Podcast – Managing the Complexities of a Renal Diet

Jessica Prohn, a registered dietitian and board-certified specialist in renal nutrition, says a renal-friendly diet plays a critical role in managing chronic kidney disease (CKD). In the latest episode of Kidney Health Connections, Prohn highlights the value of early dietary intervention, emphasizing its impact on slowing disease progression and improving patient quality of life.

Maintaining a healthy diet can be confusing for CKD patients, especially when they are also managing other conditions such as diabetes, obesity, and cardiovascular disease. As Prohn explains, there is no one-size-fits-all kidney diet, as nutritional needs depend on stage of CKD and treatment modality. An individualized approach—rooted in each patient’s unique medical history, lifestyle, and comorbidities—is essential when crafting dietary recommendations. 

Transcript:

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift of value-based care where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: During my time as a nephrologist, I had a career of counseling patients regarding their diet. I was always concerned with how complex the advice can be; eat this, don't eat this, restrict protein, eat protein.

In this episode of Kidney Health Connections, registered dietitian and nutritionist Jessica Prohn, who's a board-certified specialist in renal nutrition, joins us to discuss the importance of a renal friendly diet.

Jessica, so nice to have you today. Really excited to get to have a conversation with you.

I worked in a fee-for-service world, you know, I ended up trying to do a lot of the counseling for nutrition. I think nutritionists probably know more than most of us nephrologists in this regard, but we're now in this value-based care world where we have all this additional opportunity and resources to bear. It seems logical to me that getting to meet with patients sooner in their disease experience is better than waiting till the last minute. Is that a reasonable assumption? And if so, tell me how you kind of weave all this together.

Jessica Prohn: Yeah, and thanks so much for having me today. I'm so excited to be able to fill that need. It's definitely been a gap in care, I think, for a long time for dietitians to be able to work with patients in earlier stages of CKD. I know for myself, working in dialysis for 10 years, I often thought, “I really wish I had been able to work with this patient earlier on in their process and maybe made a little bit more of a difference.”

So nutrition really is an essential part of any chronic disease management and especially for CKD, you know, helping to manage other comorbid conditions like diabetes, cardiovascular disease, obesity, it can really play a role in a patient's kidney health outcomes and their overall outcomes.

Good nutrition can also affect a patient's quality of life too, you know, and most people, when they start feeling or eating better, they often tell me that they just feel better, they have more energy, they might have reduced uremic symptoms. And that's amazing.

Dr. George Hart: Yeah, I mean, I think the opportunity to be holistic—and you pointed out that these patients really do, they have diabetes, they have heart disease, they have hypertension, they have other issues—you know, it all comes together when they have the chance to meet with someone like you who can see the big picture.

How do you assess these patients? They don't just have kidney disease; they have other medical problems. Where do you start?

Jessica Prohn: Yeah, that's a great question. And you're right. Patients with kidney disease can be very complex.

So the assessment is the biggest piece. That's the first thing that dietitians typically do when we meet with a patient for the first time. And we need to take a careful look at the past medical history that they have, any other comorbid conditions that they're dealing with, their lab trends, their medications that they're taking, because those can affect nutritional status.

And then we take a deep dive into patient's diet and weight history for any important information about what they're eating and any changes in their weight, as well as assessing any psychosocial factors that might be affecting their nutrition. And once we do that, that gives us a really big picture of the actual patient, what supports they have, what they're actually eating.

Then we can really prioritize and hopefully identify any opportunities where we can help the patient to the best of our ability. And getting all that information also helps us to provide individualized and really custom fit, you know, recommendations for the patients that will work for them as individuals.

Dr. George Hart: A CKD stage 3 patient comes in to see you; they're obese, they're diabetic, they have hypertension, they have swelling, they love to eat out. Tell me how you're going to prioritize what you say and how you deal with that patient.

Jessica Prohn: There's a lot going on with that patient, right?

Dr. George Hart: Yeah. It's kind of every day, right?

