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Affordable Protein Foods for Dialysis Patients

      As if the diet for most dialysis patients is not challenging enough, financial constraints make it more difficult. The reality is that many dialysis patients struggle to afford the foods renal dietitians recommend. One contributing factor is the high protein requirements of dialysis patients with the high cost of better quality protein foods.
      National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure.
      Better quality protein, such as leaner cuts of meat, costs more. And although they are gaining acceptance in the dialysis diet now, cheaper vegetable proteins such as beans and nuts have not been strongly recommended in the past because of their lower biological protein value and phosphorus content.
      • Hoffman J.R.
      • Falvo M.J.
      Protein - Which is best?.
      However, phosphorus from these plant foods is in a preferred natural form and thought to be less efficiently absorbed than phosphorus from other protein sources like processed foods.
      • Noori N.
      • Sims J.J.
      • Kopple J.D.
      • et al.
      Organic and inorganic dietary phosphorus and its management in chronic kidney disease.
      Today, plant proteins like nuts and beans are more popular sources of protein in the renal diet.
      “Food deserts” can also deter dialysis patients in their effort to purchase better quality protein foods. Food deserts, or the restricted access to healthy, affordable foods because of the absence of grocery stores within convenient traveling distance, are often found in lower income areas where many people do not own cars.

      Food Empowerment Project. Food Deserts. Available at http://www.foodispower.org/food-deserts/. Accessed June 16, 2014.

      Nearby food stores may be few in number and sell limited products. Lack of transportation options can prevent patients from escaping food deserts. Therefore, protein ideas presented to dialysis patients should be broad enough to include an assortment of protein foods to fit a variety of circumstances. Renal dietitians are skilled to help dialysis patients think “outside the box” to make the best food choices. Table 1 displays a brief list of atypical (and affordable) protein food products.
      Table 1Notable Protein Products at Trader Joe's, Target, and Walmart (≤$3/lb, 6 g or More Protein Per Serving)
      ProductPriceServing SizeProtein (g)Na (mg)P (mg)K (mg)Notes
      Walmart: Pampa canned wild caught mackerel in brine$1.38/15 oz, $1.47/lb2 oz (56 g)13280N/AN/A6 servings
      Target: Market Pantry roasted and salted in-shell peanuts$2.69/1.5 lb, $1.79/lb1 oz (28 g) no shell7170N/AN/A18 servings
      Trader Joe's: Trader Joe's whole wheat cous cous$1.99/17.6 oz, $1.81/lb1/3 c (62 g) dry85N/AN/A8 servings. Whole grain. 7 g fiber. A fun change from traditional macaroni noodles.
      Trader Joe's: Trader Joe's roasted and unsalted sunflower seeds$1.99/lb1/4 c (33 g)70N/AN/A14 servings
      Walmart: Bumble Bee canned whole baby clams$1.74/10 oz, $2.78/lb2 oz (56 g)9290N/A53 servings
      Trader Joe's: Trader Joe's frozen turkey burgers$2.99/lb1 burger (112 g)22280N/AN/A4 servings
      c, cup; g, grams; lb, pound; N/A, not applicable; oz, ounce.
      Foods with 6 g or more protein per serving were considered in the search.
      Food products selected are free of phosphorus additives per available ingredient lists.
      Only products with 600 mg or less sodium per serving are included in the tables (foods with more than 600 mg were excluded).
      Only foods priced $3/lb or less are included. Products are listed from lowest to highest cost based on per pound price.
      Nutritional information was taken directly from product label.
      Protein, Na, P, K are listed per serving.
      Product information obtained from (1) Target: 1050 Ridge Road, Webster NY 14580 on June 17, 2014 and June 25, 2014; (2) Trader Joe's: 3349 Monroe Avenue, Rochester NY 14618 on June 15, 2014; (3) Walmart: 441 Commerce Drive, Victor NY 14564 on June 13, 2014.
      Food cupboards and other meal assistance programs such as Meals On Wheels should be explored for applicable patients. As an example, there are at least 61 food cupboard locations in the Rochester, NY area according to a 2014 report from the Information Center Central Library of Rochester and Monroe County.

