g protein

0.6 g/kg · CKD G3–G5, supervised lower bound
Morning
Tea with 100 ml milk. 2 idli with a thin, low-tamarind sambar made from 15 g masoor dal.
Lunch
1 katori rice, 1 katori masoor dal (30 g raw), bottle gourd curry, no papad, no pickle.
Evening
Tea, 2 Britannia NutriChoice Digestive biscuits, which use carbonate raising agents rather than a phosphate.
Dinner
2 phulka, snake gourd or tinda sabzi, 1 katori rice.
protein ≈ 35 g · K ≈ 1,100 mg · P ≈ 650 mg

48 g protein

0.8 g/kg · the default for diabetic CKD G3–G5
Morning
Tea with 100 ml milk. 2 idli, or 1 katori upma with ridge gourd.
Mid-morning
2 boiled egg whites. 7 g protein for 100 mg potassium and almost no phosphate.
Lunch
1 katori rice, 1 katori masoor dal, tinda or lauki curry.
Evening
Tea. 1 medium apple or half a mango.
Dinner
3 phulka, 50 g paneer bhurji with capsicum and onion, cabbage sabzi.
protein ≈ 48 g · K ≈ 1,700 mg · P ≈ 900 mg

72 g protein

1.2 g/kg · maintenance dialysis
Morning
Tea with 100 ml milk. 2 idli. 2 egg whites.
Lunch
2 katori rice, 1 katori leached toor dal, 75 g chicken breast curry, gourd sabzi.
Evening
Tea. 50 g paneer cubes, dry roasted.
Dinner
3 phulka, 1 katori rice, fish or mutton 50 g, cabbage.
Binders
Dosed with lunch, dinner and the paneer snack. Not with the tea.
protein ≈ 74 g · P ≈ 1,000 mg · binders mandatory
Read the phosphate line on the dialysis plan

At 1.2 g/kg on an Indian diet, a phosphate load of about 1,000 mg is unavoidable. That is not a failure of the diet. It is why binders exist. Do not solve it by cutting protein, because protein-energy wasting is the larger threat on dialysis. Solve it by binder dose, binder timing and by removing additive phosphate from the packet foods.

Section 9

The counselling protocol

What actually happens in the room, in order.

First visit, in this sequence

  1. Read the file before the patient sits down. eGFR and trend, potassium, phosphate, bicarbonate, albumin, haemoglobin, HbA1c with a note of whether ESA or iron is running, weight trend over 3 and 6 months, and the full drug list including binders, bicarbonate and any potassium binder.
  2. Set the reference weight and write it on the chart. Every subsequent g/kg number depends on it.
  3. Take a 24-hour recall in household measures, katori, roti, glass, spoon. Ask specifically about: tender coconut water, the type of salt in the house, papad and pickle, packet snacks and biscuits, cheese, cola, instant noodles, tea and how much milk, and how the dal is cooked.
  4. Screen for wasting. 7-point SGA, weight change, mid-arm muscle circumference. Handgrip only if you will have a serial reading to compare it to.
  5. Write one prescription, not a list of bans. Energy, protein in grams per day with the reference weight, sodium, and then only the electrolyte restrictions the biochemistry actually justifies.
  6. Pick a maximum of three changes for this visit. In most patients the highest yield three are: switch the salt situation, change the dal, and remove one packet food.
  7. Teach binder timing physically, with the actual tablets and a plate, if the patient is on them.

Monitoring

WhatHow often
Nutrition screeningAt least twice a year, more on a GLP-1 agonist
Comprehensive assessment by a dieticianWithin 90 days of starting dialysis, then annually or when indicated
Weight and BMIMonthly on dialysis. Three-monthly in CKD G4 to G5. Six-monthly in G1 to G3.
HbA1cTwice yearly if stable and at target, up to four times a year otherwise
Potassium after starting or changing an ACE inhibitor or ARB7 to 14 days, then periodically
Potassium after starting finerenone or a dose changeAt 4 weeks

Lines that work

On salt

"Your whole day's salt, for everything, is one level teaspoon. That includes what is already in the pickle, the papad and the packet."

On dal

"You are not giving up dal. You are changing which dal, and you are throwing away the soaking water."

On phosphate

"Your phosphate report does not go up because of roti. It goes up because of the cheese slice, the cold drink and the noodles. Those three are the ones we remove."

On binders

"The tablet has to meet the food in your stomach. If you eat without it, it does nothing. If you take it without food, it does nothing."

On a patient who has been over-restricted elsewhere

"Somebody told you to stop dal, stop fruit and stop milk. That is why you have lost five kilos. We are putting food back, carefully, and we will watch your reports while we do it."