Jessica Prohn: Yeah, those are patients I work with on a day-to-day basis. So I think number one is really getting a sense for what supports the patient might have. If they're eating out quite a bit, do they maybe have any support at home to help them with meal preparation? Is that really the underlying factor of why they are choosing to eat out? Because if it is, and they may be open to and eligible for any resources like Meals on Wheels to help get them a little bit more of a well-balanced meal provided to the home because they're not able to do their own cooking, that's definitely an option we can recommend for the patient.

If that's not necessarily this patient's profile and they just really like to eat out or they were—I've worked with truckers, you know, over the years that are, you know, eating out quite a bit because that's their life on the road. Then that might look something like making recommendations like when you do have to stop, here's a healthier swap for that burger and fries.

Dr. George Hart: What are some of the biggest challenges you hear from patients as they try and, you know, again, take in the recommendations that you're giving?

Jessica Prohn: Yeah, I think the, the biggest challenge for patients is that they're very confused to begin with. They just don't know what to eat. That's the most common thing I hear, especially when first starting out with folks, because some of the recommendations they might have received for cardiovascular disease or diabetes tend to conflict a little bit with what they see out there for CKD.

We know that medical nutrition therapy referrals are a little underutilized for CKD patients in general. So a lot of times folks are looking online for diet information for CKD, and what's most often found is what's meant for a patient on dialysis. So that doesn't necessarily fit for a person who's in stage 3, you know, doesn't have hyperkalemia. So that confusion really is a big piece of it.

I often hear from patients that they're self-restricting things like bananas, potatoes, you know, oranges. And maybe they've never had a history of high potassium, but their blood pressure's high. Those foods actually might be helpful for them.

Dr. George Hart: So I think you hit on an important part here, which is that giving advice in kidney disease, the advice can be different for early-stage CKD versus late-stage CKD. Can you flesh that out for us a little bit and give me an idea, or give our audience an idea, of the differences and what the advice might be?

Jessica Prohn: Yeah, absolutely. And I wish I could say there's one-size-fits-all for each stage. Unfortunately, I always tell my patients too, there's really no one-size-fits-all kidney diet. It's highly individualized based on the patients, like we talked about, comorbid conditions, what are their lab trends, what medications do they have onboard that might affect them, like their electrolytes, for example.

So apart from like general healthy eating guidance that we recommend for everybody—lower sodium, less processed foods, less added sugars, moderate portions of meat, which we can talk a little bit more about a little later, more fruits and vegetables—apart from that, the potassium and the protein is highly individualized to each patient.

And I even recall working with folks on dialysis that didn't have to worry about their potassium. I'm sure you've seen those folks as, well, people on PD, but even in-center, so it truly there is no one-size-fits-all. And protein, you know, again, varies depending on, you know, of course, in the earlier stages, we don't want people eating excessive amounts. But if somebody has something like cancer, you know, going on, or any other condition, that's where we really need to individualize for the patient.

Dr. George Hart: I totally agree. And I think part of the confusion is, for patients is, when we tell them early on to restrict protein, when they go to home therapy or on a dialysis, “Eat all the protein you can get your hands on.” And that shift back and forth is hard for patients. Have you found that to be the case?

Jessica Prohn: Oh, yeah, definitely. That and potassium, too. If you have somebody going from in-center or even before dialysis when they had to be very stringent on potassium, if they, you know, tended to run a higher potassium level, and then they went to PD, for example, and could eat all the potassium they want, that's a tough shift as well. But yeah, it does become a little confusing. And that's where, you know, a dietitian is very important to have on the team to really provide that guidance for the patient.

Dr. George Hart: You've talked about potassium a couple of times, and our audience probably doesn't fully understand why it's so important. Can you elaborate on the downside of what happens when your potassium is not in balance?

Jessica Prohn: Yeah, so potassium, you could probably speak to it a little better than I can, but potassium too high or too low can be really problematic. It plays a role in muscle contraction. And one of our major muscles is the heart. So it can cause some cardiac events, including death, right?

Dr. George Hart: Absolutely. And I think that one way to tackle elevated potassium is through diet. So I think what are some of the foods that are actually high in potassium?