      Monroe County Area Food Cupboards 2014. Information Center, Central Library of Rochester and Monroe County. Available at http://www3.libraryweb.org/uploadedFiles/MCLS/Central/Departments/Information_Center/Monroe%20County%20Area%20Food%20Cupboards%202013.pdf. Accessed August 5, 2014.

      The Meals On Wheels Association of America supports a national network of more than 5,000 senior nutrition programs operating in all 50 states and US territories.

      Meals On Wheels Association of America. Available at http://www.mowaa.org/. Accessed June 16, 2014.

      The United States Department of Agriculture's (USDA's) Supplemental Nutrition Assistance Program offers nutrition assistance such as food stamps to millions of low-income individuals and families.

      USDA. Supplemental Nutrition Assistance Program (SNAP). Available at http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap. Accessed June 16, 2014.

      Food stamps can be used like cash to purchase protein foods at authorized retail food stores.

      Office of Temporary and Disability Assitantce. Supplemental Nutrition Assistance Program (SNAP). Available at http://otda.ny.gov/programs/snap/#eligibility. Accessed June 16, 2014.

      While protein food choices at food cupboards and through programs like Meals On Wheels may be limited or inconsistent, they are free to qualifying recipients (oral communication, 2014).

      Hilton Parma Emergency Food Shelf. Available at http://hiltonfoodshelf.com/contact-information/.

      However, it may be a challenge for dialysis patients to meet the recommended 1.2 g/kg protein per day from assistance programs alone.
      National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure.
      Money-saving food tips are listed in Table 2.

      The Academy of Nutrition and Dietetics Foundation. 10 tips for eating right - affordably. Available at http://www.eatright.org/Public/content.aspx?id=5493. Accessed June 18, 2014.

      A few points are worth addressing. Dialysis patients may struggle to buy foods in bulk. They may not be able to afford paying more money up front to get the deal. This includes membership fees for warehouse clubs like Sam's or Costco. Storage for bulk purchases may be limited. Another consideration is a patient's ability to prepare food at home. Kitchen space/equipment, physical limitations (cannot stand, cannot see well), mental capacity, support structure (family, friends, or live alone), and schedule (work hours, dialysis schedule) all play a role in the food a patient buys and ultimately contribute to the budget for food.
      Table 2Money-saving Food Tips
      • Hoffman J.R.
      • Falvo M.J.
      Protein - Which is best?.
      Buy foods in bulk.
      Cook one's own meals instead of buying already-prepared foods.
      Look for sales / specials- peruse weekly fliers.
      Use coupons.
      Plan a weekly menu to avoid impulse buys.
      Pick store brands if they are cheaper than comparable brand name products.
      Eat “in season” and buy local - visit farmer's markets or grow one's own garden.
      Utilize local food cupboards and programs like Meals On Wheels and food stamps if relevant.
      A search of affordable protein foods with the dialysis patient in mind was done in Rochester, NY in June 2014. Foods with 6 g or more protein per serving were reviewed. Oxford Dictionaries defines affordable as “inexpensive; reasonably priced.”

      Oxford University Press. Affordable. Available at http://www.oxforddictionaries.com/us/definition/american_english/affordable. Accessed June 18, 2014.

