162 | Stop Banning Bananas: Kidney Diet Rules We Need to Rethink

So when I get a new patient and they say, How many milligrams of phosphorus can I have? I tell them, Don't do that. Don't track. There's no point.

I am fully aware that renal nutrition may not be the topic that makes everyone immediately hit play. Nephrons, renal corpuscles, the glomerulus, Bowman's capsule. I mean, I'm sweating just saying those words out loud. But for nerds like me, renal nutrition is fascinating. Okay, travel back to 2013 with me. Three years after I became a dietitian, I transitioned into working in a pediatric dialysis clinic. And while the renal anatomy still made my head spin, the nutrition side completely pulled me in because it's such a perfect example of why nutrition has to be personalized. Kidney nutrition is not a place for blanket statements. It's not an everyone should avoid beans. It's definitely not a ban all bananas. And this is definitely not where influencers should be handing out advice in a 30-second reel. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and I'm here to tell you that even if you don't work in nephrology, this episode is still going to be really helpful for you. Did you know that 15% of adults in the United States have chronic kidney disease? Which means there's a good chance that someone with CKD is going to walk into your clinic, your urgent care, your cardiology office, or your endocrine practice and ask, hey, can I eat tomatoes? Wait, do I need to avoid phosphorus? Or maybe, are electrolyte powders safe for me? Now don't worry, you don't need to become a renal dietitian to answer these questions properly, but you do need to know enough to not accidentally make your patient terrified of every food in their kitchen. Today I'm sitting down with Lauren Bud Levy. She's a board-certified renal dietitian and founder of Happy Health Nutrition, a practice dedicated to expanding access to kidney nutrition care. Lauren has been working in kidney nutrition since 2010 and helps patients across all stages of kidney disease slow CKD progression while still supporting cardiometabolic health, digestion, and quality of life. In this episode, Lauren helps us unpack what non-kidney clinicians actually need to know. We talk about what foods patients are unnecessarily over-restricting. We also get into phosphorus additives, including a super simple label reading tip that Lauren teaches patients so they don't have to obsessively track milligrams. We're going to talk about protein because yes, we live in a protein-crazed world, but CKD actually flips the script. And because it's summer, we also cover hydration, electrolyte powders, cookouts, travel snacks, and how to help patients participate in real life without feeling like they're missing everything because of their kidney diagnosis. So grab your coffee or drive safe and enjoy my conversation with Lauren. Lauren, thank you so much for coming onto the podcast. I'm so excited to unpack renal nutrition with you and some fun summer tips. So thank you so much for the gift of your time and welcome to the show.

Yeah, thank you for having me, Colleen. I'm really excited. I love talking about food and kidney-friendly ways to eat.

Upon first diagnosis of CKD, chronic kidney disease, one of the biggest questions patients ask, and even if they don't ask it, I'm sure they're thinking it a bit because they're scared is what on earth can I eat now? And so I would love to hear what's like the simplest way a non-kidney clinician could answer this.

So I would say if you're a non-kidney clinician, the first thing to do is take a look at those labs that you have in front of you as you're telling your patient that they have kidney issues or might, and try and be the most least restrictive that you can. So usually we start with are you well hydrated and looking at salt and how much salt are they eating? And then after that, you really want to give them just a couple simple ways to add more plants to their plate and moderate the amount of protein that they're eating in general.

Okay, we're gonna get into some specifics because I'm sure if you've been out of school for a little while, Lauren just said plants, and you're probably like, wait a minute, don't plants have high potassium? And what about phosphorus, right? Plant-based foods. I thought I learned they have to avoid all those foods. So we're gonna clarify that in a moment. But you mentioned something important at the beginning, and that was to not be overly restrictive. And I find that a lot of patients, when they do get started, that they think that kidney nutrition has to be restrictive. So, from your perspective and working with patients, where do you think that they unnecessarily over-restrict?

They absolutely unnecessarily over-restrict in potassium and phosphorus. Um, after they have that conversation with you, that they have kidney issues, they immediately go home and they look it up online and they're scared to eat a tomato and have wheat bread.

Yep. I think that message also, we as clinicians worsen that as well because sort of, you know, that guidelines have changed, right? Give us some of the highest yield priorities, especially with potassium and phosphorus. What do you think matters most? And what do you what do you hope that non-kidney clinicians are educating their patients on?

