45. Kidney Basics and Chronic Kidney Disease w/ Jen Hernandez, RDN, CSR, LDN

Jen Hernandez is a nationally-recognized registered dietitian, board-certified specialist in renal nutrition, and author of Plant-Powered Kidney Nutrition. In 2018, Jen founded Plant-Powered Kidneys, a virtual private practice and educational hub for people with chronic kidney disease. Jen helps people in all stages of kidney disease, focusing on evidence-based nutrition and lifestyle guidelines. The clients and students of Plant-Powered Kidneys learn how to preserve their kidney function so that they can delay or even prevent kidney failure and dialysis.

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http://www.plantpoweredkidneys.com/book

http://www.instagram.com/plantpoweredkidneys

http://www.facebook.com/plantpoweredkidneys

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Episode Transcript

(00:00):
So our next journey today is a kidney journey, and I'm very
happy to have Jen Hernandez withus here to talk about the kidney
structure, function, Physiology.We'll talk about CKD as well.
And we'll also go from a nutritional aspect related to
kidneys. Jen, thank you so much for being

(00:21):
here. Thank you so much for having me,
Jerry, and I'm really excited totalk about this.
This is my full time job. So kidneys, kidney nutrition is
that's where I'm at. See, I know you're the right
person for this and everybody who does, you know, these really
educational talks, I want them to have passion for what they're
doing. So it's awesome that you're
doing this. So let's just jump right in.

(00:42):
You know, for our listeners, we're really going to set the
ground level expectations here. Is that the beginning here?
We're going to have you understand the basics of the
kidneys and understanding especially what are the kidneys
structure, function, Physiology,and then we'll move on from
that. So without a do, Jen, please
take it away. Thank you.

(01:04):
Yeah. So we'll do like a really kind
of rough overview and then dive into some of the, you know,
questions or things that you really want me to hone in on.
But first of all, the the kidneys, everybody has kidneys
for the most part. There are some situations where
people are not born with kidneys, but everyone has two
kidneys more or less, but you can function with just one.

(01:25):
The kidneys, they're about the size of your fist, so they're
not that big and they're locatedon your lower back, so just kind
of tucked in a little bit under your ribs.
So they're really, really well protected as, as organs and
they're, they're a little hiddenaway.
The way that they're structured is they have this kind of outer

(01:46):
cortex, they have this center like mendula and then they have
the renal pelvis. So this outer area and then the,
the middle part where a lot of the action happens and then the
pelvis where things are getting filtered through.
So the actual like working the, the working unit of the kidneys
is the nephron. And there's about a million

(02:08):
nephrons in each kidney. So there's a lot of these very,
very tiny systems that are working on a lot of different
things. The actual center of the nephron
has the glomerulus, and this is like a little cluster of blood
vessels where it kind of acts like a sieve, is basically
filtering nutrients and waste kind of passing through and

(02:30):
deciding what's going to be heldonto and what is going to be
released as waste. And this is the waste that gets
developed and pushed through into our urine.
So it's going to be filtering through the ureter and then into
the bladder so that we can eliminate the waste.
What our kidneys, what our body decides it doesn't need.
So all of our blood gets filtered through the kidneys,

(02:54):
all of it gets filtered through the kidneys.
And that's where it's decided what's being kept and what's
being released. So that's, that's kind of like
the big overview picture of really how it's working now, the
different functions. These are things that again,
this is all happening 24/7 in the background without any type
of physical or or mental awareness of what's going on.

(03:18):
But as I mentioned, the one of the most important things that
the kidneys are doing are filtering the blood and removing
waste. So those are some very, very
important things that are incredibly crucial because if we
don't have these wastes removed,they're building up the body and
these toxins can cause a lot of problems, including death.
So very, very important that thekidneys are helping us eliminate

(03:41):
these toxins. And I also want to add to you
that these toxins aren't just things that we consume, things
that we eat or drink, but it's even toxic wastes that are
produced in the body just from things that are naturally
occurring. So as the body is going through
and taking care of a lot of things, sometimes we do develop
these waste products that also need to be eliminated.

(04:01):
So it's not just what we eat. And that's something that I'll
kind of touch on again in a little bit here.
But another aspect of what the kidneys do is it's filtering and
balancing our fluids and electrolytes.
So the fluids just like our waste product, it's basically
deciding how much fluid we need to hold on to and how much we

(04:23):
can get rid of, how much we can eliminate, again going through
into the urine. And then the electrolytes, those
are things like sodium, potassium, phosphorus, calcium,
magnesium. These are the electrolytes that
the body and the kidneys are deciding.
How much do I need? How much do I need to hold on
to? And what is an excess, what is

(04:44):
too much, or what is the amount that we need to eliminate that
we don't need to use? So it is constantly going
through and determining all these different electrolytes,
what we need to hold on to, whatwe need to get rid of.
And these electrolytes, they each have their own very
important functions, which playsa role in how the body is
communicating to the kidneys to say whether we hold on to