      “Inexpensive” and “reasonably priced” may leave room for interpretation, but in the present search only protein foods costing $3 or less per pound are included. This criterion eliminated many protein foods from consideration. Only 1 processed meat product qualified. Food products are ranked in Table 1, Table 3, Table 4 by per pound price from lowest to highest cost.
      Table 3Affordable Protein Foods From 1 Aldi Store in Rochester, NY (≤$3/lb, 6 g or More Protein Per Serving)
      ProductPriceServing SizeProtein (g)Na (mg)P (mg)K (mg)Notes
      Eggs
       Gold hen grade A large eggs$1.35/dz or 24 oz, $.90/lb, $.11/egg1 egg665N/AN/A$1.55/dozen at another Aldi location less than 8 miles away.
       Fit & Active liquid egg whites$1.99/lb, $.20/“egg”3 T (46 g)575N/AN/A10 servings
      Chicken and turkey
       Kirkwood frozen chicken leg quarters$4.29/5 lb, $.86/lb4 oz raw18290N/AN/ABroth and water added (no phosphates in ingredient list but broth ingredients not specified).
       Kirkwood fresh chicken leg quarters$.95/lb4 oz raw1895N/AN/A
       Mountaire fresh whole chicken$.95/lb4 oz raw2080N/AN/A
       Kirkwood frozen chicken drumsticks$2.69/2.5 lb, $1.08/lb4 oz raw2095N/AN/ABroth and water added (no phosphates in ingredient list but broth ingredients not specified).
       Kirkwood chicken thighs fresh$1.19/lb4 oz raw1485N/AN/A
       Butterball frozen whole turkey$1.19/lb4 oz raw21200N/AN/A
       Kirkwood frozen 85% lean ground turkey$1.69/lb4 oz raw1785N/AN/A
       Fit & Active 93% lean fresh ground turkey$3.29/19.2 oz, $2.74/lb4 oz raw2285N/AN/APrice was $2.99/19.2 oz ($2.49/lb) until week of 6/23/14 when it increased).
      Beef and pork
       All natural 73% lean ground beef$10.99/5 lb, $2.20/lb4 oz raw1775N/AN/A
       All natural frozen 75% lean ground beef patties$6.99/3 lb, $2.33/lb1 patty (4 oz) raw1875N/AN/A
       Half pork loin in 8% solution$2.99/lb4oz raw21320N/AN/AIngredients: pork, water, salt.
       All natural 85% lean ground beef$8.99/3 lb

      $3.00/lb
      4 oz raw2175N/AN/A$.80 more per pound than less lean ground beef listed previously.
      Fish
       Northern Catch canned chunk light tuna in water$.69/5 oz, $2.21/lb1/4 c (56 g)11180N/AN/A2 servings. Canned chunk light tuna in oil is $.79/5 oz.
       Northern Catch canned wild Alaska pink salmon$2.49/14.75 oz, $2.70/lb1/4 c (63 g)14230N/AN/A7 servings
       Sea Queen frozen swai fillets$5.99/2 lb, $3.00/lb4 oz raw15350N/AN/ASwai is the only ingredient
      Processed meat
       Appleton Farms premium pork refrigerated sausage roll$2.89/lb2 oz (56 g) cooked11420N/AN/A
      Dairy
       Friendly Farms skim milk$2.29/128 oz, $.29/lb1 c (245 g)8125N/AN/AGram weight from USDA

      USDA. Welcome to the USDA National Nutrient Database for Standard Reference. Available at http://ndb.nal.usda.gov/. Accessed June 27, 2014.

       Fit & Active yogurt plain$1.79/32 oz, $.90/lb1 c (227 g)8170N/A380
      Friendly Farms low-fat cottage cheese$2.29/24 oz, $1.53/lb1/2 c (113 g)13410N/A180Sodium content is 820 mg for 1 cup high
       Friendly Farms Greek yogurt plain$3.89/32oz, $1.95/lb1 c (227 g)2475N/AN/ACompared with Aldi's Fit & Active plain yogurt above, this Greek yogurt is higher in cost, has 3× as much protein, and is lower in sodium.
       Friendly Farms Greek yogurt 4-pack peach$3.29/24 oz

      $2.19/lb
      6 oz (170 g)1455N/A190Sale. Convenience. Friendly Farms individual Greek yogurt and Friendly Farms 100 calorie individual Greek yogurt are $.75 each (5.3 oz) and $.14/oz and $2.26/lb.
      Peanut butter and nuts
       Peanut Delight creamy peanut butter$3.49/40 oz, $1.40/lb2 T (32 g)9135N/AN/A35 servings
       Peanut Delight natural creamy peanut butter spread$1.69/lb2 T (32 g)7140N/AN/ANo hydrogenated oils. 14 servings.
       Southern Grove dry roasted unsalted peanuts$2.39/lb1 oz (28 g)7010019016 servings
       Southern Grove party peanuts$2.39/lb1 oz (28 g)890N/A21016 servings
      Beans
       Dakota's Pride canned pork and beans$.49/16.25 oz, $.48/lb1/2 c (130 g)6440N/AN/A3.5 servings. 6 g fiber. Sodium content is 880 mg for 1 cup high.
       Simply Nature refrigerated soymilk original$2.29/64 oz, $.57/lb1 c (243 g)7120N/A260Gram weight from USDA.