So in 2020, uh the National Kidney Foundation released the Kadoki guidelines that updated that potassium and phosphorus should only be restricted if those values are high. And what we are learning more and more is that it's really related to the additives when it comes to phosphorus and the types of foods when it comes to potassium, on how much we really need to pay attention to those restrictions, because we know with potassium that there's other things going on that can elevate your potassium. So we really want to look at the root cause, and oftentimes diet's not the root cause. So when we're looking towards what's some of the take homes of how to then advise your patient on what things to avoid with potassium, is to first ask them what they've eaten recently. And then is that typical for them? So oftentimes I will find clinicians will ask, what have you eaten? They will hear one of the top five old school potassium foods tomatoes, potatoes, oranges, bananas, avocados, and they'll say, Well, don't eat that. But actually, potassium comes from lots of different sources. One of those parts that we don't think about is how much potassium is in meat. So oftentimes, with in with individualized approaches, we can really just right-size the portions of protein and hit the real root cause of what the elevation is related to.

That list you just ramble off. Like, I have nightmares about that when I was studying that in undergrad, but also PA school, because PAs get kind of a flyby when it comes to medical nutrition therapy. They are pretty much taught to avoid those top five high potassium foods. So I'm really glad that the new guidelines have allowed for more liberalized diet because those foods you just listed are extremely nutritious for other areas of that patient's health. So I think it's really important to number one, make sure if you've got a patient who's got CKD of any kind, you need to also be referring them to a dietitian if you don't have one in clinic so that the dietitian can really give them specific guidelines based on their labs because it's going to differ based on each patient. And we actually unpacked the kind of the basics of a renal diet way long ago with another kidney dietitian. This was episode 43, and it's the nutrition and kidney disease. What's a renal diet? I will link down to that below. If you want to learn more about kind of the basics and how the guidelines changed, go listen to that episode after this one. I think it will be really helpful for you to get a little, a little background there. Now, Lauren, sodium gets talked about a lot in CKD and kind of in general. So I would love to hear some of your tips on how patients can reduce sodium without feeling like the food is very bland.

Yeah. So the majority of the salt or sodium we get in our diet is from takeout or ordering out foods. So oftentimes the easiest place to start is to cook at home more often. The amount of salt we're adding to our foods is not always the culprit. So I talked to my patients about how it's not a no-sodium diet, it's a low sodium diet. So if you find that your person eats out or door dashes every single day, then trying to reduce the number of times is always going to be the most impactful. When it comes to cooking from home, looking for no added salt products is great. But really just encouraging people to use all the rest of the spices in their spice cabinet and things like vinegar and lemon juice and lime juice as ways to flavor without having to be very heavy-handed on the salt or condiments that we add into things.

Yeah, I think that's so important that you said that it's not a no-salt diet. And people often go to the extremes of like, okay, well, I can't eat any salt at all. And so what is the uh sodium guideline for patients with CKD?

Yeah, so we trish traditionally think about it as less than 2,300 milligrams per day. And, you know, anywhere from the 1500 to 2300 is appropriate. Research shows that if you're trying to get your patient under 1500, they're probably not able to do that.

Yeah, it that's hard. If you eat one time out, right? You already probably have gone above that. My dad is uh has high blood pressure, and I've been trying to educate him because he does eat out a lot. So he actually looked up his favorite breakfast sandwich at Dunkin' Donuts, and I think it had like 2,200 milligrams of sodium in it. I'm like, dad, that is like twice how much you need to have for the entire day. So that kind of education can be really, really helpful. That sort of awareness of just how much sodium is in convenience foods or foods cooked in a restaurant can be very, very impactful. Now I'm thinking of something. When I work with patients with high blood pressure, I often will tell them to pair a high or higher sodium food with a high potassium food to sort of buffer that sodium effect. But I'm curious, is that not a good idea for our CKD patients because we're thinking of potassium, or would that still be an effective strategy?

