A practical approach to a low protein diet in Brazil

The protein intake proposed for healthy adults is 0.8 g/kg/day and corresponds to the dietary protein requirements plus a percentage to achieve safe intake [12]. This recommendation is quite similar to the recommendation for the protein intake of nondialysis CKD patients, which is approximately 0.6 [13] to 0.8 g protein/kg/day [4, 13]. However, the term “low protein diet” (LPD) is used to describe this recommendation because a diet restricted to 0.6 g protein/kg/day is 25 % below the recommended level (0.8 g protein/kg/day) [14].

Some diets are more easily ‘adapted’ into LPDs, which renders protein restriction more practical and feasible. Legumes and cereals with a very small amount of dairy products or meats compose the Mediterranean diet. The Okinawa diet contains 30 % green and yellow vegetables, less rice and sugar and more sweet potatoes, small amounts of fish and more soy and legumes. Indeed, the Dietary Approaches to Stop Hypertension (DASH) style diet, with a greater intake of fruits, vegetables and whole grains, may be protective against rapid GFR decline in older white women [15]. In these diets, adaptation to eating habits is adequate and feasible. By contrast, adherence to the LPD may be more difficult in places such as Brazil where the diet is rich in animal protein sources or plant-based foods with considerable amount of protein, such as rice and beans [10, 16].

Brazil is a developing country with a wide range of cultures and important socio-economic limitations. In general, the eating habits of Brazilians are not desirable and have worsened during the last several decades [17]. Brazil has current trends of incorporating Western dietary habits, which are characterized by a high intake of red meat, sugar, fat and refined grains. However, in an international comparison of dietary intake between Brazilian and American people, Bezerra et al. [18] reported that Brazilian young adults did not consume a diet similar to Americans due to traditional plant-based foods, such as rice and beans, which are important contributors to the Brazilian diet [10].

In a probabilistic sample, Souza et al. [19] observed that the protein intake is relatively high in adults of a metropolitan city of the Rio de Janeiro State (approximately 1.3 g protein/kg/day for males and 1.1 g protein/kg/day for females). In another study developed in a city of the São Paulo State, healthy individuals between 18 and 29 years had a high protein intake (1.6 g/kg for male and 1.4 g/kg female) [20]. Moreover, in a cross-sectional weighted dataset with 2631 Brazilians from the Health Survey for São Paulo, Brazil, Carvalho et al. [21] concluded that red meat processed intake was excessive in almost the entire studied population, and that the consumption of meats, particularly poultry and processed meats, has increased over the last decade to approximately 163 g meat/day. In a recent study, Fisberg et al. [11] observed that the mean meat intake adjusted for sex and age was 182.3 g/day, almost the double of recommended by Brazilian Ministry of Health (100 g/day) [22].

A description of the typical food habits in Brazil is complicated because the country is large and each region has peculiar characteristics. In general, Brazilians have four meals per day: breakfast, lunch, snack and dinner. The typical food for breakfast is coffee, milk, bread with butter or cheese and fresh fruit. For lunch, which is sacred to Brazilians, the typical foods are rice and beans (every day) accompanied by a protein (meat or eggs), vegetables and “farofa”, a toasted flour of manioc. The afternoon snack is coffee or juice accompanied by bread, cookies or typical cakes. Dinner usually consists of the same foods as lunch [23]. The patterns of food acquisition depend on the geographic and socio-economic characteristics, such that the acquisition of dairy, fruits, vegetables and processed meats is associated with a higher household education, whereas the acquisition of manioc, flour, milk and sugar occurs more frequently in less educated households and in rural settings [24].

The national consumption trend of protein-rich foods, particularly meat, is elevated including among families with modest incomes [11]. Therefore, it is easy perceive the challenge of LPD adherence for nondialysis Brazilian CKD patients.

All referred patients, except palliative cancer patients with a short life expectancy (<6 months, estimated by oncologist), are included in the dietary LPD program. Only nutritionists are responsible for nutritional counseling and LPD prescribing (in Brazil is defined by Law that diet prescription is an activity that can only be performed by dietitians).

During the first nutritional appointment, the following information is obtained:

During the second nutritional appointment, which is held one week later, the following occur:

During the third nutritional appointment, the following occur:

Some strategies are designed to improve LPD adherence, such as the following:

Unrestricted meals are not allowed. On special occasions, such as parties and Christmas, better options among the meals served are indicated, such as fruits with a lower potassium content during Christmas and cakes with fruit fillings during birthdays.

Despite the controversy regarding the effectiveness of LPD for slowing CKD progression, the adherence to protein restriction is important for better metabolic and clinical control. Therefore, motivating patients to adhere to dietary protein restriction is an essential point for the management of nondialysis CKD patients [14]. To maintain the LPD over time, the diet prescribed must be pleasant, varied and not too restrictive [14, 33]; therefore, intensive counseling by a skilled dietitian is necessary.