Tiffany Archibald 00:01
The DNA podcast series, let’s talk about kidneys provides education dedicated to exploring the journey of those living with chronic kidney disease. We’re here to inspire meaningful conversations and to help people living with CKD gain a better understanding of their disease. Hello, everyone on today’s episode of Let’s Talk About kidneys. We are going to be talking with Dr Rao, one of our nephrologists here at Dallas nephrology associates. And our topic for today is going to be on dialysis patients and their diet. Welcome, Dr Rao. How are you today?
Dr. Archana Rao 00:38
Thank you. I’m doing very well. How are you? Tiffany, good, good.
Tiffany Archibald 00:43
So can you tell us a little bit about your the locations that you see patients at, and your role here with DNA?
Dr. Archana Rao 00:50
Sure. So I’ve been with the Dallas nephrology since 2008 it’s about 15 years. I joined right after I finished training in nephrology. So been here quite a while. I care for patients in the more east side of the metroplex. So that’s the areas of Mesquite, Sunnyvale, part of Richardson, Garland, that area, and I take care of quite a few dialysis patients. I also care for patients with CKD who need to be seen in the office as well as hospital. So pretty much what a general nephrologist would do on a day-to-day basis.
Tiffany Archibald 01:34
All right, so we’re going to dive right into the specifics of dialysis patients and their diet. So how does a patient’s diet change once they start dialysis? You can kind of walk us through that process from CKD to becoming a dialysis patient.
Dr. Archana Rao 01:53
So you know this is such an important topic, because we’re talking about food, right? And food, obviously, is so important just nutritionally, right? We get nutrition. We need to maintain ourselves. But even more than that, right, food is so embedded in our culture, right, who we are, what we do, day to day to day. So food and kidney disease is such an important topic for us to go through, so I’m excited we’re doing that so and you’re right before we get into talking about dialysis, I think it’s important to take a step back and talk about the kidney disease patient pre dialysis, right? So most often, these are patients who have some stage of chronic kidney disease, maybe stage one to four or five, and dietary changes or dietary modifications become necessary even in these stages, right? And why is that? Because you know the risk factors for kidney disease are diabetes, high blood pressure, right? And as you know, the kidneys are really responsible for maintaining a balance of various minerals in the body, whether it’s potassium, whether it is phosphorus, our salt intake, our fluid intake, all of this really plays a huge role in the sense of wellness a kidney patient may feel so dietary guidance, or food guidance ought to begin much early in the kidney disease journey, right? And some simple things, although there might be very specific, patient related guidelines. The general guidelines belong to, most importantly, salt intake, right? A lot of it has to do with mineral intake, like potassium, phosphorus, et cetera. And on the topic of salt intake, what I would say is that, in general, we all need to learn to consume less sodium than we do, right? So that is probably a guideline that a pro that applies across the board to almost all of our patients. So let’s begin with that and talk about low salt diet, which really means that we need to be a lot more mindful of the food choices we make. I typically tell patients, anything that comes in a packet, like a packet of chips or anything like that, tends to contain high salt, right? And when eating outside, if someone consumes fast food in general that has a lot more salt in it, right? And canned items tend to use sodium as a preservative, so all of those items in a broad category are probably to be avoided, okay,
Tiffany Archibald 04:55
So for people that are listening right now, um. Dietary restrictions and limitations must begin prior to dialysis. So what you’re saying is that if a CKD patient is doing a good job prior to dialysis, monitoring their sodium, monitoring their fluids, do you feel that makes it a good transition for them to go into that dialysis diet.
Dr. Archana Rao 05:23
Absolutely. I think adaptation of lifestyle, including diet that begins much before, not only makes it a smooth transition, but more importantly, has a role in delaying the progression. So you see the patient already gains more wellness, longevity of kidney health, for example, right? And it is a tough ask. Tiffany, you know, asking people to modify what they do for food is one of the tougher things that people can do, because food is cultural. Folks eat a certain way. They’ve already always had a certain kind of a predisposition. It depends on time availability. How do they go about getting their nutrition in? Varies probably day to day, person to person. So that adaptation, when it begins way early on in the journey tends to have a long term benefit for the patient, in general quality of life, as well as just the journey itself with the disease becomes a lot smoother.
Tiffany Archibald 06:33
Okay, so what are the most common dietary changes a patient should expect to implement?
