How to Treat Heart Failure & Kidney Failure with Diet

How to Treat Heart Failure & Kidney Failure with Diet
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One way a diet rich in animal-sourced foods—meat, eggs, and cheese—may contribute to heart disease, stroke, kidney failure, and death is through the production of toxin called TMAO.

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

One way a diet rich in animal-sourced foods—meat, eggs, and cheese—may contribute to heart disease, stroke, and death is through the production of an atherosclerosis-inducing substance called TMAO. With the help of certain gut bacteria, the choline and carnitine found concentrated in animal products can get converted into TMAO.  But, wait a second: I thought atherosclerosis—hardening of the arteries—was about the buildup of cholesterol.

“Cholesterol is still king.” TMAO just appears to accelerate the process. TMAO appears to increase the ability of inflammatory cells within the atherosclerotic plaque in the artery wall to bind to LDL cholesterol, which makes it “more prone to gobble up [that] cholesterol.” So, it’s just “another piece of the puzzle [of] how cholesterol causes heart disease.”

And, TMAO doesn’t just appear to worsen atherosclerosis—contributing to strokes and heart attacks—but also heart failure and kidney failure. If you look at a really high-risk group, like diabetics after a heart attack, nearly all those who started out with the most TMAO in their bloodstream went on to develop heart failure within 2,000 days—about five years, whereas only about 20% of those starting out with medium levels in the blood went into heart failure, and none in the low-TMAO group.

Not only do those with heart failure have higher levels of TMAO than controls, and those with worse heart failure have higher levels than those with lesser stage disease, if you follow people with heart failure over time, within six years, half of those who started out with the highest levels were dead. This finding has since been replicated in two other independent populations of heart failure patients.

The question is, why? It’s “probably unlikely” to just be additional atherosclerosis, since that takes years. For most of those that die of heart failure, the heart muscle just conks out, or there’s a fatal heart rhythm. So, maybe TMAO has toxic effects beyond just the accelerated buildup of cholesterol.

What about kidney failure? People with chronic kidney disease are at particularly “increased risk for the development of cardiovascular disease,” thought to be because of a diverse array of “uremic toxins.” These are toxins that would normally be filtered out by the kidneys into the urine, but may build up in the bloodstream as our kidney function declines. When we think of uremic toxins, we usually think of the toxic byproducts of protein, putrefying in our gut—which is why specially formulated, plant-based diets have been used for decades to treat chronic kidney failure. Those who eat vegetarian form less than half of these uremic toxins in the first place. But, those aren’t the only uremic toxins. TMAO, from the breakdown of choline and carnitine, in mostly meat and eggs, may be increasing heart disease risk in kidney patients as well, by apparently downregulating “reverse cholesterol transport”—meaning subverting our own bodies’ attempt at pulling cholesterol out of our arteries.

And indeed, the worse people’s kidney function gets, the higher their TMAO levels rise, and those elevated levels correlate with the amount of plaque they have clogging up the arteries in their heart. But, get a kidney transplant, get a working kidney going, and kidney patients can drop their TMAO levels right back down. So, TMAO was thought to be kind of a biomarker for declining kidney function. But then, this study was published from the Framingham Heart Study, which found that elevated choline and TMAO levels among individuals with normal kidney function predicted increased risk for developing chronic kidney disease—suggesting TMAO is both a biomarker and itself a kidney toxin.

Indeed, when you follow kidney patients over time, and assess their freedom from death, those with higher TMAO—even controlling for kidney function—lived significantly shorter lives, indicating this is a diet-induced mechanism for progressive kidney scarring and dysfunction, strongly implying “the need to focus preventi[ti]ve efforts on dietary [modification].”

What might that look like?  Well, maybe we should reduce “dietary sources of TMAO generation, such as some species of deep-sea fish, eggs, and meat.” But, it also depends on what kind of gut bacteria you have. Remember, you can feed a vegan a steak, and they still don’t really make any TMAO, because they haven’t been fostering the carnitine-eating bacteria in their gut. Researchers are hoping, however, that one day, they’ll find a way to replicate the effects of a vegetarian diet “by selective prebiotic, probiotic, or [antibiotic] therapies.”

Please consider volunteering to help out on the site.

Image credit: Pixabay. Image has been modified.