(05:07):
something or get rid of it. Like sodium, for example.
If we're getting a lot of, if we're eating a lot of sodium and
maybe it's noticing about the blood pressure is coming up,
it's going to say, OK, we don't need all of this sodium, so
let's eliminate some extra sodium.
So it might focus on getting ridof that if we're eating maybe a
high sodium diet or something. Or if you have blood pressure

(05:28):
control issues, the body is going to be working on that.
So it's taking care of all of these different things to help
determine how these other situations, how these other
pathways and roles in the body are being handled.
And then I do really want to kind of circle and hone in on
blood pressure because not only are the kidneys looking at the

(05:48):
electrolytes that are related toblood pressure control, but it's
also focusing on producing hormones associated with blood
pressure management too. So it's controlling those
electrolytes, but it's also likeactually making something to
help us take care of our blood pressure management.
The kidneys also are very important in other hormone

(06:12):
productions. So this includes making red
blood cells. So it uses apropoietin to help
make red blood cells, which, youknow, many of us think of.
You know, we need oxygen and thered blood cells are what's
carrying the oxygen through to our organs.
So our organs also need oxygen. So it's helping to make the red
blood cells and to get this distributed throughout the body.

(06:35):
It's also very important in the formation and activation of
vitamin D. So the vitamin D that we're
getting from the sun and in somecases even from supplements and
foods, they need to be activatedinto the hormonal version of
vitamin D. So the kidneys play a very
important role in that as well. And then tying in the vitamin D

(06:57):
with the electrolytes like calcium, phosphorus, and
magnesium. The kidneys are also playing a
very important role in our bone management.
It also helps communicate with another hormone known as
parathyroid hormone. It's a hormone that's coming
from your parathyroid. So everyone thinks about thyroid
glands, but there's also parathyroid glands.

(07:20):
And those glands create parathyroid hormone or PTH for
short. And the kidneys are
communicating via vitamin D to let the parathyroid hormone help
balance our bones. So it's a very complicated
structure, but the kidneys are just so much more than just
filtering waste. I think that's what a lot of
people think of with kidney disease is, oh, it's just going

(07:41):
to take care of the waste products.
But it's doing so much more. And, and that's why when
somebody has kidney disease, it's I've never in my 12 plus
years as a renal dietitian, I'venever, never come across
somebody who only has a diagnosis of kidney disease.
There's always something else going on, whether it's related
to the cause of their kidney damage or does a production or

(08:05):
result of the kidney damage. It is not in a silo.
There is a lot of things going on.
So it is a, a very, very complicated health condition and
diagnosis. And that's why a lot of people
with kidney disease, they often feel very overwhelmed because
it's not just a very simple, youknow, let's just look at this
one thing and let's just go low carb or something like it's,

(08:26):
it's very, very complex for themto be thinking about all these
electrolytes that are in our diet and then all the macro
nutrients as well, thinking how they need to balance all of that
to protect their kidneys and subsequently all of these other
systems that are connected to the kidneys too.
So. Pause there.
That was awesome. I mean, that was exactly what

(08:48):
we're looking for. So it's good to level set and
have people again understand what is, what is the structure,
function, Physiology, whole thing.
So let's dive a little bit further into you mentioned
something and I thought this wasa great segue and related to
people not knowing the kidneys have become a multi faceted

(09:08):
function 1 related to bones. So what what are some other
areas that is it's great to set the platform, but also to look
at what's been said out there that maybe you've observed that
is not necessarily accurate about the kidneys or that we
need to be careful about consuming information relating
to kidneys that's out there currently.

(09:29):
Yeah, I mean, there's quite a bit, there's a lot of wild
information out there. I actually, I just posted on
Instagram and Facebook about potassium because this is
something that is incredibly misunderstood.
And I guess I misunderstood and I just mean that there's a lot
of people following really outdated guidelines.

(09:51):
So historically potassium was something to be really cautious
with and it was, and even when Iwas working in dialysis and, and
this was 5-10 years ago in, in the, the hospital and outpatient
settings, potassium was just like, you don't want to eat
potassium. Just cut out your beans, cut out
your tomatoes, cut out your avocado, cut out your tomatoes,

(10:12):
etcetera. You know, cut out all the high
potassium foods, which when people start getting into it,
like potassium is in a lot of stuff.
And when people are told to be careful, a lot of us have this
kind of like all or nothing approach.
And so a lot of people think I can't have any potassium.
But potassium is an essential nutrient even with, even for

(10:36):
people with chronic kidney disease.
The, the problem, the root issueis in some cases, and this is
usually later stages. So there's five stages of kidney
disease, Stages 12345 and 3 is kind of split 3A3B, but there's
five different stages. So stage 4 and stage 5, the
later stages of kidney disease, there is a a more likely chance,

(10:59):
but not high, just more likely than like stage 2 for people to
have to be cautious with potassium.
Because what happens is, again, if the kidneys are not filtering
things well, including potassium, then that amount is
collecting more in the bloodstream.
And so we see a high potassium level and we would think, Oh my
gosh, you're eating too much potassium, You got to cut that

(11:21):
out. And so the research has not
backed that up. And the guidelines that came out
in 2020, which is five years ago, but people are still just
learning about this. But the guidelines are saying
it's not necessarily dietary potassium.
It's not the foods that we're eating.