So we still want them to eat lower sodium. And then having potassium definitely helps to control or lower blood pressure. I like to think about whole foods. So we want to pair it with a fruit or a vegetable that's going to have some fiber to it. That really is much easier and better. Whereas sticking to the low sodium convenienced foods, oftentimes they are have potassium chloride added to them, which actually will increase your patient's blood potassium. So doing a whole food version of the potassium source paired with a either naturally lower in sodium, like an unsalted nut, or if they're going to have salted nuts, a smaller portion of those salted nuts with the grapes or with your apple or something like that.

Yeah, I think that's really helpful. All right, we've talked a little bit about potassium. I still want to linger here on the phosphorus guidelines and the changes there, because I do think that there's still a lot of confusion, not in the kidney world, but in the maybe primary care world on like low phosphorus foods and the sort of the additives you had mentioned, like that's really what we're looking for is to limit those phosphorus additives. So can you give us a little education on phosphorus foods that might have been a no-no before and now are okay? And what would should we be looking out for?

Yeah, absolutely. So the first thing that we want to do is to teach our patients to read the food label because that's how they're gonna have the least restrictive diet possible. And in the ingredients section of the food label is the four-letter cluster P-H-O-S or FOS. So it can look like phosphoric acid, sodium phosphate. You get the point. Um, if your patient identifies that, they should put it down, put that food down and pick up something else. Traditionally, we always told our patients, oh, it's fast food, dark sodas, you know, those types of things. But phosphorus additives are becoming more and more common in lots of different foods. And I work very hard not to demonize the foods that those that they're finding that have phosphorus in them, because many times it is what we would consider healthy foods. So instead, I try and tell people read the label, put it down, pick up another brand because it doesn't have to have phosphorus in it. And then from there, the foods that we used to say were high in phosphorus, like nuts and beans and those things. If it has fiber, it is not bioavailable and your patient is not getting as much phosphorus from it. So if it comes from a whole food, if it comes from a plant, it's gonna be least bioavailable. If it comes from an animal like meat, um, it's going to be slightly more bioavailable, but it's really the phosphorus additives we need to focus on. So when I get a new patient and they say, How many milligrams of phosphorus can I have? I tell them, don't do that. Don't track. There's no point. You're gonna drive yourself crazy. It's not mandated on the food label. You have to find it in the ingredients.

That is really, really helpful. And I think you're right. Patients need a lot of education on that because we are so used to just avoid this list, eat that list, and it's not really as black and white as that. I'm glad you mentioned that P H O S, and that is what we can educate our patients to look for on the ingredients list. And I actually unpacked how to read a food label with a focus on kidney health in a previous episode as well. It was a really helpful episode, kind of learning and orienting ourselves to a food label, but really with that lens of kidney health. That's episode 32. So if you want to dive deeper into kind of understanding phosphorus and how to find it on a food label, go listen to that episode after this one. I think it will be really, really helpful for you. All right, now we need to talk about the one macronutrient that everybody is talking about now because everyone is so focused on weight loss, and that is protein. It can be super confusing for our kidney patients because we are surrounded by high protein, high protein. It's healthy. But then they're told that they maybe need to limit it, right? So please explain to us and how can we educate our patients on how do we tell them about protein needs across those different stages of kidney disease because that's where it can change.

Yeah, what I really like to use is the word right sizing, because I think that that really embodies what we're trying to do. We're trying to not or overburden the kidney with protein. And by teaching our patients that it's a right sizing, it kind of brings their brain around the fact that, okay, other people might be able to have a high protein diet or follow these things, but this isn't right for me. The other thing is, and if you're in primary care, is GLP ones are definitely prescribed in this population. And so oftentimes I am flipping the script on my patients and trying to make sure that they're getting enough protein because if they're not eating, then that's not enough protein. And that can be very hard for patients. So learning to identify where and what are protein sources and about portion size is a really great way to help either increase when needed or decrease when needed. And decrease is usually what we're trying to do, except with the that GLP1 population.

Yeah, it's tough. It's definitely not a one size fits all. Now, do you like what kind of camp are you on? Are you more of like the plant-based protein, animal-based protein, or are we somewhere in between?