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

One way a diet rich in animal-sourced foods—meat, eggs, and cheese—may contribute to heart disease, stroke, and death is through the production of an atherosclerosis-inducing substance called TMAO. With the help of certain gut bacteria, the choline and carnitine found concentrated in animal products can get converted into TMAO.  But, wait a second: I thought atherosclerosis—hardening of the arteries—was about the buildup of cholesterol.

“Cholesterol is still king.” TMAO just appears to accelerate the process. TMAO appears to increase the ability of inflammatory cells within the atherosclerotic plaque in the artery wall to bind to LDL cholesterol, which makes it “more prone to gobble up [that] cholesterol.” So, it’s just “another piece of the puzzle [of] how cholesterol causes heart disease.”

And, TMAO doesn’t just appear to worsen atherosclerosis—contributing to strokes and heart attacks—but also heart failure and kidney failure. If you look at a really high-risk group, like diabetics after a heart attack, nearly all those who started out with the most TMAO in their bloodstream went on to develop heart failure within 2,000 days—about five years, whereas only about 20% of those starting out with medium levels in the blood went into heart failure, and none in the low-TMAO group.

Not only do those with heart failure have higher levels of TMAO than controls, and those with worse heart failure have higher levels than those with lesser stage disease, if you follow people with heart failure over time, within six years, half of those who started out with the highest levels were dead. This finding has since been replicated in two other independent populations of heart failure patients.

The question is, why? It’s “probably unlikely” to just be additional atherosclerosis, since that takes years. For most of those that die of heart failure, the heart muscle just conks out, or there’s a fatal heart rhythm. So, maybe TMAO has toxic effects beyond just the accelerated buildup of cholesterol.

What about kidney failure? People with chronic kidney disease are at particularly “increased risk for the development of cardiovascular disease,” thought to be because of a diverse array of “uremic toxins.” These are toxins that would normally be filtered out by the kidneys into the urine, but may build up in the bloodstream as our kidney function declines. When we think of uremic toxins, we usually think of the toxic byproducts of protein, putrefying in our gut—which is why specially formulated, plant-based diets have been used for decades to treat chronic kidney failure. Those who eat vegetarian form less than half of these uremic toxins in the first place. But, those aren’t the only uremic toxins. TMAO, from the breakdown of choline and carnitine, in mostly meat and eggs, may be increasing heart disease risk in kidney patients as well, by apparently downregulating “reverse cholesterol transport”—meaning subverting our own bodies’ attempt at pulling cholesterol out of our arteries.

And indeed, the worse people’s kidney function gets, the higher their TMAO levels rise, and those elevated levels correlate with the amount of plaque they have clogging up the arteries in their heart. But, get a kidney transplant, get a working kidney going, and kidney patients can drop their TMAO levels right back down. So, TMAO was thought to be kind of a biomarker for declining kidney function. But then, this study was published from the Framingham Heart Study, which found that elevated choline and TMAO levels among individuals with normal kidney function predicted increased risk for developing chronic kidney disease—suggesting TMAO is both a biomarker and itself a kidney toxin.

Indeed, when you follow kidney patients over time, and assess their freedom from death, those with higher TMAO—even controlling for kidney function—lived significantly shorter lives, indicating this is a diet-induced mechanism for progressive kidney scarring and dysfunction, strongly implying “the need to focus preventi[ti]ve efforts on dietary [modification].”

What might that look like?  Well, maybe we should reduce “dietary sources of TMAO generation, such as some species of deep-sea fish, eggs, and meat.” But, it also depends on what kind of gut bacteria you have. Remember, you can feed a vegan a steak, and they still don’t really make any TMAO, because they haven’t been fostering the carnitine-eating bacteria in their gut. Researchers are hoping, however, that one day, they’ll find a way to replicate the effects of a vegetarian diet “by selective prebiotic, probiotic, or [antibiotic] therapies.”

Please consider volunteering to help out on the site.

Image credit: Pixabay. Image has been modified.

50 responses to “How to Treat Heart Failure & Kidney Failure with Diet

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  1. With all of the toxic compounds which are created from the ingestion of animal products, it is amazing that human beings can live as long as they do while eating such a diet. Big Ag starts the disease process and Big Pharma comes along and helps to finish off the process undermining liver and kidney function.