      USDA. Welcome to the USDA National Nutrient Database for Standard Reference. Available at http://ndb.nal.usda.gov/. Accessed June 27, 2014.

       Dakota's Pride canned black beans$.59/15.5 oz, $.61/lb1/2 c (130 g)7400N/AN/A3.5 servings. 7 g fiber.
       Dakota's Pride canned light red kidney beans$.59/15.5 oz, $.61/lb1/2 c (130 g)8250N/AN/A3.5 servings. 6 g fiber.
       Dakota's Pride canned chili beans$.59/15.5 oz, $.61/lb1/2 c (130 g)8470N/AN/A3.5 servings. 2 g fiber.
       Dakota's Pride canned great northern beans$.59/15.5 oz, $.61/lb1/2 c (130 g)7410N/AN/A3.5 servings. 6 g fiber.
       Dakota's Pride canned cannellini beans$.65/15.5 oz, $.67/lb1/2 c (130 g)6360N/AN/A3.5 servings. 5 g fiber.
       Dakota's Pride canned garbanzo beans$.65/15.5 oz, $.67/lb1/2 c (130 g)7270N/AN/A3.5 servings. 6 g fiber.
       Dakota's Pride canned lima beans$.79/15.5 oz, $.82/lb1/2 c (130 g)7330N/AN/A3.5 servings. 7 g fiber.
       Benita dry pinto beans$1.89/2 lb, $.95/lb1/4 c (50 g) dry715N/AN/A25 servings. 14 g fiber.
       Benita dry black beans$2.49/2 lb, $1.25/lb1/4 c (36 g) dry110N/AN/A18 servings. 8 g fiber.
       Dakota's Pride dry great northern beans$2.49/lb, $1.25/lb1/4 c (36 g) dry820N/AN/A25 servings. 13 g fiber.
      Grains
       Fit & Active whole grain thin spaghetti$.89/13.25 oz, $1.07/lb2 oz (56 g) dry90N/A2006 servings. Whole grain. 5 g fiber.
       Millville Get Balance crunch$2.69/15.1 oz, $2.85/lb1 c (53 g)9100N/AN/A8 servings. Made with whole grains. Has higher whole grain content than the Millville Get Balance original cereal. 8 g fiber.
       Millville Get Balance cereal original$2.69/14.9 oz, $2.88/lb1 c (52 g)1380N/AN/A8 servings. Made with whole grains. 10 g fiber.
      c, cup; dz, dozen; g, grams; lb, pounds; N/A, not applicable; oz, ounce.
      Foods with 6 g or more protein per serving were considered in the search.
      Food products selected are free of phosphorus additives per available ingredient lists.
      Only products with 600 mg or less sodium per serving are included in the tables (foods with more than 600 mg were excluded).
      Only foods priced $3/lb or less are included.
      Within each subcategory, foods are listed from lowest to highest cost based on per pound price.
      Nutritional information was taken directly from product label.
      Protein, Na, P, K are listed per serving.
      Product information obtained at Aldi on 915 Ridge Road, Webster NY 14580 on June 17, 2014; June 22, 2014; June 27, 2014; June 29, 2014; and June 30, 2014.
      Table 4Aldi “Dollar Menu”—Protein Foods for $1/lb or Less
      ProductPriceServing SizeProtein (g)Na (mg)P (mg)K (mg)Notes
      Friendly Farms skim milk$2.29/128 oz, $.29/lb1 c (245 g)8125N/AN/AGram weight from USDA.

      Target. Target introduces new grocery wellness brand, Simply Balanced™. Available at http://pressroom.target.com/news/target-introduces-new-grocery-wellness-brand-simply-balancedTM. Accessed June 20, 2014.

      Dakota's Pride canned pork and beans$.49/16.25 oz, $.48/lb1/2 c (130 g)6440N/AN/A
      Simply Nature refrigerated soymilk original$2.29/64 oz, $.57/lb1 c (243 g)7120N/A260Gram weight from USDA.

      Target. Target introduces new grocery wellness brand, Simply Balanced™. Available at http://pressroom.target.com/news/target-introduces-new-grocery-wellness-brand-simply-balancedTM. Accessed June 20, 2014.