(11:42):
It's more likely a connection between something else going on.
So I'll give you an example of something that I would come
across very often. So diabetes is the number one
cause of chronic kidney disease.Diabetes, high uncontrolled
blood sugars. Uncontrolled blood sugars can
actually cause high potassium levels, not having to do

(12:03):
anything with what we're eating.But it's the high blood sugar
that is pushing potassium outside of the cell.
It's supposed to be inside the cell and it's pushing it out of
the cell, causing a reading of ahigh potassium level.
But again, like somebody could be fasting and it still shows
high potassium because the glucose is is pushing it out.
So that's an example of how somebody could have a high

(12:26):
potassium level that has nothingto do with food.
And now we're really focusing more on that to say we need to
look at these non food causes ornon potassium food causes that
could be creating a high potassium level.
But again, it historically we used, we would see a high blood
potassium and we'd say cut all your foods, like stop eating all
of this. And it just causes so much fear

(12:48):
and anxiety for people that they're just like, I can't have
any. I can't have any.
But that that's been something that I have spent years, like
again, this came out in 2020. I spent literal years educating
people on this and talking to them about these other potential
causes of high blood potassium that have nothing to do with the
foods. So there, there is a lot more

(13:10):
behind that. That's not just a matter of
getting rid of potassium. And then the other side kind of
argument, the argument for potassium in a renal diet is 1.
Potassium is incredibly important for blood pressure
control and high high blood pressure or hypertension, that's
the second top cause of kidney disease.
And so most people in the general population are not

(13:33):
eating enough potassium, which alot of guidelines are
recommending up to 4700 milligrams per day.
If you ever do, I'm sure you probably talk with people who do
like food logs and food tracking.
You have them look at their potassium intake.
It's probably closer to like 2000 or 2500.
It's significantly low. And so again, we're we're

(13:55):
looking at people saying, oh, cut out potassium, but like
they're not even eating that much potassium to begin with.
So, but, but potassium is just so, so, so powerful and has been
shown and studied that a low sodium diet paired with a high
potassium diet is really powerful in controlling blood
pressure. So again, just this whole topic

(14:17):
about potassium, this is a lot of what I educate my my clients
on is understanding the power ofpotassium.
And just because you have kidneydisease doesn't mean you should
be cutting out potassium. Like you should really be better
understanding how much you're typically eating, finding ways
to work with the dietitian so that they can kind of help
support you in a Safeway to eat enough that it actually helps.

(14:39):
And I've had a lot of clients, alot of students that have
doubled their potassium level and have been able to come off
blood pressure medications because their blood pressure is
looking so much better that theydon't need the medications.
Or they're dropped down to like what's known as like a CKD, like
a baby dose of these medicationssimply used to protect their
kidneys, not used to help control high blood pressure.

(15:01):
So I would say like that's a really, really big topic in the
kidney community. And so if you ever talk to
somebody with kidney disease andyou mentioned potassium, they'll
probably, oh, I can't have that.Like, well, why like let's you
know what, what about this, what's going on here?
Because it it is really, truly agreat area of opportunity and I
spend a lot of my time talking with people about that.

(15:24):
That's great information. I, I think the a potassium talk
often gets overshadowed by the other one, another P talk, which
is protein quite a bit. That is a larger societal huge
discussion in society right now.But I want to jump back, just
move back just a little bit, little bit.
You talked about diabetes. Is there a differentiation in
this the disease pathology with kidney, kidney disease in terms

(15:49):
of type one versus type 2 diabetes for this?
It's, it's essentially they're, they're essentially the same.
What's happening is the excess glucose, the extra sugar is
causing damage to those, to the,the nephrons to those kidney
filters. So with that glucose large
molecule coming through and damaging that kidney function,

(16:11):
it basically takes the way that,the way that I've explained it,
it's like taking a colander and you just get like, I don't know,
like a hammer and you just kind of punch a couple holes in it
and now you have these bigger holes.
And so like you can still, you know, filter out some things,
but like if you put blueberries in there, you're going to lose
some blueberries. Like that's just the way it is
because those that filter is gone.
So it's kind of that same case. Regardless of the regardless of

(16:35):
the the situation behind diabetes, it ultimately it's
just a matter of blood sugar control to help make sure that
that extra glucose isn't causingthat kidney damage.
Is there an increased risk for someone with juvenile diabetes
since it's starting so much younger and that insulin
resistance for kidney disease versus someone who has onset of

