Saturday, 12 April 2014

The Renal Diet Recipes

Much of food TV, food writing and of course, food blogging, is aspirational, part of a 'lifestyle': female chefs on TV are always young, slim and unsweaty, food writing is often about rare and expensive ingredients and time-consuming methods, while food blogging can be so twee. Who ties up their freshly-made cookies with ribbon? Who always drinks from a retro paper striped straw? As a self-confessed food geek, I'm always trying hard-core DIY recipes so I plead guilty to the second sin. And I am sometimes prone to the third vice, of prettying up my food photography and recipes, unlikely to be replicated by the average, home tired-from-work cook.
But at the other end of the scale from all this 'lifestyle' cookery, are the people whose diet is so limited as to be dreary, but they have no choice. I've been working with Vital Arts to create vibrant tasty recipes for renal patients, people on dialysis. 
Dialysis is a full-time job; people with kidney failure must go in to the renal ward for five hours, three times a week. Work is difficult and holidays are virtually impossible. The patients are tired all the time. Dialysis, while keeping them alive, is exhausting: you have all your blood taken out, cleaned and put back in. During the process, you feel at your most vulnerable, the life blood is literally being drained out of you. Most renal patients have diabetes. The diabetes explosion in the West will inevitably lead to a surge in demand for dialysis a few years down the line. 
There aren't enough kidneys for transplant. Immediately after my visit, I signed up online to donate my organs. Do it.
Most of the patients on the dialysis ward at the Royal London Hospital, the largest in Europe, are from ethnic minorities: African, Caribbean and from the Indian sub-continent. One of the reasons for this is that there are less donated organs from ethnic minorities and cross-racial organ donation often don't match for both blood and tissue types.  Ethnic minorities wait longer for organ donation and spend longer, often years, on dialysis. 
The renal diet is very restrictive. No potassium, no salt, and about half a litre of liquid a day, including all the liquid they have in their food. Sufferers are reduced to sucking ice cubes to allay thirst. Their kidneys have shut down and they cannot process the excess liquid. No potassium means for instance, no bananas, no yams, few nuts, few tomatoes, a tiny amount of coconut milk. Potatoes must be boiled and drained then cooked again, to rid them of potassium. And imagine a life without salt. In addition, the fact that most renal patients are diabetic means that they must restrict sugar, fruit and carbs in their diet as well as fat: double whammy. 
The people on the ward tend to go in for dialysis with the same people, on the same shift, every week, so they get to know each other really well. They develop close relationships, especially those that are picked up and dropped off by NHS bus, spending three days a week with each other. One of the favourite topics of conversation is food, so Vital Arts asked me to create some recipe cards of dishes that they could eat. The official NHS diet sheets tend to feature British food; in fact the over-boiled, bland food that the British have been trying to move away from, is exactly what a renal patient should be eating. But as dialysis patients come from different cultures, they want more inspirational recipes, dishes they can salivate over. At the same time the recipes should be fairly simple, for people on dialysis have little energy to cook. 
I went along to chat to some patients about the food they like and came up with three recipes. Vegetables and fruit are a problem for people on dialysis, they contain too much fluid. Therefore it is easier to have a protein based, meat diet. So one of the recipes is a chicken recipe, which has been tested. It's the only meat recipe I've ever included on this blog. 
Finally there was an excellent recipe given by a lady of Nigerian origin, a yam chips and tomato stew: she convincingly told us that her Nigerian diet was fine for people on dialysis. But the NHS dieticians said no, it was far too high in potassium. All of the below recipes were checked by the NHS dieticians, I was told to use less oil, less olives, to boil vegetables then drain the water away before using them. 

Shamim's Chicken Tagine with ras el hanout
 Shamim, 54, is originally from Pakistan. She’s been in the UK for 35 years. Her husband has his own business selling gear boxes for cars and Shamim used to work for him. She has been on dialysis for one year now. Her daughter and her daughter-in-law, from Dubai, cook for her but are careful to comply with her diet.
This is a recipe from her daughter-in-law. It’s spectacular, a feast for a family and uses a North African cooking pot called a tagine. This is shaped like a cone, condensation runs up the insides and back down into the food. If you don’t have one, you can use a shallow casserole dish with a lid or, as many modern North Africans use, a pressure cooker.