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    1. Thank God for the Documentary section on Netflix. After watching “What the Health” a few weeks ago a lot of things make sense now (and I found this website.) And thank God also for social media. At a time when big business, big government, and big trade and educational association seem to be scratching each others backs, no one cares for the human being. Diovan ain’t cheap either. If only my doctor said “look, stop eating meat, chicken, eggs, diary, anything from an animal” and you will begin to lower your blood pressure.
      Hence on the 8th I am not eating animal based food for two weeks to see what effect it has on me. I am looking to see what will happen with my blood pressure.
      Thank you for the film and for this website.




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      1. hi Peter100, I look forward to hearing how your trial goes. I did my 30 day trial 2 years ago with outstanding results in my blood work and overall feeling of well-being. Since that time, I have read many accounts of people healing themselves in spectacular fashion with the whole food plant based diet. This link is for videos and articles regarding blood pressure https://nutritionfacts.org/topics/hypertension/ You’ll find helpful info there about factors influencing hypertension, and what foods can help us keep our blood pressure healthy.




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      2. Kudos on a wise decision. Two weeks is good, but I would give it 30 days if I were you. Since I have eliminated animal products, refined sugars and flours, as well as alcohol, I have dropped over 50 pounds with no effort. In fact, I had to find ways to eat more so I could stop losing. My blood pressure and cholesterol are great and I take no meds of any sort. I am 70 and grateful for a plant based diet every day.




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      3. Good decision Peter. Dr Greger has a free App available. Dr Greger’s Daily Dozen on android or just called DAILY DOZEN for apple devices. It’s what a healthy diet looks like.




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      4. Good luck, Peter. Remember, adding oils will undo a lot of the good as it paralyses your arteries. Eat oily whole foods, but no extracted oils. Don’t use margarine, even if vegan. If you completely remove added salt for that period, your blood pressure will drop, and if you have had any fluid retention, it will mostly go away. Eat lots of starches to stop feeling hungry. Potatoes are wonderfully filling and nutritious, and you can pour dhal or soup over them, eat them with avocado, cover them with vegan gravy, or roast them with a little water in the pan on long slow heat. The bits in contact with the pan will brown that way. Lots of oil free recipes online. Brand New Vegan has some tasty ones, too.




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  2. Researchers are hoping, however, that one day, they’ll find a way to replicate the effects of a vegetarian diet “by selective prebiotic, probiotic, or [antibiotic] therapies.”

    Eat whole food, mostly plants, not alot…… duh Prolly less expensive than the selective prebiotic, probiotic, or antibiotic therapies.

    m




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  3. Question: What about choline intake from plant sources? Does that still create TMAO? And if not, is there value in taking a supplement, for example Lecithin from non GMO sunflower oil?




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    1. Habitual animal product ingestion creates the conditions which starts the cascade which turns carnitine and choline into TMAO…

      ‘“dietary sources of TMAO generation, such as some species of deep-sea fish, eggs, and meat.” But, it also depends on what kind of gut bacteria you have.’

      “Remember, you can feed a vegan a steak, and they still don’t really make any TMAO, because they haven’t been fostering the carnitine-eating bacteria in their gut.”




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  4. What about choline from vegetarian sources such as avocados, beans, bean sprouts, cabbage, cauliflower, chlorella, corn, fruits (all), grains (all), green beans, green vegetables (leafy), hemp (milk/oil/powder/seeds), lentils, nutritional yeast, nuts, peanuts, peas, seeds (all), soy, spinach, wheat, wheatgerm and wheatgrass? Do they have the same effect as animal sources of choline?




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    1. Yes, I’m a bit confused about this as well. I started researching choline when I noticed that several popular multivitamin supplements ADD choline to their formulas, indicating that some in the supplement industry seem to think it’s a required nutrient.Other articles I found support this and attempt to quantify MDRs, e.g., 550 mg /day for adult males.

      I don’t need to be convinced that a WFPB diet is optimal for health; I’m on board there. My question is: if the MDR for adult males is about 550 mg/day (and allowing only plant sources), does this contribute to the TMAO problems described in the video?




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      1. I’m with you on the choline information battle. I just yesterday watched a You Tube video of an interview with Ray Kurzweil in which he stated before being interrupted by the interviewer (numerous times throughout the interview) that phosphatidyl choline is something he takes (among his 90 supplements daily.)