(16:56):
diabetes later in their life in relation to kidney disease?
You know, I, I'd have to look atthe statistics and the research
to see if there is a higher correlation.
I can tell you from my own experience, I, I have not, I've
only had a couple PEDs patients in my, in my work, but you know,
pediatric nephrology is like a specialty on top of the

(17:16):
specialty. So I'm sure if you talk to
somebody who focus on PEDs, theycan probably give, you know,
some more, some more insight to that.
In my world, in adult nephrology, it is, it is really
there, there is a reason that diabetes is the number one
cause. And it they do really focus on
type 2 diabetes from this, from this perspective, because it is

(17:38):
something that it's not that having like a high blood sugar
is going to like derail everything.
It's it's years upon years, justlike chronically high blood
sugars. That's just kind of like making
it hard for the kidneys to work and just causing damage over
time. So that's why, you know, if you
if you have diabetes, you might notice that your doctor is

(18:01):
checking your GFR, which is yourglomerular filtration rate.
That's the estimated kidney filtration rate.
And so it's listed as a number, but people kind of associate it
as like a percentage. So if your GFR is like 90, then
it's like 90%. Normal is considered 90 or
above, but 60 and like the 60 to90 range is depending on your

(18:23):
age, it could be considered normal, but it could also be
considered like stage 1 or stage2 kidney disease.
So anytime you see like a GFR, like in the 60s or 70s, it's a
good thing to ask your provider about, especially if you have
diabetes, because that could be something that they're going to
be checking more frequently or getting it tested again to just

(18:45):
kind of verify that that is truly what it is.
Because it needs to be checked at least twice across like 3
months for it to be confirmed asa CKD diagnosis.
Awesome, awesome information. Let's turn into this again.
I think this is as we talked about potassium a little bit,
turn more into the nutritional conversation.
This is obviously be very, I think nutrition's very sensitive

(19:08):
for a lot of people and I think it's very important to have
honest conversations about nutrition and educated
conversation. So in in conjunction with this,
let's dive into the nutritional aspects of kidney health here.
Yeah. I mean, there's a lot of
different areas. Where do you want me to start?
I wanted you to start area that works that you see the most and

(19:29):
that really makes most sense foryou talking and then we can just
kind of go out from there, you know?
OK. Well, I'll start from kind of
this this kind of like higher goal view.
So I'm going to start with just kind of energy and calories to
begin with. And then we'll get into some of
the macro nutrients and then I'll touch on some of the
micronutrients. Perfect calories in general,
people with chronic kidney disease are actually at a higher

(19:52):
need for calories and that makesit even harder because again,
people are really scared to eat when there's foods that they're
told that they have to cut out and avoid.
So 9 times out of ten, 9.9 timesout of 10, I am encouraging
people to eat more calories and,and a lot of the population and
work with they're in the boomer era.

(20:13):
So they're in their 50s, their 60s.
And a lot of people in this generation have grown up through
a lot of diets. So there's a really strong diet
culture, diet history involved. And when I'm telling somebody to
go from 1200 calories to 2000 calories, they're thinking like,
Oh my gosh, she's trying to killme.

(20:34):
Like they're the how in the world, how's this going to
protect my kidneys? And I'm talking like, regardless
of weight goals, this is just simply when the body is in a
chronic disease state and it needs the energy.
It needs the energy to do all the things that it's trying to
do. So I do work with clients to get
them up to a higher calorie goalto make sure that they're not

(20:57):
losing weight. Because one of the scariest
things is when somebody with kidney disease is losing weight
unintentionally and in an unsafemanner, it's more likely than
not they're losing lean body mass.
And that puts them at an increased risk for sarcopenia
and it puts them at an increasedrisk for dying.
It's just simple as that becausetheir body is literally wasting

(21:18):
away. And so I really do focus on them
getting a higher calorie goal than the average person because
of this increased need. So for people that do you know,
kind of look at calorie estimates, look, the standard is
25 calories per kilogram. We're looking at 25 to 35
calories per kilogram for most people.

(21:41):
And there's some there's, there's a reason, there's a
range. And in some cases it might be a
little bit lower and might be a little bit higher, but that's
usually kind of where we're starting at and kind of
adjusting that goal from there. So they have a higher calorie
need. Now getting into the macro
nutrients, there's also a shift there.
So between the carbs, the fats and the proteins.