      Dakota's Pride canned black beans$.59/15.5 oz, $.61/lb1/2 c (130 g)7400N/AN/A
      Dakota's Pride canned light red kidney beans$.59/15.5 oz, $.61/lb1/2 c (130 g)8250N/AN/A
      Dakota's Pride canned chili beans$.59/15.5 oz, $.61/lb1/2 c (130 g)8470N/AN/A
      Dakota's Pride canned great northern beans$.59/15.5 oz, $.61/lb1/2 c (130 g)7410N/AN/A
      Dakota's Pride canned cannellini beans$.65/15.5 oz, $.67/lb1/2 c (130 g)6360N/AN/A
      Dakota's Pride canned garbanzo beans$.65/15.5 oz, $.67/lb1/2 c (130 g)7270N/AN/A
      Dakota's Pride canned lima beans$.79/15.5 oz, $.82/lb1/2 c (130 g)7330N/AN/A
      Kirkwood frozen chicken leg quarters$4.29/5 lb, $.86/lb4 oz raw18290N/AN/A
      Fit & Active plan yogurt$1.79/32 oz, $.90/lb1 c (227 g)8170N/A380
      Gold hen grade A large eggs$1.35/dz or 24 oz, $.90/lb, $.11/egg1 egg665N/AN/A
      Kirkwood fresh chicken leg quarters$.95/lb4 oz raw1895N/AN/A
      Mountaire fresh whole chicken$.95/lb4 oz raw2080N/AN/A
      Benita dry pinto beans$1.89/2 lb, $.95/lb1/4 c (50 g) dry715N/AN/A
      c, cup; dz, dozen; g, grams; lb, pounds; N/A, not applicable; oz, ounce.
      Only foods priced $1/lb or less are included. Products are listed from lowest to highest cost based on per pound price.
      Foods with 6 g or more protein per serving were considered in the search.
      Food products selected are free of phosphorus additives per available ingredient lists.
      Only products with 600 mg or less sodium per serving are included in the tables (foods with more than 600 mg were excluded).
      Nutritional information was taken directly from product label.
      Protein, Na, P, K are listed per serving.
      Product information obtained at Aldi on 915 Ridge Road, Webster NY 14580 on June 17, 2014; June 22, 2014; June 27, 2014; June 29, 2014; and June 30, 2014.
      The search focused on 4 food retailers with strong national presence: Walmart, Target, Aldi, and Trader Joe's. Walmart, the nation's largest retailer and grocer, currently has more than 4,000 US retail locations.

      WalMart. Our locations. Available at http://corporate.walmart.com/our-story/our-business/locations/. Accessed June 20, 2014.

      At present, Target is represented in 49 states and 1,780 stores.

      Target. Target global locations. Available at https://corporate.target.com/careers/global-locations. Accessed June 20, 2014.

      Aldi, a German grocery chain, has approximately 1,300 stores in 32 states right now and is aggressively expanding.

      Aldi. Locations. Available at http://aldiuscareers.com/locations. Accessed June 20, 2014.

      Springer S. Aldi to accelerate store growth. Supermarket News. Available at http://supermarketnews.com/retail-financial/aldi-accelerate-store-growth. Accessed June 20, 2014.

      Tuttle B. Right business, right time: Struggling economy means boom times for discount grocer Aldi. Time. Available at http://business.time.com/2012/10/08/right-business-right-time-struggling-economy-means-boom-times-for-discount-grocer-aldi/. Accessed June 20, 2014.

      In 2013, Trader Joe's stores numbered about 400 in the United States in 42 states.

      Trader Joe's. Find a Trader Joe's. Available at http://www.traderjoes.com/stores/index.asp. Accessed June 20, 2014.

      Affordable protein foods were discovered at all 4 retailers. Each retailer presents different strengths to customers to assist with the search for affordable protein foods. Walmart's advantage over its competitors is it delivers one-stop shopping with large product offerings. This is a huge benefit to customers who may have limited opportunities to get to 1 store once a week let alone several stores during the week. Over the past few years, Target has been expanding its food products to include more fresh groceries like chicken and eggs.