        He of course has the full faith and resources of Google the company behind him as he is something like chief science officer… or something. Anyway, he stated that some scientist he talked to informed him that phosphatidyl choline is high in breast milk and is very high in a newborn baby, hence the smooth skin. He said we start losing that nutrient rapidly shortly after and eventually end up with about 10 percent, even at an earlier age.

        He also said taking that could reverse wrinkled skin.

        I’ve been taking phosphatidyl serine for some time now. Was happy to see that it has a pathway to change to phosphatidyl choline but probably not in large amounts. Not sure what the benefit of taking the phosphatidyl serine is otherwise… it’s just one of those things I read about and started doing without holding on to the initial information that brought me to it.




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    2. Dr Greger seems to explain this in his statement: ” Remember, you can feed a vegan a steak, and they still don’t really make any TMAO, because they haven’t been fostering the carnitine-eating bacteria in their gut.” So, as long as we’re eating whole plant foods alone, our gut flora won’t take the choline we get and in fact, need as a required nutrient, and make TMAO from it.




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    1. Goat milk does seem to digest better than cow milk. There are several healthy populations in Europe who only consume goat or sheeps milk. There’s also that thing about two types of cow milk. Holsteins are the bad one, but several in Southern Europe especially only drink the good one.




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      1. There’s also that thing about two types of cow milk. Holsteins are the bad one, but several in Southern Europe especially only drink the good one.

        I find that interesting. Growing up we seldom had a Holstein but did on occasion. Dad mainly brought home a Jersey or Guernsey from the sale to be our milk provider. I’m guessing he may have liked the taste better because the Holsteins would invariable out-produce the Jerseys or Guernseys.




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      2. But both bovine and goat have casein, the protein that causes allergy… Goat may digest easier, I didn’t vomit, but I still had asthma, allergies, and caught any virus bacteria in the vicinity. I was the kid who missed the most school every year and I was on goat milk. Got off milk and I am almost never sick. (Cocoa powder cuts the little remaining asthma, too.)




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    2. Goat’s milk would indeed lead to the production of tmao and associated health problems. It contains animal proteins which have deleterious effects upon our health as mentioned in the many videos on this site. https://nutritionfacts.org/topics/animal-protein/ The topic of dairy can also be searched through this site. Goat’s milk is for baby goats! A plant based beverage might be best.. I use soy or almond milk on porridge for example, and drink clear herbal tea or water. Wishing you the best in health !




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      1. Susan, pardon my inability to accept a general answer to a specific question. ‘-)

        Goat milk is I think structurally different to cow’s milk… you know, capric acid, caprilic acid, caproic acid… if not different, certainly differing in amounts.

        And I understand you thinking that the link you suggested covers any animal related protein. Still, I have to know if TMAO has been specifically identified as being a component of goat milk.

        I personally believe the three (isomers of 06, 08, and 10, but not necessarily in the order I placed them above) MCTs are important to health. Yes, they are available in coconut oil which also has the 12 isomer of lauric acid. But I get some protein from Swanson’s pasture fed goat whey concentrated protein (80%.)

        What I need to know is if this particular type of animal product contains the TMAO and if so, how much. I would really like to see the research on that before ditching an important part of my health regimen.

        Otherwise, thanks for your response.




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        1. hi Lonie, goat’s milk does not contain TMAO, nor does any animal product —- TMAO is produced in the liver of a person who consumes goat milk or cow’s milk, or other meat or animal food. The bacteria in the gut in a person eating animal foods is different than that of a vegan. The diagram on this video is a representation of the process. https://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ We need some choline in our diet, but is supplied in plant foods. Eating a wfpb diet fosters gut bacteria that are health promoting, not TMAO producing. Hope that clarifies things a bit.




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      2. Dr Greger seems to explain this in his statement: ” Remember, you can feed a vegan a steak, and they still don’t really make any TMAO, because they haven’t been fostering the carnitine-eating bacteria in their gut.” So, as long as we’re eating whole plant foods alone, our gut flora won’t take the choline we get and in fact, need as a required nutrient, and make TMAO from it.