(22:02):
Proteins we already touched on alittle bit, right?
So protein is a really big topic.
And this is something that is a bit of a shock for people with
kidney disease and in a couple different ways.
But protein is a big molecule and it's very difficult.
It's, it's a bit more for the kidneys to handle and getting

(22:22):
not too deep into the science, but basically the, the protein
molecule, it has amino acids, but it also has a nitrogen
component. And it's this nitrogen component
that's considered a waste product that the body manages.
So when the protein is digested,it's supposed to be getting rid
of some of this nitrogen. In the labs, you might see it as

(22:43):
BUN or blood urea nitrogen. In people with kidney disease,
BUN climbs up this, this nitrogen component is building
in the blood. So the recommendations are in
moderate stages and late stages of kidney disease.
A low protein diet might be beneficial.
And I say might because there are some caveats there, like it

(23:04):
wouldn't be appropriate for someone who's in the hospital or
who has recently been in the hospital.
It wouldn't be appropriate for somebody who has uncontrolled
diabetes because they need that protein to help with their blood
sugar stabilization. It's not going to be appropriate
for a 90 year old who's, you know, this is, this is not a
point of doing a lot of aggressive interventions or
somebody who's not eating well, somebody who's been losing

(23:26):
weight and is already in a stateof maybe some protein and lean
body mass loss. So there's some situations where
a low protein diet is really notgoing to be conducive in the big
picture. But for somebody who is
metabolically stable, who is doing well and they might
benefit, then maybe .8 or .6g per kilogram.

(23:46):
That's what the international guidelines recommend for stages
3 to 5. I personally, when I'm working
with people, I'm actually just starting them at the .8 because
as you know, protein, proteins and everything.
I mean they have like protein pop Tarts, I saw protein soda.
I mean, there's protein everything.
So we as a society are for the most part doing totally fine on

(24:09):
protein for the, for the .8g. And I often times when I'm doing
my protein calculations for somebody, I'm even when they're
cutting back on food, they're still getting like a gram of
protein per kilogram of weight. Like they're still doing fine.
So when we talk about getting them to the .8, it feels like a
restriction. But in this case, I'm like, no,
we're just going to do like a normal, We're just going to do a

(24:30):
normal protein intake for you. And then we'll see how we, we'll
see how we go from there. And so one of the first things
we see in the labs is usually the BUN can come down a little
bit. It's maybe not crawling up so
high. So keeping a more moderate
protein intake is very helpful. And again, if they're doing
anything below .8g per kilogram,it's really important that they

(24:51):
have a dietitian and their doctor that is aware and
supporting them in this because they are at higher risk of
malnutrition. They are, they're at higher risk
of, of a lot of other. I, I tell my clients it's like,
it's like taking butter cheese and making it Swiss cheese.
Like you're just poking a lot ofpulls into it.
You don't want to risk it. So you want to have thought, you
want to have those people to kind of help oversee and make

(25:12):
sure this is safe. The worst thing in the world is
to cut out this food and then find out your labs are worsened
and your kidney functions worsened.
So you really want to do it safely.
So that's the protein overview. Carbohydrates, I usually aim for
just the standard, the standard 45 to 65%.
But in many cases, I'm going towards that 65% because again,

(25:36):
if we're going a little bit moreconservative on protein, then
we've got it. We've got to find ways to kind
of shift calorie needs. We got it.
We got to make the macros all out up.
So I'm going to be looking at more like 65% carbohydrate, but
then I'm also focusing on fiber.I'll talk about fiber in a
second, but but that's a really important part when we're
looking at carbohydrates. And then finally, when it comes

(25:58):
to fats, you know, I'm kind of looking at the remaining
whatever, whatever that looks like around 3035% or so for fat
content. But the quality of fats is
incredibly important because again, the kidneys are, it's not
an isolated disease. They are at risk of a lot of
cardiovascular issues. The number one cause of death

(26:19):
for people with kidney disease is not just the kidneys, it's
actually heart related. It's it's left ventricular heart
failure, it's heart attack, it'sstroke, it's something
cardiovascularly related. So it's very important to not
put them on like a keto diet with a really with a very high
amount of fats. They need to keep that fat

(26:39):
controlled. So about 35% or so from fats,
really focusing on polyunsaturated fats,
monounsaturated fats, and then, you know, talking about
saturated fats. And I do try to encourage people
to keep animal fats to to a limit.
You know, it's not necessarily not necessarily totally

(26:59):
eliminating them. And that I tell people there's a
reason I made plant powered kidneys and I didn't call it
vegan kidneys because we want tohave that flexibility.
You want to be able to include as much as possible so you know,
but you but you do want to be cautious with saturated fats
from animals because that is strongly associated with
cardiovascular problems that people with kidney disease are
again already at a higher risk of having.

(27:21):
So that's kind of the overview of the macros.
Is everything sounding good? So.
Far sounds great I mean, it sounds amazing.
Yeah. I think the, yeah, I'm curious,
like for people that you know, that are going to listen to
this, they're thinking about thenutritional conversation, it's
good to keep it within this context of kidney disease and
really cuz people start going into, you know, you talked about

(27:44):
older populations who are in thetime frame of experience so much
diet culture and experience a yo-yo of all different types.
And I could see people listeninggoing, well, how does this
relate to my like what types of diets that people are on, you
know, carnivore, plant based, vegetarian, vegan, all that
stuff. What you think are larger

(28:05):
conversations, but keeping it within this, I think centralizes
it and and makes it just easier.Like let's think about this in
terms of kidney disease. And that's not going through
this rabbit hole of other stuff.Like, let's just focus here for
for right now, you know? Yeah.
And and that's, that's a lot of it too, with people kidney
disease again, because they get lost in the weeds too.
So it's like, OK, let's look at this big picture.

