Listen to this podcast, in which Sara Colman, RD, CDE, the manager of Kidney Care Nutrition for DaVita interviews Natalie Sexton, MS, RDN, CSR, LD, a dietitian for DaVita in Longview, Texas, on the importance of clinicians emphasizing moderation rather than elimination in a kidney-friendly diet. Natalie and Sara discuss the typical diets for end stage kidney disease patients on dialysis, including the different modalities of peritoneal dialysis, home hemodialysis and in-center dialysis. They examine how the kidney diet compares to some of the generally popular diets, what some of the biggest misconceptions are about kidney friendly diets, what some of the common barriers are that prevent diet adherence, how nutrition can affect quality of life, what overall goals dietitians have for their patients, how clinicians can advise patients to incorporate some of their favorite foods, even those that are not kidney friendly, in their diets and how to use the recipes on davita.com in meal planning and other nutrition resources available to patients and clinicians.

Podcast Transcript:

Sarah Colman, RD, CDE (00:43): Hello, and welcome to the DaVita Medical Insights Podcast. My name is Sarah Colman, RD, CDE and I'm the davita.com nutrition manager for DaVita kidney care. Over the past decade, we've seen a shift from a strict mineral based kidney diet to one that includes more healthy whole foods and even questioning the benefits of the old kidney diet. Today's can they diet continues to evolve with even more research. I'm excited to join on the phone today by Natalie Sexton, MS, RDN, CSR, LD, a dietician for DaVita in Longview, Texas, as we discuss the importance of clinicians emphasizing moderation rather than elimination and kidney friendly diet. Thank you for joining us, Natalie.

Natalie Sexton, MS, RDN, CSR, LD (01:28): Hi, Sarah. Thank you for having me today. I'm very excited to be here and to be able to speak on such an important topic.

Sarah Colman, RD, CDE (01:36): Great. Well, let's get started. Can you tell me about the typical diets for end-stage kidney disease patients on dialysis, including modalities such as peritoneal dialysis, home hemodialysis and in-center dialysis?

Natalie Sexton, MS, RDN, CSR, LD (01:52): Yes, I do have a little disclaimer first. The diet guidelines that I'm talking about today are focused on patients who have what we call end-stage kidney disease. So they are on some form of dialysis. Nutrition recommendations are very different for people with chronic kidney disease, stage one through four or those trying to preserve remaining kidney function. So just to be clear, these diet guidelines we're going to talk about are focused on patients who are receiving dialysis treatment. So the most basic diet guidelines, once a patient's on a high protein diet, the dialysis treatment increases their calorie needs, their protein needs, so we do need them to increase their protein intake, which is something they may have not been used to if they had been following a low protein diet prior to dialysis.

Natalie Sexton, MS, RDN, CSR, LD (02:55): We also want them to limit their potassium intake. So certain fruits and vegetables are going to be high in potassium. We would want them to try to limit those, cut back as much as possible. We also want them to watch their phosphorus intake. That's usually found in foods either naturally or sometimes your food companies add that as a preservative. So that's another thing that they have to watch out for. Low salt or low sodium is another one of the diet recommendations, and then low fluids. So sometimes patients on dialysis, you have to limit their fluid intake to avoid gaining too much fluid in their body. So that's pretty common for them to have to follow. Now, those are typically the recommendations for the in-center dialysis patients. Those are the patients that are coming usually three treatments a week. For the patients doing home dialysis, they may be doing shorter, more frequent dialysis treatments, so they may not have to be quite as strict with their diet.

Natalie Sexton, MS, RDN, CSR, LD (04:14): Then they get a little more wiggle room since they are doing more frequent treatment. Then with PD, or peritoneal dialysis, the PD solution absolutely removes more potassium from the blood than just your standard hemodialysis. So those patients actually may have to follow a high potassium diet. They may be encouraged to eat certain foods that your in-center or your home dialysis patients are told to limit. Then also the PD solution is a kind of a sugar solution, so your body does absorb some of those calories. So this can cause problems with weight gain or blood sugar levels, so they may have to work with their dietician to try to modify their calorie or their carbohydrate intake.

Sarah Colman, RD, CDE (05:12): Well, sounds like a lot to remember when it comes to kidney diets. Good thing we have the dieticians there to help work with patients and guide them in what they need for their individual needs. So we know that there's a lot of diets out there. It seems like every month or so we have a new popular fad diet. We have people who are eating keto or very low carb. We have other healthy type diets like Mediterranean Diet. So overall, how does the kidney diet compare to some of these popular diets or general healthy eating recommendations?