Jessica Prohn: Yes. So like I talked about earlier, so bananas, oranges, potatoes are high in potassium. Those are our biggest ones that we tend to tell patients. But a lot of the fruits and vegetables do contain some potassium. When a patient's on a lower potassium diet, it doesn't mean we don't want them having, you know, fruits and vegetables at all. We're just going to make recommendations for maybe some lower options and of course talking with them about portion size, because that's everything.

But I always like to point out that meats contain potassium too. And the standard American diet tends to be very excessive in meats. So that's a place where we can actually scale back and make room for some of those fruits and vegetables too.

Dr. George Hart: Are you telling me my steak is not as healthy for me as it might be? You know, what are some of the established dietary guidelines that are useful for patients with kidney disease?

Jessica Prohn: Yeah, well, we touched upon it a little earlier that general healthy eating guidelines that are appropriate for everybody. You know, less processed foods that give a lot of, you know, added salt and added sugar, we want people to be scaling back on those foods. Eating more fruits and vegetables. Eating more plant foods in general, because they're high in dietary fiber and we know that's very important. So things like whole grains, legumes and nuts.

And then we do want people choosing lean types of protein. This is true for all disease states, cardiovascular disease and diabetes as well. So thinking more along the lines of poultry, seafood, and plant-based proteins rather than the red meats and the processed meats.

Dr. George Hart: It sounds almost like a heart smart, Mediterranean type diet. Is that fair?

Jessica Prohn: That's totally fair. You know, the DASH diet, Mediterranean diet, you know, those are all applicable. These are the dietary guidelines for Americans too. So following those guidelines is appropriate for people with kidney disease. Again, we do have to sometimes fine tune a little bit with the protein and the potassium, but most people with kidney disease can follow those recommendations.

Dr. George Hart: As you're working with patients, it's obvious that sometimes it's not the patient who's doing the cooking and it's their caregiver, their partner, their spouse. How do you work through those type of issues?

Jessica Prohn: It's really important for us to know who's doing the shopping and the cooking. It's always part of my initial assessment to ask like, “Who in your household does the shopping? Who in your household does the cooking?” And then looping them in because I, you know, over time and experience working with people, when you're telling the middleman what, you know, the recommendations, that can be really tough, right.

So you have to involve any family members or caregiver that's providing, you know, making the meals and doing the grocery shopping so they know what to be looking for. They're looking at those nutrition facts labels and preparing healthy meals.

Dr. George Hart: Yeah, so I practiced in the south, you know, where, you know, the diet there is different from the diet, say in Chicago or here in Massachusetts, perhaps, where we're filming this today. How do you deal with patients all over the country—what are some of the regional, I mean, how do you take into account regional differences in how people eat?

Jessica Prohn: Yeah, that's a really important factor. It is so true. I've worked with patients, you know, from anywhere from Massachusetts to Texas to Chicago. And yeah, the cuisine can be very different. So I think staying curious, first of all, knowing a little bit about the cultural differences about what people are eating is really important as us dietitians. And if we don't know, we'll ask our colleagues and, “Hey, what are your grocery stores like?” And you can even look online now, which is really great, to see what they're selling in the grocery stores and what the restaurants are like.

But being clued into what people are actually eating and what's available to them and what's part of their day to day and their comfort, because food is comfort, right? We want to eat the foods we know and we've been brought up on. That's all really important.

So again, we can tailor recommendations regardless of the, you know, the types of foods they're eating. We can make recommendations to continue to include some of their favorite foods, but try to make sure they're making room for those healthy foods as well.

Dr. George Hart: So you meet with a family, you meet with a patient, they tell you, you know, “This food's terrible. I can't eat this diet. You know, I'm used to having salt in my diet.” What are some of the practical ways to help patients get away from salt and to use other food or spice additives that will make food taste well for them?

Jessica Prohn: Yeah, yeah. And you hit the nail on the head with the spices. It's really all about flavor. We want food to taste good. As dietitians, we don't want people eating the cardboard diet that I hear patients say all the time.

Dr. George Hart: Yeah, my twigs and bark.

Jessica Prohn: Yes, exactly. So we want patients to enjoy their foods. And it can take a little getting used to, but you can really create flavorful meals with a variety of herbs and spices. I'm also a big fan of using, like, lemon juice and vinegars to bring about a salty flavor; it kind of creates that pungent sense in your mouth. So, you know, adding vinegar or lemon juice or lime juice to foods can really bring about that nice flavor.