(28:25):
Let's focus. Let's let's create this like,
like hierarchy of opportunities,like what can we really look at?
What can we hone in on? And let's just take it from
there because what often what often happens is when we do
simplify it, there's this trickle down effect of more
benefits happening in other areas.
So that's why I tell them like, let's just look at one thing at

(28:47):
a time. We set goals and I said, let's
just pick one goal and it's going to focus on one topic, one
area. What's like you're, what's the
thing that's really, it's keeping you up at night.
It's making you sit down to an empty plate.
Like what is that? That's really concerning you?
And that's what we're going to focus right now.
And we just try to keep it as assimple as possible because,
yeah, it can get incredibly complicated and there's a lot of

(29:07):
what ifs. A lot of what?
Ifs, a lot of what ifs. And I think the connection to
cardiovascular disease is not a common talking point.
This. I think people don't look at
kidney disease and make this association with cardiovascular
disease and this this I've rarely seen this discussed.

(29:28):
I want to dive further into this, but I want to finish on
the nutritional aspect and fiberfor sure.
But let's let's bookmark this especially to come back that
because this is I know a lot of people will listen to this ago.
Oh no, I've never heard that this.
Relation. They just won't.
They won't associate it together.
But all of these think about being in a state of chronic
disease is really a cascading effect.

(29:50):
I mean, it is like a waterfall that keeps slamming into rocks
and wearing it down and destroying other things and
carving something else out together with that.
So just to bookmark that for sure.
Yeah, absolutely, absolutely. Whereas there's a lot we can
dive into about that and how closely associated they are.
OK, So we've done our our quick overview of calories,

(30:12):
micronutrients. I'll talk, I'm going to touch on
just a couple micronutrients that people with CKD are really
focused on. If you meet somebody and you
bring up some of these, they'll be like, Oh yeah, I know about
that. Like it's already on their
brain. So the first and foremost is
sodium. And this is something that is
again, it's just all over the place whether we realize it or

(30:33):
not. But sodium is very closely tied
to kidney health because again, one of the top causes of kidney
disease is high blood pressure and a high sodium diet is
connected strongly with with hypertension.
So when there's kidney damage, it's the sodium isn't being
filtered as well and blood pressure is not being controlled

(30:55):
as well, right? The kidney function is not
creating the hormone and helpingto manage the blood pressure.
So it is very important. And this is what I tell people,
even for somebody who has who has CKD caused by diabetes, if
they don't have a history of hypertension, I'm still focusing
on hypertension. Nutrition goals, including a low
sodium diet. The guidelines say CKD period

(31:18):
means a low sodium diet and so alow sodium diet is 2300
milligrams of sodium or less perday.
In some cases for people who have really uncontrolled blood
pressure or they have congestiveheart failure or other other
other problems with their heart or their cardiovascular system,
they might be on maybe like 1800milligrams or as low as 1500

(31:42):
milligrams. So it can kind of vary a little
bit, but in general, starting with 2300 milligrams or less is
a good goal because most people tend to get it out 1000
milligrams sodium extra on top of the the heart healthy
guidelines. So focusing on that low sodium,
it really, really is important for not only controlling blood

(32:02):
pressure and to help keep all ofthat, which means there's less
stress because you think about like if blood pressure is higher
and it's physically putting moreforce into these very delicate
nephrons is very delicate kidneyfilters, there's all this
pressure pushing in that can cause that damage as well.
So when we're focusing on keeping the blood pressure down,

(32:23):
having less sodium, that alleviates the stress on the
kidneys. Another thing too is that it
actually one of the common, one of the common symptoms or or
conditions associated with kidney disease is a term called
proteinuria, which is protein leaking in the urine.
That's that's an indication thatthere's kidney damage because

(32:44):
again, protein being a big molecule, it shouldn't be in the
urine. It should be retained.
But if there is a high level of protein in the urine, that is
indicative of the of the kidney damage.
And research has shown that a low sodium diet is really,
really powerful to help reduce proteinuria, especially when

(33:04):
people are given medications, prescription medications to help
with their blood pressure, whichalso helps with the proteinuria.
A low sodium diet is, is is key for the medication just to work
effectively. So focusing on a low sodium diet
is really important. And that's something that I talk
with people a lot because sodiums and everything, I mean,

(33:24):
breads and rolls and like tortillas, like I know right now
the, the high fiber tortillas are like such a big, such a big
thing. Maybe they've been a big thing
for a while, but I don't know, Instagram's pushing them in my
reels. So I'm just seeing a lot of
these high fiber tortillas and I'm looking at the nutrition
label and everyone's focused on the fiber, which is great.
But then the tortilla, like 1 tortilla has like 607 hundred