      Vega T. Shopping at Target? Now you can pick up a dozen eggs. The New York Times. Available at http://www.nytimes.com/2010/12/17/business/media/17adco.html?_r=0. Accessed June 20, 2014.

      Reformatted Target stores with new food layouts aim to offer customers one-stop shopping similar to the Walmart experience. Target introduced its new Simply Balanced collection last June.

      Target. Target introduces new grocery wellness brand, Simply Balanced™. Available at http://pressroom.target.com/news/target-introduces-new-grocery-wellness-brand-simply-balancedTM. Accessed June 20, 2014.

      This line is an outgrowth of its Archer Farms store brand and designed to be free of many preservatives and lower in sodium.

      Target. Target introduces new grocery wellness brand, Simply Balanced™. Available at http://pressroom.target.com/news/target-introduces-new-grocery-wellness-brand-simply-balancedTM. Accessed June 20, 2014.

      Aldi sells low cost food items mostly under its own labels in small simple stores. Aldi advertises Wednesday “Fresh Meat Special Buys.”

      Aldi. Fresh Meats. Available at https://www.aldi.us/en/grocery-items/fresh-meats/. Accessed June 20, 2014.

      Earlier this year, Aldi launched its Simply Nature line of affordable all-natural or organic products.

      My Private Brand. Aldi launches Simply Nature. Available at http://mypbrand.com/2014/01/06/aldi-launches-simply-nature/. Accessed June 20, 2014.

      Trader Joe's is owned by the same German parent company as Aldi and demonstrates similar efficiencies equaling lower prices.

      Sapong E. Trader Joe's has them wowed. The Buffalo News. Available at http://www.buffalonews.com/20130216/trader_joe_x2019_s_has_them_wowed.html. Accessed June 20, 2014.

      More of a boutique grocery store with unique food products, like Aldi Trader Joe's limits inventory and focuses on the chain's private label.

      Sapong E. Trader Joe's has them wowed. The Buffalo News. Available at http://www.buffalonews.com/20130216/trader_joe_x2019_s_has_them_wowed.html. Accessed June 20, 2014.

      Although it sells fresh meats and fish too, Trader Joe's is appealing for its convenient ready-to-eat foods. Trader Joe's “adventurous” and reasonably priced food products offer variety and, consequently, are a valued weapon to help renal dietitians creatively stretch food dollars. Unlike warehouse retailers like Costco, Walmart, Target, Aldi, and Trader Joe's do not force customers to purchase bulk quantities to receive lower prices.
      Results of the search were narrowed to concentrate on food products from 1 retailer–Aldi. Aldi is highlighted because of its noticeable (and continued) growth as a discount food retailer. Expected store count expansion is 50% in the next 4 years.

      Springer S. Aldi to accelerate store growth. Supermarket News. Available at http://supermarketnews.com/retail-financial/aldi-accelerate-store-growth. Accessed June 20, 2014.

      Tuttle B. Right business, right time: Struggling economy means boom times for discount grocer Aldi. Time. Available at http://business.time.com/2012/10/08/right-business-right-time-struggling-economy-means-boom-times-for-discount-grocer-aldi/. Accessed June 20, 2014.

      Table 3, Table 4 show affordable protein food items from 1 Aldi store location in Rochester, NY in June 2014. Table 4 is the Aldi “Dollar Menu” for the most affordable protein foods costing $1 or less per pound. As stated earlier, Table 1 shows a short list of notable and somewhat atypical protein food products from the other 3 retailers.
      Protein foods presented in Table 1, Table 3, Table 4 include eggs, meat, fish, processed meat, dairy, peanut butter, nuts, beans, and grains. Real food and not supplements is discussed. Although granola bars with added protein are gaining popularity and are a cheaper alternative to the protein bars currently on the shelves, they are priced well above $3 per pound and accordingly were omitted. Although it is known that some foods with phosphorus additives may not be high phosphorus content, such foods are excluded from the tables. In addition, any products with more than 600 mg of sodium per serving are not listed in the tables. Nutritional information as reported in Table 1, Table 3, Table 4 was taken directly from product labels. The USDA National Nutrient Database for Standard Reference was used in a few cases as a reference for serving size.

      USDA. Welcome to the USDA National Nutrient Database for Standard Reference. Available at http://ndb.nal.usda.gov/. Accessed June 27, 2014.