Serves 6 people

1 tbsp of olive oil
1 medium chicken, jointed, cleaned
1 onion, sliced
3 cloves of garlic, minced
5 carrots, boiled for 10 minutes, then sliced. Water discarded
A pinch of saffron, ground
Juice of half a lemon
1 tbsp of ras el hanout spice mix (can be bought but recipe below)
3 black olives, stoned
handful of fresh flat leaf parsley, picked off the stems
150ml of water

Garnish with fresh parsley and or dried rose petals

Ras el hanout spice mix

This can be ground and used for several weeks if kept in a dry place. Every Arabic shop has it’s own spice mixture, here is a standard approximation of this recipe. Ras el hanout means from the best in the shop.
2 sticks of cinnamon,
10 cloves
1 tbsp of coriander seeds
1 tbsp of cumin seeds
1 tbsp of fenugreek seeds
1 tbsp of fennel seeds
1 tbsp of brown mustard seeds
2 tbsp of dried rose petals

Dry roast all of the ingredients except for the rose petals in a heavy bottomed frying pan, making sure you do not burn the spices. You want the oils and flavours of the spices to emerge.
Then grind all of the ingredients in a powerful blender or a pestle and mortar.

Method for the tagine:

Heat up your tagine or shallow casserole on a medium heat and when it has reached temperature, turn down the heat to low. First brown the chicken pieces in the oil, then place all the ingredients in the tajine, in order, with the chicken on top in your cooking vessel. Then add the rest of the ingredients. Cook for about an hour. If cooking in a casserole, first brown the chicken pieces in the oil, then layer up the casserole dish and bake at 160º for 1 hour 15 minutes. (If using a pressure cooker, follow the manufacturers instructions)

Garnish with parsley and rose petals. Serve with couscous.

Selina's Bangladeshi Fish Curry

Selina is 48, originally from Chitagarh in Bangladesh. She has been on dialysis for just over a year. She’s been in the UK for 25 years, coming here as a 15 year old with her sister. Her sister died ten years ago. She’s done several jobs while in the UK, worked in a shoe shop, in sweet shops and in a dry cleaners. She is helped by an English gentleman, a pensioner from the East End, who sometimes accompanies her to hospital for her dialysis, and cooks for her. He cooks typically English food which is rather bland, but good for a renal diet. But this is a favourite dish of hers, from her country.

Serves 2

1 tbsp sunflower or olive oil or mustard oil 
1 tbsp of turmeric powder
400g of tilapia fillets, washed and patted dry with kitchen paper
1 tbsp of vegetable oil
A pinch of red chilli powder (optional)
1 bay leaf
4 green cardamom pods, crushed
1 tsp of cumin seeds
2 cloves garlic, minced
1 brown onion, finely diced
1 whole green chilli, deseeded, sliced thinly
1 thumb of fresh ginger, peeled and finely chopped
1 tsp of ground coriander
1 tsp of ground cumin
1/2 tsp of turmeric powder
2 tomatoes, chopped finely
a handful of fresh coriander leaves, picked from their stems
Juice of half a lime.

Rub the turmeric powder and oil over the fish fillets and leave to marinate for ten minutes. Pre-heat the grill and grill the tilapia fillets until golden on each side. Handle them gently as you do not want the fillets to break up. Once cooked, lift out the fillets and set aside.
In a frying pan, fry the oil, red chilli powder if using, the bay leaf, green cardamom, and cumin seeds.
Add the garlic, onion, ginger and green chilli then add the ground coriander, ground cumin and turmeric powder.
Stir on a medium heat for five or so minutes, then add the tomatoes. Cook for another five to ten minutes then add the tilapia fillets. These should take around five or so minutes to cook. Garnish with coriander and a squeeze of lime.

Serve with chapatti.

Kalla's Kiri Hodi 
Kalla, 51, was brought up in Sri Lanka and Malaysia. She’s suffered from high blood pressure since her early 20s, hence she has been on dialysis for four years in the self-care section.
The renal diet means no nuts, no seafood, no aubergines, all of which are extensively used in the Malaysian and Sri Lankan food of her youth but Kalla occasionally has some as a treat when her mother comes to visit. Asian fruit and vegetables are particularly high in potassium.
String hoppers are a kind of steamed rice cake like idli. One requires a mould and a basket or pallet to steam them. 
But for this recipe, we have used rice noodles or you could serve rice. 
Kalla’s mother makes her own chilli powder. She grows her own chillies and takes it to a local miller, where they ground spice mixtures in small batches.
Note: liquid is obviously a problem with the renal diet so only a small amount of the Kiri Hodi gravy must be eaten. Generally a dry curry is best for those on dialysis.
This meal is eaten for breakfast or dinner. Hoppers are one of the most ancient foods, dating from the 1st century.