Dr. Archana Rao 06:42
Okay, so if we are talking about chronic kidney disease patients, like I said, it’s a lot to do with salt intake, a lot to do with avoiding processed foods. The typical minerals we focus on are potassium, phosphorus. We also focus on fluid, like water intake, how much and how much not to and these essential principles continue into the dialysis journey. So what we inform patients, and they will hear this over and over again, that we are focused on this, because the end point is to maintain a balance of these minerals in the body, because when it gets too high, they have toxic effects. So we want to create a balance so that internally, the metabolism, the internal chemistry, is most conducive for, let’s say, overall wellness. You know, we wanted us to be healthy internally as well. So these will be the main principles that will be discussed with a dialysis patient, or maybe even with a kidney disease patient.
Tiffany Archibald 07:46
Okay, and so I know that protein is something that is important. Can we talk about why protein is important and the amount of protein dialysis patients consume absolutely protein.
Dr. Archana Rao 07:59
Such a big, big deal really, because many of the kidney disorders can cause huge fluctuations in protein levels in the body. Okay, there is a lot of inflammatory changes that happen in the body. And therefore, you know, consuming the right amount of protein becomes very, very important. Now, the protein consumption guidelines might vary depending on the kidney disease stage itself, but if we speak specifically about dialysis patients, we do want them to consume adequate amount of protein, probably in every meal.
Tiffany Archibald 08:37
Okay, so, and when you say adequate amount, can you if it’s if they’re having three meals a day, how much protein should be consumed in each meal?
Dr. Archana Rao 08:46
About a fist sized, you know, serving of protein with every meal. Some of the common protein supplements or sources in a diet would be, let’s say, for breakfast one could do egg whites, scrambled eggs, you know, egg whites are a nutritious source of protein. They’re also very well tolerated and adapt well to the body. There are, you know, a lean meats, chicken, you know, turkey, fish. These are all excellent sources of protein. There’s also lentils, beans, soy, which are, let’s say, non animal sources of protein. So typically, most of our patients need to have a decent portion of protein in their plate, you know, at least a fist sized protein serving right there on the plate.
Tiffany Archibald 09:39
Right and so for those that are listening. I think it’s some you touched on a good point. You cover different types of protein, because there may be someone listening that do does not consume, you know, animal protein. So you talked about the lentils. Just give us three examples for those people that you know. We already know that fish and the turkey and seafood. But what are some examples of lentils that people can consume?
Dr. Archana Rao 10:07
There’s actually a variety of lentils. There are dry beans, there’s kidney beans, there’s various lentil preparations. There’s also soy preparations. These are all excellent, non animal or, let’s say, plant based sources of protein. And there’s actually a variety of ways to prepare them, right and now, milk cheese, etc, they are also plant based sources of protein. However, for kidney patients, they may not be the most optimal sources, and the reason is they tend to be higher in phosphorus, so it’s a less preferred way of getting protein. Often, patients can also get protein shakes, like whey protein. They can consume protein like that. That’s also very, very desirable to do. Often, dialysis patients will be given some supplements in the form of bars or little liquid supplement drinks, all of which are really geared to enhancing the nutritional status, protein level in the body so they can be healed and repair and you know, just keep everything very stable.
Tiffany Archibald 11:19
Let’s jump into the specific diets for the different types of dialysis. So first, let’s cover hemodialysis dietary needs. What specific dietary needs should hemodialysis patients be aware of, particularly concerning their potassium and their fluid management. I know fluid is very important. I have a personal experience on dialysis and consuming too much fluid, but I’ll let you kind of cover that Absolutely.
Dr. Archana Rao 11:51
That’s a great question, because in a patient who is doing hemodialysis, right? So there’s two ways they can do that. One is they would go to a dialysis center, and they would be receiving the treatment approximately about four hours each treatment, and they might do that three times of the week, the other four days in the week they’re not getting dialysis. Well, the other way they can get hemodialysis is to do it at home, where the prescription might be a little bit different. They may do it much more often. They may do it for lesser time, but have a more, let’s say, regular rhythm to it, and two very important things, fluid, hugely important because when a person leaves the dialysis clinic until they come back in right how much fluid they consume will really matter to them. You know, too much fluid consumption frequently leads to what we call fluid overload. This can manifest as swelling to the legs. Just manifest as difficulty breathing, sluggishness, inability to get around, and sometimes it can also cause the patient to have, let’s say, a sudden onset of difficulty breathing. It’s actually a very distressing series of symptoms that the patient experiences. So some practical ways of avoiding getting to that level would be, strangely enough, salt consumption is super important. Like in other words, increase in salt consumption creates retention of fluid. Okay, so sometimes we don’t instinctively think of those two as connected. So frequently we tell patients, you know, do not add extra salt to your diet if you’re actually going out and have a celebratory weekend. You know, choose smaller portions. Request that, you know, they prepare the meals, if possible, with lower salt. And how does one drink less fluid? You know, that’s a tough question too, because we are often served classes of fluid or water in really large classes, sometimes 12-16, ounces, and that’s not ideal for someone who’s having to be on a fluid restricted diet. So some practical tips are to request, let’s say, a small cup and drink water out of it. Another really nice trick would be, if you’re at a restaurant, just fill it up with eyes and ask them not to put a lot of water in, so that immediately limits how much fluid you’re taking in. I find that might be in because, you know, you in the middle of, let’s say, a nice family celebration dinner.
