In the mid-1800s, Richard Bright recommended a milk diet for patients with edema and proteinuria (1). Fishberg in 1930 and Addis in 1948 recommended protein restriction for uremic patients, but neither identified the biological value of the protein (2,3). Many at this time believed that dietary protein restriction would decrease the workload and stress on the kidneys. In 1948, Kempner proposed a diet consisting of rice, fruit and sugar for the treatment of acute and chronic renal failure, and it became known as the Kempner Rice diet (4). This diet contained about 20 g protein, 150 mg sodium and 2000 calories. The Kempner Rice Diet was also used in patients with heart disease who did not respond to salt restriction alone, but it was not recommended for people with diabetes because of the high fat and sugar content.
In 1948, Borst (5) reported that a protein-free, normal calorie, low salt diet improved uremia and edema in patients with advanced renal failure. As this diet did not contain usual food items and was very limited, it was not well accepted by patients and health care professionals. For example, some of the recipes and food items in the Borst diet are Borst Soup and butterballs (see Table 1).
The goal of the Kempner Rice and the Borst diets were to preserve life until the kidneys recovered; they were the alternative to dialysis in the 1950s and early 1960s. These diets emphasized the need for adequate caloric intake in severely ill patients to prevent weight loss and to increase the satiety value of the diet. The control of fluid, salt and potassium afforded by these diets was probably as important as the protein restriction. Borst soup and butterball use continued into the late 1960s and early 1970s, especially in smaller cities and rural areas where dialysis was not yet available (6). Later on, renal diets were supplemented with rolls of hard candy, mints, marshmallows and jellybeans placed on hospital food trays and given to patients during dialysis treatments.
Sample Foods in the Borst Diet
Borst Soup Water (1.5 l) Custard powder (100 g) Sugar (150 g) Butter (100 g)
Procedure: Heat slowly until hot, but do not boil. Serve in a soup bowl. Nutrient Analysis: 1750 calories, with negligible amounts of protein and potassium. Sodium content is dependent on the salt content of the butter used. Butterballs (6) Unsalted butter or margarine (84 g) Powdered sugar (100 g) Vanilla extract (3/4 tsp) Peppermint or other flavoring (four drops) Procedure: Cream sugar and butter together. Add flavoring. Divide into 10 equal balls. Roll in sugar, if desired. Place in freezer to harden. Store in freezer until time for serving. Flavoring may be omitted and powdered soft drink mix used on the outside of the balls. Yield: 10 balls
Nutrient Analysis: 103 calories, negligible amounts of protein, sodium and potassium
By 1960, Rose and Wixon (7) established minimum daily requirements of essential amino acids (EAA). This discovery was made in individuals without kidney disease and contributed to the understanding of amino acid metabolism. They reported that the nitrogen from serum urea could be used in the synthesis of nonessential amino acids (NEAA) endogenously if sufficient EAA were present in the diet. Rose et al. also discussed the importance of balanced meals containing adequate carbohydrate, fat and protein to ensure overall nutrition adequacy.
In 1963, Giordano applied the concept of high biological value (HBV) protein to the renal diet (8). At this time, only protein of animal origin was considered HBV. He stressed the need for a specific quality of protein as well as quantity, based on the EAA recommendations of Rose et al. Adequate caloric content with vitamin and mineral supplements were part of the diet. Giordano was able to show that uremic patients were able to maintain positive nitrogen balance and obtain relief from uremic symptoms on 2 g or 3 g of nitrogen or about 20 g of protein/day.
In 1964, Giovanetti and Maggiore achieved similar results using the same principles of a protein-restricted diet with HBV protein food sources (9). A powdered synthetic EAA mixture or eggs was used. Pasta prepared from low protein wheat starch and wafers made from cornstarch were utilized to control the amount of NEAA, while supplying adequate calories. This diet, which became known as the Giovanetti or the Giordano-Giovanetti (G-G) diet, produced positive nitrogen balance, relieved uremic symptoms and maintained blood urea nitrogen levels.
In 1965, Berlyne et al. (10) and Shaw et al. (11) modified the G-G diet by utilizing an 18-g to 21-g protein diet with 12 g of protein from milk and egg sources. High caloric levels were maintained with special wheat starch products that were available commercially. This diet was supplemented with iron, multivitamins and methionine, the only EAA not naturally present in foods. Due to the restrictive nature of the diet, they recommended use of 20g protein only if blood urea nitrogen was greater than 200mg/100mL or if the urea clearance was less than 10 mL/min. These new diets provided a method of treatment for kidney disease when surgery or medications alone could not be used.
In 1968 and 1973, Kopple et al. (12,13) conducted studies comparing 20-g and 40-g protein diets of HBV in individuals with uremia. They found that both diets relieved uremic symptoms and that biochemical improvements were similar; however, maintenance of body weight was more optimal on the 40-g protein diet. Most of all, the 40-g protein diet was more acceptable to the patient because of the greater variety of food selection.
Manufacturers were able to meet the demand for high calorie, low protein food products because patient adherence to their high calorie supplements was not always consistent. Lprotein wheat starch flour (Cellu-low Protein Baking Mix, Chicago Dietetic Supply, La Grange, IL; Paygel-P Wheatstarch Flour and Dietetic Paygel Baking Mix, General Mills, Minneapolis, MN) was used to make bread, muffins, cookies, cakes and pancakes. A 40-g slice of low-protein bread supplied 0.2 g protein and 115 calories. The caloric content could be increased further with the addition of butter or margarine and jelly. However, because of the lack of gluten in the wheat starch, few patients and dietitians were able to make an acceptable bread product. Some recipes added whipped egg whites to decrease density and improve texture. Low protein pasta (Carlo Erba, Milan, Italy
Sample Menu (40 g Protein, 20mEq Sodium Diet) (15)
1/2 cup Apple Juice
2 slices French Toast
4 t. Syrup
6 t. Unsalted Margarine 2 t. Milk Coffee, Sugar
"Thickened white sauce.
One serving Vegetable
Veloutea 3/4 cup Strawberry Ice
Cream 4 Scotch Wheat Starch
Cookies Coffee or Tea with sugar
1/2 cup Minted
Melon Balls One serving Chicken
Curry 1/2 cup Rice
Soft Drink and A-Protein distributed by General Mills) was a welcome addition to the diet as it could be flavored with cream, butter, herbs, and other seasonings. A powdered carbohydrate, protein-free supplement (Controlyte, D.M. Doyle Pharmaceutical Co, Minneapolis) was added to water, juices and soft drinks. High calorie, low electrolyte beverages (Cal-Power, General Mills; Hycal, Beecham Products, Clifton, NJ) provided 400-600 calories in less than 8 fluid ounces. Electrodialyzed whey (lactalbumin) (Wyeth Laboratories) was suggested as another source of HBV protein; it was mixed as a milk shake-like beverage with water, oil, a carbohydrate source and flavoring (14).
Protein was prescribed in standard amounts that did not necessarily reflect the patient's body size or weight. Protein recommendations were based on the patient's signs and symptoms, as well as the level of kidney function. Meal patterns of 30, 40, and 50 g protein/day were published (see Table 2 for an example of a 40-g protein diet). If nausea and vomiting were present, the dietary protein prescription would be reduced to alleviate symptoms.
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