Kiri Hodi with String Hoppers or rice noodles

Serves 2

String Hoppers
225g of plain flour or  white or roasted red rice flour (available at Indian shops)
A pinch of salt
335ml of hot water

Kiri Hodi
400g of King Fish
1/2 a red onion, thinly sliced
1 small green chilli, deseeded, sliced thinly
3 -4 fresh curry leaves
2 garlic cloves, minced
1/2 tsp ground turmeric
1 cinnamon stick, whole, removed from sauce before serving
1/4 tsp of fenugreek seeds, dry roasted
50ml coconut milk
200ml of soy milk
Juice of half a lime
Garnish: fresh coriander

String hopper method:
Prepare a double boiler/ bain marie steamer with hot water just enough water to rest below where you will place the string hopper baskets.
Mix the flour and salt in a bowl then add the hot water, mixing it together. Do the ‘ball’ test. If you can press the crumbly dough into a large ball then you have the right texture. It shouldn’t be too wet however. It is important to knead the dough while it is hot. If the dough is too hot for your hands then empty the dough into a ziplock bag and knead it with a tea towel.
Knead the dough until it is fully mixed with no lumps.
Using a string hopper mould, place the dough into the gadget and squeeze out the noodles onto the string hopper pallet or basket, using a circular motion.
Place the pallets of noodles into the double boiler and steam the noodles over the boiling water for 5 to 10 minutes.

Kiri Hodi method:
Put all the ingredients except for the lime juice in a saucepan on a medium heat and let it cook for about 5 minutes. Then add the lime and a pinch of salt, bring up to a boil then switch off. Keep stirring and serve with string hoppers.

Vermicelli Rice Noodles:
Soak the rice noodles in boiling water for 15 minutes, then serve.


  1. Really interesting subject matter, what an important topic to discuss. Did you take these photos? I really like them, the lighting is beautiful.

  2. I remember your tweets about this and was looking forward to hearing more. I hope some work is being done to encourage more people from minority ethnic groups to sign up for organ donation.

  3. Fascinating topic and one that makes me feel a bit guilty about my casual attitude towards food. My father died of renal disease but he was never given a proper diet to follow. Excellent work, Kerstin. I am sure this will be helpful to lots of people.

  4. Some well put comments about the ubiquity of aspiration and tweeness. This is a truly great post and I really appreciate the time and energy invested in so many personal stories. Particularly welcome is Shamim's tagging and the reminder about el hangout spice mix. Kiri Hodi also looks lovely. Hoppers, wow! Thanks to all the contributors.

    1. It was enlightening talking to the patients, the kind of food reportage I love doing.

  5. Thank you for working so hard to help those suffering. Such a restricted diet, not to mention the dialysis itself, is suffering indeed. I agree the pictures are wonderful. Thanks again! Christina in the US

    1. Thanks. Do check out the work of vital arts, who created this project, a really useful, self funded organisation.

    2. Thanks so much, Kerstin. Really happy with how these came out and looking forward to getting the patients feedback. It's been great working with you! Rachel, Vital Arts (

    3. You are more than welcome Rachel, it was a fascinating project.

  6. I understand completely as I have a dietary restriction. Makes famil cooking even more of a challenge as growing teenagers in particular need a balanced diet. These recipes provide super inspiration

  7. Easy to get sucked into the 'string round the cookies' kind of food photography. Personally like more honest food pics - and then it's more about the food than the (fake) lifestyle.
    A friend has had 3 kidney transplants and was on dialysis for a while - I witnessed what a toll it took on her and how incredibly time consuming it is ....just to stay alive. To have that burden plus a restriction on your eating habits sounds pretty unbearable. I love how you've turned your resourcefulness and imagination to this project. Great stories behind the pictures and recipes. I've had a kidney donor card forever and still carry it when in the UK. I don't understand why people object to the 'opt out' rather than 'opt in' sort of scheme. It would transform so many lives. Great post Kerstin.

    1. Thanks Sally. I also have a weakness for twee food pix. In fact I think I even have a lovely pix of home-made biscuits tied with some fashionable twine!
      The really worrying thing is that ethnic minorities don't donate organs. I have no idea why. Jehovahs witnesses? And I guess there are less available ethnic minority organs in general in the UK as they are but 14 % of the population.

  8. What a wonderful post! I feel rather humbled to have read it, such fantastic work

    1. Thanks Cate. Vital Arts are doing...well...vital work!

  9. What a great project. In Australia our Aboriginal people have a shamefully high rate of dialysis. There are cultural reasons for it that are incredibly complex - one of my favourite stories of resilience in the Aboriginal community is how they brought dialysis to a remote community through an art auction - - but now your story makes me wonder about issues of nutrition and how they affect dialysis patients too.

    1. Thanks for your comment Johanna. What kind of diet do aborginals tend to have? I imagine those that stick to a traditional diet don't have kidney problems? Why do they tend to have dialysis?
      I've never been to Australia, and that is something I MUST rectify.

  10. What an excellent, thought provoking and poignantly matter-of-fact bit of writing. Thank you, and also to the people who shared their stories and recipes.

    1. Thanks Lee. They are the heroes in the story.

  11. I love this post. My mom was born with polycystic kidney disease and spent 6 years on peritoneal and the last 6 months of her life on haemodialysis so I am horribly familiar with the toll dialysis takes. Dietary advice from her renal specialist was minimal so she had to find out all this info the hard way. I love all three recipes as well as the personal stories behind them.


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