So I'm absolutely in the plant-based protein um camp for sure. I think that it makes it easier for our patients to eat a full amount of food. Animal protein is very protein dense. And when you try and tell somebody how much protein they can have and what that physically looks on the plate, it's really unnerving for a lot of people. However, I don't necessarily tell people they have to become vegan or vegan overnight. That's not the goal. Our goal is always to meet the patient where they're at and be able to push their comfort zone in a way that's sustainable. And so sometimes we're talking about what's what's your what are favorite foods that are naturally vegetarian? That's a great place to start with your patient. So bean tacos are a favorite of people, or using beans in place of ground beef in stuffed peppers, things that are naturally vegetarian are much more likely to get your very high meat eater people to try some more plant-based options.

All right, let's talk numbers because I've got really smart listeners, and we know guidelines now have increased for protein for general population, anywhere between 1.2 to 1.6, depending on the guideline or the study that you're looking at, obviously, age, gender, physical activity, all the things. However, that's pretty high. So, what are the guidelines in your population? What are you, you know, recommending, or when you're doing the math, kind of what is the target that you're looking for?

Yeah. So in those 2020 guidelines from Kadoki, they did update stages three through five to be 0.55 to 0.6 grams per kilogram body weight. However, with the Cadigo, the global kidney guidelines coming out just recently, that has been a little bit more liberalized at 0.8 grams per kilogram. Now, that lower number is for somebody that's nutritionally stable and doesn't have diabetes. And half of the people who end up with end-stage renal disease do have diabetes. So we want to definitely make sure that if you're going to give your patient a number and you're going to use those calculations, that you look at what the math says, because sometimes that number can be very low if your patient is small and it might not be an achievable goal that it might cause more harm. So we definitely want to look past the number as we do those calculations.

Yeah. Now, just to clarify for anyone listening, this is not the same recommendation for someone who is already on dialysis. Is that correct?

Yes, thank you. That's a really great differentiation. Once you're on dialysis, now our mode switches from preserving kidney function into optimizing new your nutritional health in a setting where it's using protein. So now we switch flip the script script to 1.2 grams per kilogram. And so it's a much different focus for our dialysis population.

Yeah. Yeah. I think that differentiation is really, really important. And again, I like how you said if you are giving numbers at all, because you don't, you don't have to, right? You know, we are thinking them because we're the scientist, we're the clinician, but you don't always have to. That's where I think visual guides can be helpful and portion sizes is really more ideal for educating a patient, even though you may be thinking in numbers.

And you know, I will say too, is that I always start with, what do you eat now? And if somebody is eating an entire chicken breast at a meal, which is not an unreasonable expectation, right? But your numbers are saying that they can only have a third of a chicken breast. Can we meet them halfway? Can we pull it back a third? Um, and especially in the primary care setting when you're seeing protein spill, but not kidney decline, right? This is a great time to have that conversation because we live in a protein world. Can you just reduce it by 25%? Um, because you can see real big difference and preserve function that way.

You had mentioned earlier that animal protein also contains potassium. Can you talk a little bit more about that?

Yeah. So, you know, we hold our potassium in our cells, and animal protein ultimately is flesh. We don't want to like to think about it that way. Yeah. But it is. Um, and so it is potassium rich. Um, and some of the favorite sources, like salmon, are very high, very rich in potassium. And yet we tell our patients to eat, go eat your salmon, but you tell them that broccoli is high in potassium and broccoli is only half the amount that. Salmon is. And so we, you know, we want to look at the overall diet quality and our goals when we're trying to evaluate what we should tell people, right?

I really like how you ask, what are you eating now? So you can get an idea of how much protein they have. I will do this even with my weight management patients because if I did a calculation and they need 120 grams of protein per day and they're only eating 60 right now. Well, if I tell them to, you know, double that intake, that's really, really challenging for them. But if we take baby steps and increasing maybe 10 to 20 grams per week, it's much more feasible. And I find the same is now true when we're trying to go from high protein diet down to a lower protein, kind of working backwards and going a little bit more slowly based on what they're currently eating.

Yeah, I agree. That's exactly how I handle the situation too.

All right. Since we're heading into summer, I thought it would be really fun to talk a little bit about cookouts, maybe traveling, how do we handle barbecues and that kind of stuff? Plus, I don't know where you live, but I am in South Florida. It is like 95 degrees, and the humidity is turned up to where you are sweating the moment you walk out your car. So we'll talk a little bit about hydration too. And that's where I want to start with hydration. I'm curious about how much water do these patients need to consume? And then what is our guideline on electrolyte supplements?

