An individual plan is better than a “renal diet”
There are many many benefits of visiting with a renal dietitian for kidney failure. First and foremost – quality of life. Any chronic disease diagnosis is scary. Kidney disease is no exception. With the diagnosis of chronic kidney disease, people can often feel overwhelmed – with a lot of that overwhelm coming from “What do I eat now?” The internet is a black hole of information, almost worthless for many patients because the renal diet information presented there is BROAD and not specific to the stage of kidney disease. In addition, every single person with renal disease needs different guidelines and has different questions. There is no one handout or diet or menu plan that fits every patient. The best service a nephrologist or primary care doctor can provide for his/her patient is to get a renal dietitian on board for nutrition.
Nutrition therapy(with a dietitian) for kidney disease makes a difference!
Research has shown that nutrition therapy for kidney disease improves lab work, helps people maintain kidney function longer/delay dialysis, and decreases confusion. In fact, some studies show that diet therapy can be MORE EFFECTIVE than adding a maximal dose ARB (Angiotensin Receptor Blocker) blood pressure medications(1). Even for people who had nutrition therapy intervention but still eventually needed dialysis there were benefits to the time they spent learning and changing their diet prior to dialysis. For example, some studies have shown decreased mortality during the first year on dialysis therapy IF the patient received nutrition therapy prior to starting dialysis (2).
This post is not about all the research surrounding nutrition therapy. That will have to come later when I can add many many more studies. This post is about getting the patient to a renal dietitian.
How come patients aren’t referred to renal dietitians?
The truth is, the referral rate stinks for people with kidney disease. That means that often a person visits their nephrologist but then is never connected with a dietitian. Some studies show as many as 88% of patients are not referred to a dietitian(not good!) (2). Conversely, some surveys have shown that more than 80% of newly diagnosed patients would LIKE nutrition information (3). This isn’t always the fault of the doctor. Sometimes they just don’t know who to refer to or when to refer for nutrition therapy. (Good news for doctors and patients the National Kidney Foundation is putting together a database of renal dietitians able to provide nutrition therapy! THANK YOU NKF!)
Some doctors do their own nutrition counseling or have the nursing staff complete this vital step. Personally, I think this can be a disservice to patients. Behavior change (diet is BIG time behavior change) is not about a do this/don’t do that counseling approach. It is about finding food preferences, targeting easy changes, talking through a plan for more difficult changes, and knowing what the main nutrition priorities are to focus on. Patients may make changes out of fear, but the best changes come from empowerment and really understanding how food is impacting kidney function. THAT is the specialty of renal dietitians. (And, yes, I am biased, but I do think the best nutrition care for renal disease comes from a renal dietitian or a dietitian with extensive experience in this area.)
When should someone with CKD see a dietitian?
There are at LEAST FIVE big events that warrant a visit with a dietitian. There are many more, but these are my big 5.
- A new diagnosis of kidney disease. If a person leaves a nephrologist or primary care physician office with a new diagnosis of chronic disease they should also be leaving with the name of a dietitian. Period. I really don’t feel like there are any exceptions to this. Otherwise the internet starts becoming the source, not the professional.
- A decline in kidney function. If someone goes from Stage 2 to now Stage 3 kidney failure or Stage 3 to 4 – especially with significant proteinuria or other associated conditions like high blood pressure, they should see a dietitian. Again, I don’t really understand why a practitioner would not encourage this. (P.S. I don’t buy the excuse “it won’t make a difference anyways.” Even small changes can make a big difference.)
- High potassium or high phosphorus levels. Sometimes a patient can look at a handout of “High Potassium Foods” and know exactly what bumped their potassium level up. But not always. I had a client once who was perfectly following every list he had been given by his doctor and had super high potassium levels. The culprit? He had switched out his milk for non-dairy creamer and was drinking 2-3+ cups/day. It took some real digging to find this out because the brand of non-dairy creamer did not list potassium content. We had to contact the company to figure out the potassium content. To make matters worse, potassium is confusing on labeled products. The labels are often not accurate or don’t list potassium at all. I’ve seen lots of products that list potassium as “0 mg” when in fact there is loads of potassium in the product. Talk about confusing for someone who is already trying to navigate several other pieces of their label! Like I said, more on THAT issue coming up. Finally, there then comes all the recommendations for a “plant based diet.” But, um, aren’t beans high in potassium? And lots of fruits and vegetables? How does that fit in??? (It does by the way. And is highly recommended. But it is sooo confusing to figure out just from the internet)
- High blood pressure. The research is stunning on the difference that diet therapy can make for blood pressure. And you know what? It isn’t just about salt. Cutting sodium is an enormous part of the picture. But, fruit and vegetable intake are an inescapable piece of blood pressure control as well. And this is where it can get dicey for people. They get confused about produce and what is really “allowed” for kidney disease. Far too often, people with early stage kidney disease (stage 3) are unnecessarily cutting high potassium produce (per the recommendations of the internet) and thus potentially impacting their blood pressure, which is already a challenge to control. And you know what? If you still have a good amount of kidney function, you don’t need to cut potassium. So yeah, working with a dietitian, could make a big difference in sorting out the produce question and identifying where all that salt is coming from in your diet.
- When a patient has questions! When a patient comes to visit with me, my first question is “What is your biggest concern?” Everyone has one when it comes to their food and THAT is what we talk about first, but there is rarely only one concern. Physician offices are busy places. Often there is not time to answer all the many questions that can come with the renal diet. But guess what? A dietitian has time and insurance will often pay for the visit. Medicare covers at least 3 hours of nutrition therapy for the first year after a referral and 2 more hours for every year after that. Private insurance will also often cover nutrition therapy if the dietitian is within their network.
A handy resource to remember referrals
I created this handy, simple flier to post in a nephrologist office as a reminder of when referrals for nutrition therapy should happen. For dietitians reading this, please use! It is uploaded to the Renal Education Library in the Freebie section. For people with kidney disease reading this, please ask your doctor about visiting with a renal dietitian. They really can be your best cheerleader and help you make the renal diet #livablelovable and not confusing! There are so many good foods to eat, even with dietary restrictions that may be needed!
- Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial
- Slinin, Y, et al. “Prehemodialysis Care by Dietitians and First-Year Mortality After Initiation of Hemodialysis.” American Journal of Kidney Disease, Elsevier, 29 June 2011, www.sciencedirect.com/science/article/pii/S027263861100850X.
- Hollingdale, Rachel, et al. “FACILITATING DIETARY CHANGE IN RENAL DISEASE: INVESTIGATING PATIENTS’ PERSPECTIVES.” Journal of Renal Care, Wiley/Blackwell (10.1111), 6 Aug. 2008, onlinelibrary.wiley.com/doi/abs/10.1111/j.1755-6686.2008.00034.x.