(33:47):
milligrams of sodium just for that one tortilla.
And that's like 1/3 of a person's sodium for the entire
day from this one ingredient forone meal.
So I just, I just kind of want to put this warning out to
people to say like if you're, ifyou're encouraging people to eat
something that has maybe extra protein or extra fiber in it,
which are good nutrients, but like don't, don't just bypass

(34:10):
that sodium because sodium is really important, especially for
people with kidney damage. It's really important for them
to be cautious with so sodium, low sodium, looking at breads,
tortillas, rolls, canned soups, of course, you know, that's
like, that's a big one. Basically packaged, packaged
foods. That's really where you're going
to find it. And one of my recommendations,

(34:32):
my like kind of rule of thumb recommendations is when you're
looking at the nutrition facts, if the sodium in milligrams is
less than the calories per serving, that's cool.
It's good to go because if we'reaiming for about 2000 calories a
day, we're also aiming for about2000 milligrams of sodium per
day. So like that's just an easy way
to see like is this going to be good for me?

(34:53):
And sodium if it's like 50 calories, but 300 milligrams of
sodium, like the calories, it's not going to give you a lot of
energy, but it's going to take up a lot of your, your
milligrams of sodium for the day.
So maybe that helps some people.I find a lot of my clients think
that that's a really easy, quickway for them to just kind of
filter through some things. I tell you what, I'm going to

(35:15):
interrupt you real quick on thisbecause I just think this is,
this is such a critical point inthis conversation.
I'm going to say why here because the protein conversation
drives me crazy. I'm just going to be honest here
just because it's often done without providing the nuance
that you just provided, which a nuance about sodium.

(35:35):
It's like push, push protein, push, push protein, but don't
discuss the nuance related to other factors within protein and
then talking about protein in the bloodstream, OK, Obviously
you're talking about this withinkidney disease.
My question is this, because this is a big question and
people listen this, my students always talk about this protein

(35:56):
and stuff. Is there a level with protein
consumption being a big moleculethen could be kind of a gateway
or a cause towards it being in the bloodstream that's like
excessive amounts? Of course.
Yeah, well, fortunately, the research shows that healthy
individuals who don't have kidney damage, a high protein

(36:16):
diet is not going to cause kidney disease.
However, there's 37 + 1,000,000 people in the US alone with
kidney disease in about half thecountry with diabetes.
It is. Yeah, it's a lot.
And, and, and diabetes and high blood pressure incredibly
rampant. So the there is some caution to

(36:38):
say, you know, if you have a family history of diabetes, high
blood pressure, kidney disease, if you have even a family
history, you are at a higher risk of developing kidney
disease. So it's important to understand
your own health and, and your medical history, not just what
you currently have going on, butlike, what are you at higher
risk of? Because that could play a role

(36:59):
where, you know, again, just a healthy individual, that protein
is not going to be problematic, but the worst thing in the world
is to push it too far. And then there is, you know,
kidney damage or there's problems that arise from that.
So does that does that help? No, that's great.
No, it's just that's what I loveabout these conversations, a
more nuanced conversation. And, and, and I've, I've

(37:21):
definitely seen the data on thatin terms of protein, but I just
for healthy individuals just parsing through especially like
the sodium discussion, I can tell you the most people I've
talked to have never had this sodium discussion related to
protein ever, like ever. And that's because it's kind of
a blanket discussion about protein versus let's dive into

(37:42):
the weeds. So thank you for doing that.
Yeah. Yeah, of course I, I always, I,
I really get heated about it, like on social media when I'm
going through things and people are saying like, oh, make this
like protein something and Add all this stuff and just like,
that's like a day's worth of sodium right there.
They totally bypass it. And I know, like, yes, your
kidneys will do you an incredible favor and eliminate

(38:05):
the sodium that you don't need. But like if you were doing that
over and over, like if you were doing that consistently, like,
yes, physical activity is going to be a really, really great
lifesaver. And getting a lot of potassium
is also going to really help offset that sodium too.
But, you know, it's just in general, high sodium diet is not
beneficial for most people. There are some health conditions

(38:26):
where high sodium diet is needed, but that's not for the
general population, That's not for the majority.
So I, I do feel like the more that people talk about a low
sodium diet, there's just, there's so many benefits to it.
Now that makes a lot of sense. Let's keep it moving.
I mean, this is unbelievable. And again, I want to keep

(38:46):
bookmarking the cardiovascular aspect to it, but if there's
anything left that you want to discuss related to this, let's
definitely get to that and then jump into that other.
Yeah, I'm going to actually the next the next micronutrient I'm
talking about. It's a great segue into the
cardiovascular. So I'll probably just think
organically bring that into the picture.
So the other micronutrient that I want to kind of highlight is

(39:09):
phosphorus. And this is another one that's
just like not talked about whatsoever.
And yet the majority of people are consuming way more than they
need, like way excessive amount.But again, when you have good
kidneys and when you have good filtration, it's not a, it's not
a big concern because your kidney is dermacy and like, OK,
we don't need that cool, move on.

