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Renal Diet Meaning
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Received: 20 June 2019 / Revised: 23 August 2019 / Accepted: 26 August 2019 / Published: 9 September 2019
Nutrition is critical in the treatment of patients with chronic kidney disease (CKD) to slow disease progression and correct symptoms. The mainstay of the nutritional approach for renal patients is protein restriction with adequate energy intake to prevent malnutrition. However, other aspects of kidney nutrition, including fiber, may also be beneficial. This article summarizes the latest literature on the role of different types of dietary fiber in CKD, with particular attention to the gut microbiota and the potential protective role of renal enzymes. Fiber has been identified based on water solubility, but other functions such as viscosity, fermentability, and colonic capacity must also be considered. In order to achieve an adequate composition and metabolism of the intestinal microbiota and to reduce the risks associated with obesity, diabetes and dyslipidemia, a sufficient amount of fiber should be recommended not only for the general population, but also for patients with chronic kidney disease.
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Chronic kidney disease (CKD) is a growing public health problem affecting approximately 10% of the global population, with diabetes, hypertension and obesity being the main risk factors for its occurrence in developed countries . The importance of nutrition in nephrology has been recognized as crucial in the treatment of chronic kidney disease to slow disease progression and correct symptoms. Dietary therapy in renal disease is based on protein restriction with adequate energy supply to prevent malnutrition and appropriate management of electrolyte disturbances . In addition, the composition of the kidney diet can also affect the gut microbiota, which has been proven to play a role in reducing toxin production and maintaining kidney function, slowing the progression of chronic kidney disease [3, 4, 5, 6] . Several aspects of renal nutrition, including fiber content, can modulate the metabolism of gut microbiota in patients with CKD . Nutritional counseling can help people limit dietary phosphorus and potassium while maintaining or increasing fiber intake [8, 9].
The aim of this article was to summarize the latest literature on the role of different types of dietary fiber in CKD, with a particular focus on gut microbiota and the potential protective role of renal enzymes.
Research on fiber use and human health is extensive and heterogeneous. Since the 70s in Western countries, the recommendations of scientific societies [10, 11, 12, 13] for the general population have recommended adequate fiber consumption for a healthy diet (Table 1). Nutritional nephrology guidelines KDOQI (Kidney Disease Outcomes Quality Initiative) , KDIGO (Kidney Disease Improving Global Outcomes)  and EBPG (European Best Practice Guidelines)  do not provide specific guidelines for patients with CKD. Beto et al.  showed the same amount recommended for the general population for all stages of CKD.
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In the general population, current guidelines recommend a total fiber intake (both soluble and insoluble) of 20–35 g per day . The average fiber intake in the United States is 17 g per day, and only 5% of the population meets the adequate intake .
Regulatory agencies recommend proper fiber intake to evaluate the benefit of faecal excretion in flatulence and regular bowel transit, as well as its metabolic effects in maintaining proper cholesterol and glucose metabolism . The role of fiber in health and disease is more complex, and modern analytical methods open the way to the complex interaction of fiber consumption in human metabolism. Apart from the total amount of fiber consumed, there are no indications that specify the types of fiber or the proportions of different fiber-containing foods to achieve optimal intake.
An appropriate definition of fiber is essential . In 2007, FAO/WHO experts emphasized that the term fiber is defined as non-digestible carbohydrates contained in grains, seeds, vegetables and fruits . This is the most internationally accepted definition. The US Codex Alimentarius Commission , which sets international dietary guidelines standards, adopted the following definition of fiber in 2009: polymers of carbohydrates (CHO) with ten or more monomeric units that are not hydrolyzed by endogenous enzymes of the small intestine. among humans and fall into the following categories: a) edible CHO polymers that occur naturally in food when consumed; b) CHO polymers obtained from food raw materials by physical, enzymatic or chemical means; and (c) synthetic CHO polymers . It was also noted that individual countries may choose to accept oligosaccharides with a degree of polymerization (DP) of three to nine inclusive, which increases the uncertainty of a correct and one-sided definition.
Fibers consist of polymers of carbohydrates with three or more monomeric units (MU) and related substances. Table 2 presents the classification of dietary fibers according to their chemical structure. Other physicochemical properties such as water solubility, viscosity and fermentability have also been taken into account .
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In order to be included in the definition of fiber, beneficial health effects such as “decreased intestinal transit time, increased stool volume”, “reduced blood cholesterol” and “modulation of glucose metabolism” are required . Adequate US intake was based on cholesterol-lowering effects. The European Food Safety Authority (EFSA) guidelines on health claims related to dietary fibers indicate that the literature uses the terms “soluble” and “insoluble” to classify dietary fibers according to physicochemical properties related to different physiological effects . ]. However, water solubility does not always predict physiological effects, so another classification has been proposed based on the main characteristic of viscosity, fermentability and large intestinal volume effect, which is related to water solubility and swelling capacity . The features used for classification overlap, leading to confusion in correlating specific fiber properties with observed health outcomes (Table 3).
Solubility refers to dissolution in water, but the viscosity (gelling ability with water) of certain soluble fibers affects fiber consistency and slows the enzymatic digestion of consumed nutrients into absorbable components. Oligosaccharides are highly soluble and fermentable fibers include fructooligosaccharides (FOS) and galacto-oligosaccharides (GOS). These short-chain fibers are highly digestible due to their small size and solubility.
Soluble, non-viscous, easily fermentable fibers (inulin, wheat dextrin) dissolve in water and are rapidly and completely fermented . Soluble, tough, easily fermentable fibers (β-glucan, gums, pectin) are similar but form a gel-like consistency with water . These properties disappear after fermentation. Soluble, tough, slowly fermented fiber (psyllium) also forms a gel-like consistency but does not undergo extensive fermentation. As such, the ability of the colon to communicate with water is preserved. It softens the stools of people suffering from constipation and adds strength to loose stools. Insoluble fibers (wheat bran, lignin, cellulose) exert a laxative effect by stimulating and irritating the intestinal mucosa, increasing secretion and peristalsis .
EFSA also included in the definition of dietary fiber polymers obtained by physical, enzymatic or chemical means that have been shown to have beneficial physiological effects . EU regulation (EC) no. The claim that the food is a source of fiber can only be made if the product contains at least 3 g of fiber per 100 g or at least 1.5 g of fiber per 100 kcal (418 kJ). A claim that a food is high in fibre, and any claim likely to have the same meaning for the consumer, can only be made if the product contains
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