Natalie Sexton, MS, RDN, CSR, LD (05:49): Yes, you're right. It seems like every month there's a news fad diet popping up. So usually when you hear the word diet, we think of cutting out certain foods or food groups or restricting yourself to a certain calorie amount until you reach a goal. So there's some sort of end goal in mind, like a certain dress size or a pants size or a number on the sale. There's some goal that the people following these diets are trying to reach.

Natalie Sexton, MS, RDN, CSR, LD (06:28): So the difference between that and the kidney diet is the kidney diet is lifelong. Of course, we do have certain, I'll say, goals that we want you to achieve. We want certain blood levels to be within target ranges. We want you to meet what we call your target weight when you come in to your treatment. So we do have small goals, but as far as the true end goal, there really isn't one. This is a lifelong way of eating. So we really want to work with our patients and help them create actions that they can implement forever.

Sarah Colman, RD, CDE (07:16): Natalie, I find that there are a lot of patients who come to dialysis with so much confusion, and I think part of that is because in earlier stages of kidney disease, they may or may not need a low potassium diet. They may be restricting protein to help decrease waste buildup in their blood. Then a person comes to dialysis, all of a sudden they may not be eliminating enough fluid, the kidneys are starting to shut down more and more. So I think this causes a lot of confusion when a person comes to the dialysis center and starts dialyzing, and they're unsure. They have mixed messages about what to eat, what not to eat, what their allowances are. So in your eyes, what are some of the biggest misconceptions that you hear about kidney friendly diets?

Natalie Sexton, MS, RDN, CSR, LD (08:08): Some of the biggest things that I hear that are definitely not true is that you can never eat a high potassium fruit or vegetable ever again. Probably the most common high potassium fruits or vegetables are bananas, tomatoes, avocados. So it's definitely a myth that you can never, ever have a single bite of those foods ever again if you're on dialysis. If anyone has ever looked at the DaVita website with our recipe book or cookbook, we have recipes that have avocados, tomatoes, bananas, potatoes, but they're all in moderation or smaller portions. So we still do want to work these foods into our diet. They can provide a lot of flavor, a lot of color to our meals, but we just have to watch how much we eat at one time.

Natalie Sexton, MS, RDN, CSR, LD (09:16): Another myth is that the diet is just simply too hard to follow, and yes, it is very complex, but it's not impossible. We're not asking our patients to track their potassium intake down to the very last milligram. I don't ask mine to even really track their grams of protein. We simplify it as much as we can and try to make it very doable. So I encouraged them to do more of just asking themselves, "Does this meal include any high protein food?" So rather than count grams of protein, I just want them to say if a high protein food is included in the meal. So for example, a patient told me yesterday that their breakfast was usually a couple pieces of toast and some black coffee. So we talked about how that didn't have a lot of protein in it. So we talked about adding an egg or two to try to get their protein intake up.

Natalie Sexton, MS, RDN, CSR, LD (10:31): So once you're sure you've got some good protein with that meal, I encourage them to ask themselves, "Are there any high potassium foods that I need to watch out for?" So if they are out at a restaurant, if the side for their meal was going to be potatoes, which we know have a lot of potassium in them, if that's something they're trying to cut back on, then we can see if we can swap that out for a lower potassium vegetable. Then third question is, "Are there any high phosphorus foods I should be careful of?" So I teach my patients to be able to identify some typical hight phosphorus foods, which ones to try to avoid as much as possible and which ones to cut back on. So for example, cheese is one of the more common high phosphorus foods. So I encourage them to either use a smaller portion or ask for the tea to be put on the side of the plate so that they can control the amount on there.

Natalie Sexton, MS, RDN, CSR, LD (11:41): So I would say compared to calorie counting and macro counting and the true keto diet where you're watching every last gram of carb that you serve yourself, honestly, the kidney diet seems a lot easier than that.

Sarah Colman, RD, CDE (12:04): But that really makes a difference. I know as soon as you tell me not to eat something, especially if it's something like chocolate that I really love, I'm going to start craving it. So I'm sure for dialysis patients, just knowing that if there's something you truly want to eat, there is a way to work it into your diet. It's working with your dietician and finding out what's the results after you've added that item. I think as clinicians that's one thing that we can do, is just really give that flexibility but also monitoring the effects of making changes in a person's usual renal diet. So Natalie, as a dietician, what are some of the common barriers that you see that prevent diet adherence?