        Wish I had noted Ruth T’s response above before posting my comments above. It seem the TMAO eminates from within our bodies so it apparently is a gut biome issue rather than a property of the animal protein itself. I don’t ever recall reading that goat protein contains any carnitine.

        This suggests to me that I’m o.k. to carry on with my goat whey for protein supplementation.




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        1. Lonnie, research shows that all animal milk, including human of course, contains carnatine. It is in the whey portion of the milk. But, milk in general is much lower in carnitine than meat. Beef (4oz) contains about 85-150 or so mg. Chicken and fish more like 3-7 for 4 oz.
          Milk about 8mg. per cup, but of course concentrates like whey would have more.
          So red meat eaters get about 50-200 mg. per day, vs. vegans at 10-12. Our bodies usually can make the rest of what we need so carnitine is not considered to be essential in the diet. There are exceptions of course, small babies, people healing from disease etc.




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          1. But, milk in general is much lower in carnitine than meat.

            Yeah, I got that same impression in what I’ve read. Also, in re: cow’s milk, it was stated that the further away from its colostrum stage, the lower the amount of carnitine. Without evidence to the contrary, I’ll just have to extrapolate that result onto goat milk.

            I’m still going to treat this as primarily a gut flora thing and continue getting MCTs and protein in a twice weekly intake of goat whey, mixed in with organic raw cacoa powder, amla, pomegranate powder and niacin powder… topped off with a little smidge of pure maple syrup and finished out with nut milk.

            OBTW I did a search for carnitine + goat milk and got a result… that I could download for a tidy sum. Decided to just spend that on more goat milk whey. ‘-)




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    3. Any type of milk is just optimal growth food for baby animals of the appropriate species…until they can consume solid food, so small specific differences aren’t really terribly relevant for adults who don’t need it at all. In all of nature it just doesn’t happen and is totally inappropriate for many reasons.




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      1. vegetater, I think you give nature too much credit.

        Why? Because mythical “nature” is made up of living mutation or methylation (epigentic changes) and not all of them are good.

        But one of those mutations… humans, are now capable of completely changing the nature of plants and animals. We are rapidly becoming capable of creating completely new creatures.

        There was a time when I was totally against anything not “natural.” Still am in many ways because I don’t take pharmaceuticals and haven’t for quite some time. But I’m not going to totally reject something like getting nutrients from a milk product based on the statement that it “is just optimal growth food for baby animals.”

        The reasons I’ve seen for animals to stop sucking is because the momma animal stopped allowing it either to prepare for breeding or because their teats became sore from the baby animal’s aggressive sucking. Keep feeding them milk in a pan or bucket and they’ll keep drinking.

        I will however stop consuming something just based on Dr. Greger’s research, although if I think there may be other research in favor of consuming something that is equally compelling, then I will decide on my own if the reward out weighs the risk.

        I can’t speak for Dr. Greger, but my impression of him is that he doesn’t want us to follow him blindly. That is, I don’t think he wants us to treat him as a cult-like figure but rather as students who study his lesson plan and if new or seemingly better knowledge presents, embrace it if the facts so dictate.

        Dr. Greger himself has admitted he has been wrong in the past and has corrected the information.




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  5. I am curious whether plant-eaters can consume l-carnitine with impunity. It came up in the comments for the safron/depression video that acetyl l-carnitine had shown some success as an anti-depressive. I am 100% WFPB and am considering trying this supplement. (I keep supplements to a bare minimum, as a rule.)




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    1. If you took carnitine supplements on a regular basis presumably you’d foster the growth of the same TMAO-producing bacteria as regular meat eating. Dr. Joel Kahn, who in his private practice has probably tested more vegan TMAO levels than anyone, anectdotally reports high TMAO levels in those taking such supplements.




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  6. Researchers are hoping, however, that one day, they’ll find a way to replicate the effects of a vegetarian diet “by selective prebiotic, probiotic, or [antibiotic] therapies.”

    Why waste the time on research if an individual can just change his eating habits, it is also would be much healthier for the planet if everyone would just go wfpb period!!!!!




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  7. Consumer Reports magazine cites studies showing a type of dairy fat called sphingolipid appears to benefit the heart. They suggest that eating full fat dairy yogurt may be beneficial to health.