Tiffany Archibald 14:43
If you’re not paying attention, that is kind of what I experienced. I just was eating and drinking and, you know, not really putting two and two together until, you know, I felt the effects of it. So, yeah, so those are some key things when going out. I know we can do a. Whole topic on eating out and things like that, but we’ll say that for another time, so that we can transition into peritoneal dialysis, dietary restrictions.
Dr. Archana Rao 15:10
So with peritoneal dialysis, which is the other form of dialysis, where really the existing peritoneal membrane is utilized to cleanse the blood, right? The key feature of this is it’s done for several hours in the day. Almost every day, it’s a lot more gentle on the body, and the dietary restrictions tend to be a lot less and the reason is, dialysis itself is ongoing for a longer time, and most patients who are on peritoneal dialysis or PD could probably consume maybe a little more potassium than a hemodialysis patient. In a hemodialysis patient, extra consumption of potassium can be very dangerous. But in peritoneal dialysis, we find it’s a lot rarer to find huge potassium changes. So there’s a little bit of difference dietary wise, depending on the choice the patient makes, like which modality of dialysis they choose.
Tiffany Archibald 16:17
That’s very good to know the distinction into the two diets. It’s not one diet across the board, and you discussed how CKD and transitioning, so I hope that people that are listening are understanding the specifics to each type of dialysis.
Dr. Archana Rao 16:34
You said it so well, because there’s no one size fits all, although we’re discussing general principles. In fact, every patient is unique. Their journey is unique, and eventually it has the dietary guidelines have to fit with who they are and their medical conditions and possibly incorporate, you know, their cultural background and, you know, ethnic food intake, etc, yeah.
Tiffany Archibald 16:59
So then, now we’re going to go into meal planning. We’re going to talk about breakfast, lunch, dinner and snacks. So what would you say a typical meal for a dialysis patient looks like?
Dr. Archana Rao 17:10
So let’s talk about breakfast, right? It would hopefully include a serving of protein, preferably egg whites, scrambled eggs are a good way to go, oatmeal, low potassium, fruit, some berries, apples, these are great. One would avoid cheeses, one would avoid milk and milk related products, right? And so we have to mine potassium as well as phosphorus. And you know, just make sure this adequate protein and avoid salted meats, you know, stuff that has a lot of salt and it should not be on that plate, right, right? So
Tiffany Archibald 17:49
if someone’s doing eggs or eggs whites for breakfast, essentially, they could avoid adding that meat and save that meat because of the salt and the sodium in it. They can add that for another meal in the day. So let’s talk about what will be for lunch.
Dr. Archana Rao 18:05
A good lunch might be, for example, a grilled piece of chicken, some salad, again, using low potassium fruits salad dressings. You know there are low sodium salad dressings, which can be used and a good serving of vegetables, and vegetables also preferably low potassium.
Tiffany Archibald 18:27
So how should vegetables be prepared, a certain way? Are steamed, I know sometimes, you know, cooking them, they say, takes out the nutrients. Which is the preferred method for dialysis patient? Or does it not matter?
Dr. Archana Rao 18:40
I don’t think it matters. You know, as long as there’s not a whole lot of, let’s say added salt, right? You could prepare it by steaming, by sauteing, make it flavorful, and you can so one can certainly add, let’s say, herbs instead of salt, so you retain some flavor. Make it a little bit more, you know, palatable. So some vegetables, some fruits, salad, and then a, you know, small portion of protein in what, whichever way, you know, whether it’s fish, grilled chicken, etc, rice is a good choice that maybe one may want to do that for dinner.
Tiffany Archibald 19:15
Let’s talk about dinner. What’s dinner for a dialysis patient?
Dr. Archana Rao 19:19
Similarly, you know, again, lean meat, protein of some kind one could have, let’s say rice is okay to have, and their own specific dietitian might tell them, hey, you know, you need to avoid this lentil or not, or maybe not, you can go ahead and have some lentils. Soups might be higher in salt, so that’s something to avoid. And if one wanted to do dessert, for example, you know an apple pie, you know a berry pie, right? And avoid, let’s say ice cream and all of those, right? And typically, I think, here in Texas. This, right? What gets people into trouble might be, let’s say, when they eat Mexican food, right? Avocados are high in potassium. Lot of Mexican food may have cheese in it. Sometimes it can be high in salt. So ways to get around that, if one is preparing the meal at home, might actually make it a healthier option for them. So there’s, of course, so many different ways people eat. You know, whether it’s store bought meals or going out to a restaurant to eat.