Natalie Sexton, MS, RDN, CSR, LD (12:54): Definitely I would say with a patient who's new to dialysis, a lot of times they're just very overwhelmed. Their whole life has suddenly changed. Depending on what type of dialysis they're doing, let's just say they're doing in-center dialysis, so that means all of a sudden for three or four hours at a time, three or four times a week, depending on their dialysis constrictions, suddenly they have to be in this dialysis center, hooked up to a machine, there's monitors everywhere, there's beeping, there's blood, there's needles. It's actually kind of scary when you think about it. As comforting as the teammates try to be with all the patients, it is a very overwhelming life altering thing to start dialysis.

Natalie Sexton, MS, RDN, CSR, LD (13:56): So in addition to dealing with all that, now we want you to remember all these different food rules and only eat these few foods and don't eat anything that you enjoy eating, it's a little unrealistic for us to expect that from our patients. So that's probably the first barrier that I see, is they're just not ready to take in the education fully just yet, or they're just overwhelmed with everything and they can't quite focus on that. So just working with them, small changes that they can make over gradual amount of time helps. Like you said, there's certain foods that you may find comfort in like chocolate or ice cream. Where if I go tell you, "Okay, no more chocolate, no more ice cream, no more this, no more that," that suddenly is just consuming your mind. That's all you think about. That's all you crave. So for someone to kind of take away that last little bit of comfort is very frustrating, very overwhelming.

Natalie Sexton, MS, RDN, CSR, LD (15:11): Another barrier would be just the lack of understanding. Our patients are just like anyone else. They're flooded with the messages from the TV commercials and the late night infomercials and the magazines about the latest fad diets. So sometimes it's just kind of a disconnect between what the media tells us, what our friends following the latest fad diet or selling a weight loss supplement is telling us, and then what our dialysis dietician is telling us. So it can all be very confusing and kind of mixed messages there. A lot of the patients haven't had true diet education before. So this may be their first experience ever being told to watch what they eat and things like that. So definitely just lack of understanding is another barrier.

Sarah Colman, RD, CDE (16:20): I think that with that, often patients are given food lists and the list may say foods you can eat. Foods to avoid or limit. That focus is so much on the word avoid, but you have to remind patients that it says, "Or limit." So there may be some foods on that list that, yes, you do need to avoid altogether, but often there's many foods on that list that that can be included. It's just limiting the amount and the frequency. I think that's one thing that we can do as clinicians, is help patients to understand that that's their focus, that it's not as strict or as awful or as bad as they initially might think that changing their diet can be.

Sarah Colman, RD, CDE (17:10): So we think a lot about quality of life with our patients and we know that when a person is not getting the right nutrient balance, if they're malnourished, if they're having appetite problems or maybe they just have that fear of eating, that can all affect a person's quality of life. So in your eyes, Natalie, how can nutrition affect quality of life and what can we do to improve it through better nutrition?

Natalie Sexton, MS, RDN, CSR, LD (17:45): Nutrition does play a big role in quality of life. So although following the kidney diet won't reverse the need for dialysis, it can help them manage some of the symptoms that they may be dealing with. So watching their salt intake, it's more than just we don't want you to eat all the salt. Watching their salt intake will help decrease their blood pressure, which can help them avoid a stroke or a heart attack. Watching their fluid intake helps them breathe easier, and it keeps their heart from having to work harder from carrying all this extra fluid weight around. Limiting their calcium and their phosphorous intake helps them improve or preserve their bone health, so it keeps their bones strong and healthy. Limiting their potassium intake can help avoid issues with heart rhythms, eating a high protein diet will help keep their albumin level up which helps keep their bodies healthy and they feel well, they have more energy.

Natalie Sexton, MS, RDN, CSR, LD (19:09): Then we can also work with our patients on if they have diabetes and they want to help manage their blood sugar levels, or they want to lose weight to prepare for kidney transplant. We work with them on all aspects of that. I have some patients that will joke around with me saying, "I know my phosphorus is high. I know I came in with a lot fluid today" and I remind them, "We do want you to meet these certain metrics, but more than that, we want you to feel good. We want you to stay healthy." So if they come in with a lot of extra fluid on them, I ask them, "How are you feeling today? How do you feel with all that extra fluid?" And they'll tell me, "It's really hard to breathe. It's hard to get around. It was hard to play with my grandkids this weekend."