Ultimately, we want our urine to be clear to pale yellow. I usually tell people by the middle-ish of the day. But a lot of our patients hear that and then they say, I have no idea what that means. What does that mean in ounces? And so that's where I say, Well, how much are you drinking now? Because I've learned if you give them a number, you may be very far from what they're doing, either over or under when it comes to hydration. And so I do very much encourage people, if they don't have any swelling issues, to, you know, try and get the eight, eight-ounce glasses around 64 ounces, but I really look at where they're at and um go from there. And depending on what their kidney issues are, they may need more water than that. Kidney stone patients need three liters, PKD patients need three liters. So sometimes we are really trying to up the water for many, many people.

Talk to me about electrolytes. It's always a hot topic, I feel like. And I'm in pediatrics, so in sports medicine. I mean, I go to the gym, all the gym people are like, oh, I've got my electrolyte. And, you know, I have my own opinion on if it's necessary for that population, but let's keep it to the kidney. Is this safe, harmful, recommended? What are your thoughts?

So my thoughts are to not use those electrolyte supplements. Instead, what I like for people to do is use food or fruit. So if they're at the gym and it's been an hour longer, come home and have some cold grapes and a snack. Because those electrolytes supplements are going to have sodium, potassium, magnesium. You know, they're going to have a lot of extra things. And if you read some of those supplements, connected to your sodium is probably or maybe phosphate. And so they can be a source of added phosphorus for your patient as well. And the person just thinks they're doing the best for themselves that they can.

Yeah, I love that. Thank you for that tip. All right. I want to hear about some summer foods or even cookout habits that can be maybe problematic for patients with CKD that they should be aware of and maybe avoid or do an alternate.

Yeah. So traditionally we will think about what do we marinate our meat in? Cause oftentimes that is loaded with salt. And then hot dogs and, you know, think those things that are really common that we think about as summertime. Um, they can be very high in salt as well. Same with the side dishes, depending on if they are bought out or if somebody brings the potato salad and things like that. They can be loaded with salt and or uh potassium if you have to restrict. So I like to tell people to bring their own dish that they can have for themselves. And not like I only eat this. You get to everybody else can eat what they want, but something that people are gonna like. Bring a salad, bring a cold fruit salad, a good quinoa salad with cold quinoa salad, veggies, and chickpeas. It's amazing when I give this recommendation how many people come back and they're like, oh my gosh, everybody loved that. They were so happy for the vegetables. Because, you know, we we do want to have a little bit of both. And that's where then you can choose a little bit of the indulgent or or higher salt or protein option because you're crowding your plate with the vegetables or and or fruit that you've brought or that is there. When it comes to traveling, bringing your water bottle with you is very helpful in this heat so that as you're going through the airport or going on the road trip that you're not getting dehydrated and bringing snacks that are easy to carry: baby carrots, an apple, peanut butter and jelly sandwich, unsalted nuts, these things pack easily on the airplane in the car, all those kinds of things. There's low sodium snacks, like low sodium popcorn that are is also easy to get as well.

Yeah, it just takes a little bit of planning. But I do love that you suggest for them to bring something for everyone to partake and enjoy because I feel like any kind of disease or chronic condition can isolate you and make you feel like you can't participate in whatever the celebration may be because you can't enjoy those same foods. And so I think making sure that your patient is still able to participate in whatever the event is in some capacity can be really good for them emotionally and mentally. And that is part of their care. We're not just here to tell them eat this, not that, but to make sure that they are overall healthy. So I really like that you give them those those tips and that strategy. Lauren, you are full of ideas and suggestions, and you have a really great uh social media page. So if people want to connect with you online, where can they find you?

Yeah, you can find me on Instagram at happy.health.nutrition, or you can go to my website at happyhealthnutrition.net.

Awesome. Thank you so much for sharing all about kidney health. I'm sure this is a great refresher for some of my listeners, or something new for those of you who are moving into kidney nutrition. So thank you so much, Lauren, for being here. Thank you for having me. And guys, thanks so much for carving out some time for nutrition today. I will see you next week.