      A wide range of protein foods is represented in the tables for several reasons. For example, processed meats are not ideal because of higher sodium content, but the reality is that patients do eat processed meats and for some this is their primary source of protein. Renal dietitians should acknowledge these less than perfect protein food choices and suggest the best alternatives (i.e., choose chicken sausage over deli bologna). Another reason for the variety of protein foods is because dialysis patients often have poor appetites and do not eat well. In these situations, allowing several types of protein foods can help increase intake. Yet another reason for presenting various protein food choices, such as vegetable proteins, is to meet the needs of dialysis patients who dislike or cannot tolerate meat products. Most vegetable proteins have fiber. High-protein grains like cereals have fiber and often contain whole grains. Historically, fiber and whole grains have been difficult to incorporate into the dialysis diet, but their inclusion is positive and delivers health benefits to dialysis patients.
      Table 5 summarizes observations made when shopping for protein foods at the 4 national retailers in Rochester, NY. Differences in availability and cost of protein foods may exist regionally and locally. Prices are fluid and can change frequently. Not only must renal dietitians be sensitive to the unique circumstances and preferences of their dialysis patients, they must also be familiar with the areas in which they work to use available resources to make the best recommendations.
      Table 5Observations Made When Shopping for Protein Foods at 4 National Retailers in Rochester, NY
      Affordable protein foods are available at all 4 national retailers. See Tables 1, 3, and 4.
      While Aldi sells a variety of affordable protein foods without phosphates, some protein products do contain phosphates (and are excluded from the tables). This is a pattern noticed at the other 3 retailers, as well. Because no golden “phosphate-free list” exists, renal dietitians must teach dialysis patients to read all labels and not make generalizations about products containing phosphates.
      Prices in one store do change from week to week. Sales seem more apparent at Target; the other retailers feature specials but appear to advertise more consistent, stable prices.
      Raw, uncooked, and plain/unprepared foods may be cheaper than seasoned/prepared food.
      Accordingly, deli meat, bacon, and sausages are more expensive (and also provide less protein) per ounce than unprocessed meats. Cheese is more costly than milk and yogurt. While phosphate-free deli meat and bacon options were identified at the retailers, they failed to make the list due to their higher cost. In fact, only one processed meat product is $3 or less per pound. The only cheese product less than or equal to $3 per pound is cottage cheese. Cottage cheese is a higher sodium cheese.
      The lowest priced meats are the cheaper cuts of chicken (like leg quarters) and whole chicken/turkey.
      Affordable and appropriate pork options are more difficult to find. Pork products seem to contain more phosphorus additives.
      Pre-portioned foods are more expensive than the alternative: Convenience equals higher cost.
      Vegetable proteins like beans and peanut butter are more affordable per serving than many other protein foods, but provide less protein per ounce than meat or fish.
      Canned fish is considerably cheaper than fresh fish and often frozen fish, too. While it does contain sodium, canned fish appears to possess superior nutritional stats (better ingredient list, sodium content) to canned meats like chicken and ham.
      Although supplements have their place, real food like fresh ground turkey or eggs is a better deal than most types of protein bars, powders, and drinks.
      Granola bars with added protein have made a noticeable entrance into the protein bar market. Although they are a cheaper alternative to the $1-2 protein bars currently on the shelves, they are priced well above $3 per pound and are excluded from the table. Review of 8 brands during the search reveals cost from $5.28 per pound to $6.72 per pound.
      It takes effort and time to find the best price deals.
      Without question, dialysis patients are challenged on many levels to comply with the renal diet. Besides numerous diet restrictions, cost is another issue that may prevent success. Good quality protein foods can be expensive. The suggested 1.2 g of protein per kilogram of bodyweight per day is a lot of protein to afford and eat.
      National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure.
      But affordable protein foods do exist, and dialysis patients should rely on renal dietitians to help identify these foods. Assistance programs like local food cupboards offer protein foods and should be used. National food retailers sell affordable protein foods and appear to recognize that there is a demand for growth in this area. Regional (and local) differences in price and variety of protein foods need to be acknowledged. Clearly, the role of the renal dietitian goes beyond teaching patients to read labels for nutritional information. Renal dietitians can also teach patients to be more cost conscious by encouraging patients to check prices, cut coupons, etcetera, to save money when they buy food. Taking a multifaceted approach will help renal dietitians make realistic, appropriate, and creative suggestions to help dialysis patients meet their protein requirements in an affordable way.