Natalie Sexton, MS, RDN, CSR, LD (20:06): So we talk about it's more than just meeting the goal on a piece of paper. We want them to be able to do all the things that they want to do. Same thing with phosphorus. We have a goal that we want the patient to meet on paper, but if they're itching, if their phosphorus is high and it's causing a lot of calciphylaxis, they're having very weakened bones and things like that, we want to help them want to change their eating habits so that they can improve those things. Not just meet this paper goal that we have for them.

Sarah Colman, RD, CDE (20:53): I think that's a great point, Natalie, that if you can tie in how your nutrition or the way you're eating can impact how you're feeling, but also how that impacts your day-to-day activities, especially when it comes to interacting with your family and friends. I think that's a real selling point when it comes to the importance of diet and what a difference it can make in how a patient is feeling. I know that we have individual goals for patients, but there's also overall goals. I thought maybe you could talk a little bit about what is your overall goal for your patients?

Natalie Sexton, MS, RDN, CSR, LD (21:40): Well, my overall goal is really just to educate my patients so that they do understand how to follow this diet, how it's going to improve their quality of life, how it will make them feel. Some of my patients, and I'm sure other dieticians, they'll jokingly call us the food police. "Oh, here comes the food police to tell me what I shouldn't be eating." That's definitely not what we want to be called. Most of us didn't become dieticians because we hate food. It's usually quite the opposite. We love food as well, so much that we chose to get a degree in it.

Natalie Sexton, MS, RDN, CSR, LD (22:27): So my goal for my patients is just to have a true understanding of the diet and the benefits of following these guidelines. Then also just to help empower them to make their own choices. A lot of times with kidney disease and having to do dialysis, they feel sort of a loss of control over their lives. So food is one of the things that they do have absolute control over. So DaVita has a program called Epic. It stands for empowering patients in their care, and it helps dieticians and teammate really try to find out what's important to the patient and really kind of give them back that sense of control over their lives. So I [inaudible 00:23:32] my patients that they are in charge of themselves. I'm not here to tell them don't eat that or to take away a dark soda if I see them with a dark soda at their treatment. My job is just to educate them so that they know that drinking that dark soda, because it has a lot of phosphorus, it may increase their phosphorus level in their blood, which could harm their bones in the long run.

Natalie Sexton, MS, RDN, CSR, LD (24:03): So as long as they understand that when they make their diet choices, then I've done my job. Now, next step, I would want to try to find out if there was a way that they could be motivated to make those healthier diets swaps and to exchange that for a low phosphorus drink, but again, that's up to them. If they're not ready to change or if that soda is just extremely comforting to them right now we definitely won't push them. Because at the end of the day, we all have to eat to live. Food really should be enjoyable. It should be something that you can still sit down and have a meal with your family members who aren't on dialysis. You shouldn't feel like you have to cook totally different meals and eat at one end of the table while they eat at the other. So we don't want it to be disconnecting.

Sarah Colman, RD, CDE (25:14): So it sounds like a lot of it coming to the patient is the matter of choice and maybe the power of choice being educated to make the best choices. At the same time, we know that patients are going to include some of those not-so-friendly kidney foods, whether it's a special celebration or it's a craving that they have. We need to prepare patients to be able to work some of those foods into their diets. So what are some things that clinicians can advise patients to do that can help them in incorporating small amounts of some of these foods that patients feel I can never have, or I shouldn't be eating this. How can we help them as clinicians to incorporate some of those foods in their diets?

Natalie Sexton, MS, RDN, CSR, LD (26:12): Yes, you're right. Our patients are definitely going to encounter times where they may not have kidney friendly food available to them. It could be on purpose, I'll say, but it could also be not on purpose. Like their power goes out. They're staying with a friend for the weekend and that friend has a bunch of junk food and things that aren't so kidney friendly at their house. So we definitely want to prepare our patients with what to do in these situations. So right off the bat, I would say portion control is number one. So when it comes to chips, candy, kind of more the dessert, sweat treat items, if you can buy those in snack size versions, usually that helps with kind of limiting yourself to a smaller portion size, rather than buying a large bag and then trying to limit yourself, reaching back in for just a few more chips or whatever it is. So buying the snack size versions of the chips and the candies.