Tiffany Archibald 20:34
You’re talking about going out to a restaurant, and we do actually can cover that topic really quick. What should dialysis patients keep in mind when ordering food at a restaurant?
Dr. Archana Rao 20:46
You know, the best chance always is to plan ahead. I think planning ahead helps so much in today’s world, most of the restaurants publish a menu online, right? So if one knows where they’re headed, just look at the menu right. And frequently there are low sodium options or healthier options. There is a, let’s say details on your calorie count, etc. So knowing ahead what to order goes a long way. And once they are in a restaurant, I think making a request like, you know, can you make this low sodium? Do you have a low sodium option, very important salads and the dressing? Can we get it on the side? Right? If one is going to an Asian restaurant, you know, can they avoid the soy sauce, for example, you know, that could be a high salt meal, so one has to be careful and maybe get it on the side and use very little of it, right? Use steamed vegetable options, serving size, you know, get a kid plate. Maybe that might be a good option so one does not over indulge. Never thought about that. Yeah. And maybe also getting the meal and then packing half of it already before one starts is a good way to portion control the meal, right? And, of course, for dessert, like we said, choosing a low potassium fruit pie is a much better option than choosing, let’s say ice cream, cheese, cake, etc. So there’s really the point I’d like to make is that it can be overwhelming when it comes from a restrictive standpoint, but actually there is a pathway for a kidney disease patient, whether they are pre dialysis or on dialysis, to really utilize food in a good way. They can be nutritionally, you know, wholesome and very relevant and enjoyable. You know, all food doesn’t have to be where people are restricted exactly just like, oh gosh, it’s time to eat, but I’m not going to enjoy it because, like you said early on, you know, ethnicity, cultural, sometimes food is the thing that, you know, keeps everyone together, make sure that they are, you know, unified. And it’s just the happy memories that a lot of people remember. So make it enjoyable, but listen to all of these tips and tricks, because that’s the way that you’re going to really have the food be more palatable, absolutely.
Dr. Archana Rao 23:30
And you know, all along the journey, we have renal dietitians that offer so much support, right? Whether a patient is seeing us in our office, we have access to a dietitian service. In all dialysis clinics, there is a well trained dietitian whose primary role is to support the nutritional needs of patients and then journey with them, give them specific ideas, tools to manage I would strongly encourage patients to utilize that, you know, to use that so that they can make the best out of it, you know, good.
Tiffany Archibald 24:08
So then let’s do grocery shopping tips. And I think that’s where it starts, because before you can get to the house and cook the foods and know what you’re cooking, you got to get the groceries. So what are some grocery shopping tips for dialysis patients and any patient out there listening, because I think it kind of can help them have a guideline Absolutely.
Dr. Archana Rao 24:30
Shopping in a grocery store can be overwhelming. There’s so many choices. So if one is into let’s say, let’s talk about the fresh food? You know, fresh fruits vegetables a whole lot more preferable, lower potassium fruits like, let’s say apples or pears or berries are much, much better choices, and avoid bananas, oranges. These tend to be higher in potassium. And on the vegetable side, you want to avoid potatoes, sweet potatoes. And you know, those kind of vegetables that are higher, again, in potassium, and also they’re quite starchy. But asparagus, green beans, you know, a lot of the green vegetables might be a much better choice, and in general, actually, there’s a beautiful chart of all of the vegetable items and fruit items that any patient can get very easily from their dietitian or from, let’s say, a website like the National Kidney Foundation. They carry some excellent lists that a patient can always use or their family member, for example.