      References

      1. National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure.
        Am J Kidney Dis. 2000; 35: S40-S43
        • Hoffman J.R.
        • Falvo M.J.
        Protein - Which is best?.
        J Sports Sci Med. 2004; 3: 118-130
        • Noori N.
        • Sims J.J.
        • Kopple J.D.
        • et al.
        Organic and inorganic dietary phosphorus and its management in chronic kidney disease.
        Iran J Kidney Dis. 2010; 4: 89-100
      2. Food Empowerment Project. Food Deserts. Available at http://www.foodispower.org/food-deserts/. Accessed June 16, 2014.

      3. Monroe County Area Food Cupboards 2014. Information Center, Central Library of Rochester and Monroe County. Available at http://www3.libraryweb.org/uploadedFiles/MCLS/Central/Departments/Information_Center/Monroe%20County%20Area%20Food%20Cupboards%202013.pdf. Accessed August 5, 2014.

      4. Meals On Wheels Association of America. Available at http://www.mowaa.org/. Accessed June 16, 2014.

      5. USDA. Supplemental Nutrition Assistance Program (SNAP). Available at http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap. Accessed June 16, 2014.

      6. Office of Temporary and Disability Assitantce. Supplemental Nutrition Assistance Program (SNAP). Available at http://otda.ny.gov/programs/snap/#eligibility. Accessed June 16, 2014.

      7. Hilton Parma Emergency Food Shelf. Available at http://hiltonfoodshelf.com/contact-information/.

      8. The Academy of Nutrition and Dietetics Foundation. 10 tips for eating right - affordably. Available at http://www.eatright.org/Public/content.aspx?id=5493. Accessed June 18, 2014.

      9. Oxford University Press. Affordable. Available at http://www.oxforddictionaries.com/us/definition/american_english/affordable. Accessed June 18, 2014.

      10. WalMart. Our locations. Available at http://corporate.walmart.com/our-story/our-business/locations/. Accessed June 20, 2014.

      11. Target. Target global locations. Available at https://corporate.target.com/careers/global-locations. Accessed June 20, 2014.

      12. Aldi. Locations. Available at http://aldiuscareers.com/locations. Accessed June 20, 2014.

      13. Springer S. Aldi to accelerate store growth. Supermarket News. Available at http://supermarketnews.com/retail-financial/aldi-accelerate-store-growth. Accessed June 20, 2014.

      14. Tuttle B. Right business, right time: Struggling economy means boom times for discount grocer Aldi. Time. Available at http://business.time.com/2012/10/08/right-business-right-time-struggling-economy-means-boom-times-for-discount-grocer-aldi/. Accessed June 20, 2014.

      15. Trader Joe's. Find a Trader Joe's. Available at http://www.traderjoes.com/stores/index.asp. Accessed June 20, 2014.

      16. Vega T. Shopping at Target? Now you can pick up a dozen eggs. The New York Times. Available at http://www.nytimes.com/2010/12/17/business/media/17adco.html?_r=0. Accessed June 20, 2014.

      17. Target. Target introduces new grocery wellness brand, Simply Balanced™. Available at http://pressroom.target.com/news/target-introduces-new-grocery-wellness-brand-simply-balancedTM. Accessed June 20, 2014.

      18. Aldi. Fresh Meats. Available at https://www.aldi.us/en/grocery-items/fresh-meats/. Accessed June 20, 2014.

      19. My Private Brand. Aldi launches Simply Nature. Available at http://mypbrand.com/2014/01/06/aldi-launches-simply-nature/. Accessed June 20, 2014.

      20. Sapong E. Trader Joe's has them wowed. The Buffalo News. Available at http://www.buffalonews.com/20130216/trader_joe_x2019_s_has_them_wowed.html. Accessed June 20, 2014.

      21. USDA. Welcome to the USDA National Nutrient Database for Standard Reference. Available at http://ndb.nal.usda.gov/. Accessed June 27, 2014.