Natalie Sexton, MS, RDN, CSR, LD (27:42): Another thing that helps with portion control is using smaller plates or bowls or glasses. If you have a huge plate but the serving size for food is one cup, when you put one cup of food on a huge plate, it doesn't look like you have very much food. But if you have a smaller dish or a smaller plate, then when you put the one type of food in there it looks like it goes further. So it's kind of a mind trick, where you now you should only be eating this certain amount, but you feel like you had more when it takes up more room on your plate. Another good way to do portion control is if you're out at a restaurant to order off of the kid's menu or split a meal with a friend, or have the cook or the waiter divide your meal in half and put half in a to-go box to eat at a another meal time. So those are some things to do for portion control.

Natalie Sexton, MS, RDN, CSR, LD (28:56): Another tip would be to measure your food. Even as a dietician working with food, many, many years, I still have to measure food sometimes. I don't trust myself to accurately estimate what a half of a cup or a quarter of a cup looks like. So if you're not sure, just get out those measuring spoons and measure it. Another big tip would be to make healthier versions of the foods that you love at home. So when my patients tell me that they love pizza, they just cannot give up pizza, I just tell them, "Good. I don't want you to give up pizza. I want you to learn how to make a healthier version of that pizza." So I share the DaVita recipes with them, where you still have the tomato sauce, but you control how much that you put on your pizza so it'll have a little bit less tomatoes, little bit less cheese. Maybe we added in some extra meat or some extra vegetables to make up for that.

Natalie Sexton, MS, RDN, CSR, LD (30:17): Same thing with burgers, casseroles. I encourage so many of our patients to look on the DaVita website at the recipes because there's a lot of comfort food like chilies and soups and things like that that can be made in very kidney friendly, healthy ways. Then another thing would be to stop kind of mindless eating. I think our culture today, rarely do we sit down at a dinner table anymore. We're always eating on the go, eating in front of the TV. So we may end up eating a large amount really, really quickly and not realize that we're full because we ate our whole meal in five minutes, or we were focused on watching a TV show and we just keep eating, keep eating, keep reaching back into that bag for more and more. So it's really easy to kind of let your portion sizes get away from you when you're not focused on your meal. So just truly being engaged at meal time, and that can definitely help portion control and things like that.

Sarah Colman, RD, CDE (31:50): Great tips, Natalie. I think another thing too is you talk about the recipes on davita.com, which we have over 1100, and part of it goes with planning a meal. So if you are trying a new recipe, planning what goes with that meal or thinking of a way to then kind of put everything together. I know as a dietician, that's one of the things that you do, is just helping patients to come up with ideas for meals, that also what they want may be providing them with a kidney friendly version of that, like you mentioned the pizza, and then putting it all together into a satisfying meal. I think that's so important.

Sarah Colman, RD, CDE (32:34): Thanks for those tips that you provided and all of the great information, Natalie. Is there anything else you'd like to add for our clinician audience today?

Natalie Sexton, MS, RDN, CSR, LD (32:45): Really just to encourage your patients to look at the DaVita diet [inaudible 00:32:55] section for recipes and things like that, and then having the clinicians ... Go on there yourself, see how user-friendly it is. I go on there all the time just for recipes for myself. It has a very cool search feature where if you have one ingredient that you're like, "It's about to go bad in my fridge, I need to use it, but I just can't think of a recipe to use it," you just type in that one ingredient and it pulls up tons of recipes. So I personally use that all the time. So I definitely encourage the clinicians to check out the resources available to our patients, just so they're familiar with them themselves.

Natalie Sexton, MS, RDN, CSR, LD (33:44): Then don't hesitate to reach out to the dietician at your clinic. I may be biased, but I think our DaVita dieticians are some of the best in the field. They work so hard to provide awesome care for the patients. They're constantly coming up with tips and blog posts and recipes and educational handouts and just so much to help our patients. It really does take a village to take care of these patients. So the more closely that we work with each other, the better care that we provide.

Sarah Colman, RD, CDE (34:29): That's pretty awesome, Natalie. Thanks again for joining me and discussing the importance of clinicians emphasizing moderation rather than elimination in kidney friendly diet.

Natalie Sexton, MS, RDN, CSR, LD (34:42): Thank you so much for having me today, Sarah. I really appreciate the opportunity to talk about this topic.

Sarah Colman, RD, CDE (34:49): Wonderful. Thank you. So listeners, thank you for tuning in and be sure to check out other DaVita Medical Insights episodes for more kidney care educational podcasts. You can also find additional kidney care, thought leadership and industry news by following @DaVitaDoc on Twitter. Thank you so much for joining our podcast today.