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    1. http://jn.nutrition.org/content/129/7/1239.full
      Sphingolipids in Food and the Emerging Importance of Sphingolipids to Nutrition

      Funded by the National Institutes of Health (GM46368) and NCI (CA61820) as well as by Dairy Management, Inc.

      Studies with experimental animals have shown that feeding sphingolipids inhibits colon carcinogenesis, reduces serum LDL cholesterol and elevates HDL, suggesting that sphingolipids represent a “functional” constituent of food. Sphingolipid metabolism can also be modified by constituents of the diet, such as cholesterol, fatty acids and mycotoxins (fumonisins), with consequences for cell regulation and disease. Additional associations among diet, sphingolipids and health are certain to emerge as more is learned about these compounds.




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  8. My husband died a year ago from kidney failure and ultimately heart failure. I find it sad and distressing that while he had kidney disease (prior to kidney failure) that the medical professionals said that there was no special diet to follow unless he had kidney failure. And at that point (and on peritoneal kidney dialysis) the diet recommendation was to load up on protein (animal protein – eggs especially) in order to improve the level of albumin in the blood. The theory was that patients that had higher level of albumin had better outcomes, and peritoneal dialysis removed protein. Is it possible that maybe there was a correlation but not a causation? – i.e. patients that survived well just had high albumin but was not caused from consuming animal protein. With kidney disease, and in the hospital for multiple times after kidney failure, there was no recommendation for my husband to follow a whole foods, plant based diet. The diet was supposed to be high in protein, low in phosphorus, low in sodium, careful about potassium. Therefore, the diet was the opposite of that – e.g. white bread because whole grains were high in phosphorus. Dr. Greger, are there any studies on what patients with kidney FAILURE can do to improve their survival? I feel like there needs to be some change that focuses on the whole foods, plant-based died and certainly doing that PRIOR to kidney failure would be the most advantageous. I’d like to understand and help get the word out even though my husband can no longer benefit from this.




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    1. Hi Mary. This is Dr. Daniela Sozanski, PhD, PScD Naturopath in Atlanta, GA and Moderator for Nutritionfacts.org.
      I am very saddened by your loss. I do not know what anyone could say to console you.
      I will try to comment on your note regarding a diet for kidney failure. There is abundant information about the merit of a plant based diet in kidney disease and or kidney failure. Dr. Greger has a number of videos on the topic, which I invite you to check out https://nutritionfacts.org/topics/kidney-failure/ and https://nutritionfacts.org/topics/kidney-disease/; as in any health condition approached with nutrition, there should be consideration towards particular plants, vegetables, fruits, herbs etc that represent a focus care for kidney issues.
      One more thing, it seems to be a fact that Nutrition classes have not been historically abundantly offered….or hardly at all, in Medical schools. This is probably why some physicians’ reluctance to impart nutritional or dietary advice to patients. My feeling however is that things are changing as there is more and more awareness of the dietary benefits for health.
      I hope this helps, regards, Daniela




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  9. Dr. Greger has done several videos on Vitamin B-12. As one of the moderators for NF.org, I’d like to suggest you check out these two:
    https://nutritionfacts.org/video/vitamin-supplements-worth-taking/
    https://nutritionfacts.org/video/vitamin-b12-recommendation-change/
    to start. There are several others on this important vitamin if you want to learn more. Go to the search box on upper right and type in Vitamin B12 for more information and keep checking this site .




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  10. Can you please tell me if it is possible to reverse kidney failure with a plant-based diet after a patient has already begun dialysis? Are there any studies to support the use of a plant-based diet in dialysis patients?




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  11. Hey Lauri, thanks for writing. The good news seems limited to patients with chronic kidney disease BEFORE they need dialysis.
    The process of dialysis removes a lot of protein from the body, hence the higher protein recommendations and requirements for dialysis patients.
    Of course, the problem is a proinflammatory effect of animal protein. One could use soy protein (tofu, tempeh, edamame) to help provide needed protein while also contributing fiber and antioxidants, as long as the phosphorus was removed with the use of phosphate binders and keeping the intake of other phosphorus-containing foods low. Several studies have shwon cardiovascular benefits of soy protein in dialysis patients, but all were small and need repeating. It’s unknown whether the intake of other vegetarian protein sources (e.g., nuts) have any health-promoting effects in dialysis patients.




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