Dr. George Hart: What are some of the spices that make a difference?

Jessica Prohn: You know, it kind of depends on the dish, but there's lots of herb and spice blends that you can get that are salt free. If you're making an Italian dish, parsley, basil, oregano really can flavor up your meal. Added to chicken, you can add anything from tarragon to cumin. There's so many, really any herb and spice, as long as it doesn't have salt in it, like the garlic salt or the onion salt. I always tell people they experiment.

Dr. George Hart: Yeah, we want food to taste good because it brings such comfort and that's an important quality of life issue.

Jessica Prohn: Exactly.

Dr. George Hart: I don't think we can have a conversation about nutrition without addressing obesity. And there's obviously a lot of fanfare these days and interest in some of the newer medications that are out there. How do you incorporate these new opportunities with GLP-1s and, in terms of treating obesity, and how does that complement what you're trying to do from a nutrition standpoint?

Jessica Prohn: That's such a great question. And the GLP-1s, like you said, they're getting such great attention for a number of reasons. I mean, the weight loss aspect, they're very effective in terms of helping people lose weight. And we've seen great results for, you know, cardiovascular and kidney outcomes as well.

But one thing I think people may be a little less familiar with is that there is a risk for malnutrition with people taking anti-obesity medications. And our population of CKD patients are at higher risk of malnutrition already for a number of reasons. Number one, you know, chronic inflammation, metabolic acidosis, secondary hyperparathyroidism, all of those things create, you know, are catabolic processes in our body and can lead to malnutrition which affects quality of life and poor outcomes.

The goals of our nutrition care really doesn't change. We want to optimize what people are eating to keep them healthy for the long run. It's a little harder to make sure that folks are eating, you know, a healthy diet when they are taking these medications because they just don't feel hungry to eat. So we have to use strategies like setting a timer, or eating by the clock instead of their hunger cues, and then really making sure that the foods they're eating are nutrient dense and really good nutritious foods so they can make sure they're meeting what they need.

Dr. George Hart: Yeah, I used to tell—you talk about nutrient dense—I used to always encourage patients when they walked by the fridge to grab a handful of roast beef or turkey instead of chips, that kind of a thing.

I'm a recovering transplant physician, so my goal is as much as possible to take patients who have CKD and preemptively transplant them, or even ESKD patients and see them get transplanted. But you mentioned the challenge of being protein malnourished. What are some specific strategies that you advise patients on regarding how to increase the protein and get the appropriate kinds of protein in their diet?

Jessica Prohn: Yeah, and it's not always just about the protein, right? And if we are dealing with, well, if they are protein malnourished, then we want to be increasing that protein. But overall calories is really important as well because our body's going to use protein to use for energy if we're not getting enough overall calories.

So number one, we're looking to make sure that the patients are eating enough overall calories that they're meeting their protein needs. And if not, providing some recommendations about how to meet those. For protein specifically, again, we always are going to be recommending plant-based proteins and lean protein—so chicken and turkey, poultry, seafood. But we can also utilize things like peanut butter. You know, sometimes people don't have much of a taste for meats, so using things like peanut butter or a handful of nuts is a great little snack that people can incorporate. Same thing with eggs or yogurt as well.

Dr. George Hart: Oh, I like you already. I'm a big peanut butter fan.

Jessica Prohn: I love peanut butter too.

Dr. George Hart: This is wonderful. Jessica, this has been great and I've enjoyed all this conversation. I'm actually getting a little hungry now, and I think it's about time for me to take a break and maybe go get a peanut butter and jelly sandwich or something like that. So this is great.

You know, a healthy diet is just such an important piece of how we treat patients holistically, and it, you know, I don't think that it gets enough of the conversation. So today was very helpful, and I really appreciate it.

I hope this was helpful for you in the audience today. And again, if you have interest in learning more, not just about the dietary contributions for kidney disease but all the other aspects of kidney health, please go to our website at interwellhealth.com. Thank you very much.