Dr. Archana Rao 25:43
And I recall while on diet, on the machine, there was, and I don’t it probably was a dietitian, but they brought around the chart, and I remember taking it home, putting it on the refrigerator, one of the charts I put on the pantry so that you just need those reminders you don’t want to be a patient that just kind of goes into this blindly, because, unfortunately, you do have to be very calculated. So if you get the chart, like you said, from the National Kidney Foundation or from your renal dietitian, or for or while you’re at dialysis, and they give you those charts, like, don’t just lay them on the table or leave them in the car, like, put them in places so that you have those visual reminders. That’s the thing that I would just suggest, excellent, excellent point. In fact, that’s what we suggest, too. A lot of them are not just a list with words, they’re also pictures. So there are so many ways for us to get that information, but keeping it in locations where you would see it all the time, reminds us what’s okay, what’s not okay? Because once you’re in the grocery store, maybe you don’t remember, is this okay? Is this not okay? The other aisle would be in the frozen aisle, you know. Again, frozen fruits, fresh fruits, are so much better than canned, right? And there are also frozen meals. And if one is maybe needing a prepared meal from the grocery store, there are low sodium options that are prepared TV dinners, and those are much better options. And then when you look at the labels. Label is so important. You know, what is the sodium content? You know, you do not want a meal to have more than maybe 600 milligrams of sodium. And what you want to also watch out for is phosphorus, P, H, O, S, any of those complicated ingredients that has the phos or phosphorus is probably to be avoided. And you know how it is, the labels are the ingredients are innumerable, very complicated. So knowing those four key letters, P, H, O, S allows a patient to easily tell that this is okay, or maybe this is not okay. So we want to avoid preservatives. We want to keep it fresh. Lean meats are a better choice. We talked about eggs, soy protein. These are all very good choices of protein. And so when you have the right ingredients, a whole lot easier to prepare the right meals, right So, yeah, I think those are all some very practical tips, Tiffany, to help a patient.
Tiffany Archibald 28:24
Okay, and so that’s shopping. So you touched a little bit about the prepared meals that you can find in the grocery store. There are other prepared meals that aren’t necessarily frozen. Can you think of any, or give any examples of prepared meals that would be more ideal for dialysis patients?
Dr. Archana Rao 28:46
So prepared meals, I think, as long as they contain, let’s say, more grilled meat versus fried meat, that would be a request. There are so many varieties these days, so I think it’s a lot better to understand what are the principles of it. So grilled a whole lot better than fried. That’s one thing, low sodium always right, and low sodium dressings, low phosphorus dressings, avoiding cheese, you know, keeping it real simple, these meals can actually be very nutritious for patients.
Tiffany Archibald 29:18
There are several grocery stores, and there are several companies that specifically do the prepared meals. And another trick that I’ve seen kind of on social media, is that you can go to certain restaurants and you can order a family style meal, and then it’s also good to it’s a form of meal prepping. So even though you’re the patient and then you have this particular diet, if you order a family style meal, then you will have lunch and probably dinner for three or four days just by ordering a family style meal for yourself. So that’s one trick I can just kind of share out there that I used in. Saw on social media. So we are going to conclude right now. And so I just want to kind of have you give us a summary about the importance of maintaining a proper diet and how that will effectively manage your CKD, absolutely.
Dr. Archana Rao 30:20
Nutrition food is such a key component of who we are, and there’s no doubt that you know, for a kidney disease patient, whether they are experiencing any stages of CKD or whether they are a dialysis patient, it is a huge central component of the treatment, the management the management and planning or adapting or being aware of it most important, and then planning ahead and being adaptable to a few changes goes a very long way.
Tiffany Archibald 30:53
So we’re going to end with some encouragement. We do encourage all dialysis patients to maintain ongoing communication with their healthcare providers, dietitians, nephrologists, the nurses that round at the dialysis clinics, if you are going in center, and then if you aren’t, what are some last minute tips for, say, a patient that is on peritoneal dialysis at home? How can they stay in communication with their healthcare providers.
Dr. Archana Rao 31:22
So they have various ways. I mean, they they can call the team anytime, day or night when they run into issues. They typically all patients will have blood work done about once a month. They usually should be very familiar with their numbers, and the dietician is always available for them. Now, if they have specific questions, one key component could be maintaining a diet dairy so you just write down everything that you eat, so you can get very specific guidelines for your way of eating and how it can be tweaked to be better for you. But there’s always help out there. You know, whether one is a home therapy patient or an in center patient, the team backs all of these patients. So they have, they have availability of resources all over, all the time, in fact. And of course, there are online resources like the National Kidney Foundation. A lot of the dialysis organizations also provide a lot of good online tips, guidelines, etc, that can be very, very helpful. Thank
Tiffany Archibald 32:28
Thank you so much for joining us today. I know that this topic is going to be one that can span different populations of patients, whether it’s CKD, hemodialysis, peritoneal dialysis, or just a caretaker that may say, hey, you know what? These are some good dietary restrictions I can include in my lifestyle as well. So we thank you so much. Dr. Rao for education. Awesome, awesome time. You did amazing. Thank you. All right, thank you. Thank you for joining us today for information about Dallas nephrology associates, please visit our website at D N, E, P, H.com, if you found our information helpful, feel free to share it with others who may also be affected by chronic kidney disease.