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SINGAPORE – When Neo Ah Lek, 74, started kidney dialysis about seven years ago, she was advised by a National Kidney Foundation (NKF) dietitian to consume a high-protein diet to replace the proteins lost during treatment and prevent her muscles from wasting away.
This is a complete shift from the guidance given to those in the advanced stages of kidney disease, who would be advised to limit protein intake to safeguard their remaining kidney function.
The kidneys are needed to process the metabolic by-products of protein digestion.
Initially, the protein requirement did not worry Neo much. “I am easy with my food and didn’t deliberately go out of my way to choose a special diet. I would eat what I felt like eating,” said Neo in Mandarin.
In recent years, however, as her health gradually declined, her appetite decreased and her consumption of the calories and the protein that her body needed grew erratic.
In May 2025, some time after she stopped working as a service crew member at a fast-food outlet, a routine monitoring session by an NKF dietitian revealed that Neo had moderate malnutrition and low protein levels. Her weight had dropped by 3kg, which was alarming as she then weighed 34kg.
To support patients like her, NKF provides personalised dietetic guidance and oral nutritional supplements, often in the form of a special formula milk at each dialysis session.
Its team of 12 dietitians regularly visit its 45 dialysis centres to assess patients’ dietary intake and guide both patients and caregivers on practical ways to meet protein requirements safely, said NKF principal dietitian Yee Chooi Fong.
This initiative has helped to halve the malnutrition rate among NKF patients from 42 per cent in 2017 to 21 per cent in 2025, she said.
This occurred despite the patient population at Singapore’s largest dialysis provider rising from 3,440 to 5,339 during the same period.
Neo, who lives alone, is among the 2,100 NKF patients who have benefited from the programme in the year ending June 2025.
Six months after she started on the formula milk, her nutritional status and blood test results improved. She has since regained the lost weight.
Approximately 14 per cent of people in Singapore have chronic kidney disease, a figure projected to rise to one in four by 2035.
Neo, who started dialysis after hypertension caused her kidneys to fail, said she ate out more during her working years.
“I might have a bowl of fish ball noodles but not the fish balls due to the sodium content, a plate of chicken rice, or a plate of economical rice with one meat dish and other non-meat dishes,” she said.
NKF provides personalised dietetic guidance and oral nutritional supplements, often in the form of a special formula milk at each dialysis session.
ST PHOTO: SARAH LEE
Yee said those meals may not have enough protein.
“Dialysis does more than remove waste products from the blood. It also causes the body to lose protein... With dialysis typically taking place three times a week, these losses accumulate significantly over time,” said Yee.
When she consults with malnourished patients, Yee typically helps them to increase their protein intake to 1.2g per kilogram of body weight per day to replace nutrient losses, maintain muscle strength, support immunity and stay well enough to tolerate ongoing treatment.
This is also the general requirement for healthy seniors aged 50 and above, though dialysis patients face multiple challenges in meeting the need, as they have to strictly control their intake of potassium, phosphorus, sodium and fluids, she said.
Moreover, as they age and their disease progresses, they tend to develop complications that reduce their appetite, making it more difficult for them to maintain their high-protein diet, Yee said. Neo, for instance, also has bone disease.
In particular, older dialysis patients are at significantly higher risk of malnutrition due to age-related muscle loss, loss of appetite, chewing difficulties and denture issues. This is often compounded by chronic conditions such as diabetes, high blood pressure, heart disease and stroke, which are common among dialysis patients, said Yee.
NKF data shows malnourished dialysis patients face a 20 per cent higher risk of hospitalisation.
For dialysis patients aged below 50, the protein need is 50 per cent more than the minimum recommended dietary allowance of 0.8g of protein per kilogram of body weight per day for healthy adults, Yee said.
Having adequate protein intake in dialysis care is often under-recognised, said NKF medical director Jason Choo.
He said many patients carry over pre-dialysis advice to restrict protein, and miss the fact that requirements need to increase once dialysis starts. At the same time, their daily focus on fluid, potassium and phosphate limits means having adequate protein can fall off their radar.
“When intake is insufficient, the harm is gradual and cumulative, resulting in muscle wasting, falling albumin and a weakened immune system. Patients may only feel more tired, but this slow decline strongly predicts poor outcomes,” Choo said.
“Death is often recorded as infection, cardiac events or falls, but poor nutrition is frequently the silent contributor.”
Structured support, including dietetic guidance and oral nutrition supplementation, is key to bridging this gap, he added.
“A useful way to think about muscle is as a reserve that the body draws on during illness or stress.
“The principle is the same for seniors and dialysis patients, whereby it is necessary to protect muscle early to preserve resilience when it is needed most,” he said.
To help dialysis patients eat well, NKF launched supermarket tours in mid-2025. These tours – three have been conducted so far – aim to teach them how to identify dialysis-friendly food options and make more informed decisions when preparing meals at home.
Today, Neo makes an effort to watch her protein intake. Her dietitian has advised her on increasing it, such as by adding an egg to her meal outside or making a tuna sandwich instead of having plain bread for breakfast.