(39:29):
But for people with kidney disease, when you're consuming
larger amounts of phosphorus, then this phosphorus fills up in
the blood and actually causes bone damage and cardiovascular
disease. So I'll get into some more like
the the back end of that, but I want to 1st explain the dietary
phosphorus differences because there is some nuances within
that. So phosphorus, there's two

(39:50):
types, there's organic and inorganic phosphorus, organic
phosphorus, think of it as the phosphorus that's just naturally
found in foods. So we have phosphorus, we
naturally have phosphorus in ourbodies, that's part of our
composition. Animals, animal meats, animal
proteins naturally have phosphorus in them because it's
part of their body composition. Plants have phosphorus.

(40:12):
It is part. It comes from the soil.
It is part of plants as well. So.
It is already found in a lot of foods.
Inorganic phosphorus is the kindthat's added to a food product
for various reasons on primarilyit's used as a preservative.
It can be used as a nutrient booster.

(40:32):
So like a food with added iron, it might be in the in the form
of ferrous phosphate. So it's a it's a type of iron
with phosphorus that comes with it.
These added. This inorganic phosphorus is the
kind that is more problematic for people with CKD because it

(40:53):
is more easily absorbed. Our bodies do not have the
enzymes to breakdown the organicphosphorus.
We we don't have that ability. But the inorganic kind is easily
broken down like it. Again, some of it is nutrient
related, so it's made to be broken down so our bodies can
absorb it. So this inorganic phosphorus is

(41:15):
the problem child because it's in so many things.
And if you ever like if you everstart looking at ingredients
list, just look for PHOS becauseit can be really deceiving.
The easiest like go to example is like a cola, a cola, a dark
cola soda. You'll probably see phosphoric
acid. That's, that's like my, I've

(41:37):
been giving this example for 10 plus years and this is the kind
again, that's really easily absorbed and it's found in a lot
of our foods, a lot of our processed foods, not all of
them. There are some companies that,
you know, don't use phosphorus additives, which is fantastic.
And even now there's bit, there's currently some
legislation that's trying to move through to help make

(41:59):
phosphates more prevalent on list on labels because of the
association with these phosphates and cardiovascular
disease, bone diseases, kidney diseases.
So it's this is the problem. So in the in the realm of again,
protein, when people are are eating protein rich foods or

(42:21):
they're eating protein supplements, they're taking
protein shakes, powders, bars, whatever, that's a place where
phosphorus might be. And so if they're focusing on
protein and not to mention I'll also add again, like we have pro
or we have phosphorus, animals have phosphorus.
Protein rich foods tend to just come with higher amounts of
phosphorus anyway. So what's happening is if

(42:43):
somebody's eating a lot of protein, they're kind of
automatically eating more phosphorus.
And so that in of itself can be problematic because what happens
is when this phosphorus is absorbed and if it's not
filtered, well, you have this extra phosphorus floating
through the blood. And phosphorus and calcium are

(43:03):
basically best friends. They love to be together.
And what happens is this phosphorus is coming through and
it's like, where in the world iscalcium?
Where's my BFF? And it's pulling calcium from
where your body keeps it, which is in the bones.
And so it's pulling, it's literally pulling calcium out of
our bone, creating these crystals that are floating

(43:25):
through the blood and eventuallythey're settling in our soft
tissues. And if this is happening months
and months and months, years andyears and years, all of these
crystals are hardening our our arteries.
And this is, this is known as vascular calcification,
literally turning our vascular system or arteries or veins into

(43:45):
stone. And a visual example I use with
clients to explain this process is you ever see like Red Vines
or even like, I don't know, likelike a like a licorice that's
hollow, right? It's flexible, it's squishy.
It you can, you can bend it, youcan move it.
Compare that to an uncooked penne pasta, very rigid, not

(44:09):
good, not moving, not flexing the way you want it to.
So you're going from this red vine type artery to this penne
type artery. That's not going to be helpful
in blood pressure control where your blood pressure, your
cardiovascularism, it's supposedto flex, right?
It's supposed to be able to openand close and adapt to our body.

(44:31):
And dilation, Yeah, I was just talking with students about this
in blood vessels and endotheliallining of blood vessels and
pliability and flexibility. It sounds what you're saying is
this also is now becoming another factor towards
decreasing that pliability and that.
Yes, absolutely. And, and this is something that
that just over time, just like, you know, kind of like a

(44:54):
parallel example would be high cholesterol levels, you know,
when that, when that plaque is just kind of filling up the
arteries and the blood vessels, it's making it harder for blood
to come through. And so it's, it's creating
again, high blood pressure, it'screating heart thickening.
So again, the number one cause of, of death for people with
kidney disease is less ventricular heart failure.

(45:15):
So it's causing these problems and it's just reducing blood
flow in general. So there's a lot of problems
that are coming from and this islike chronically high
phosphorus. This is again, this is not like
if I have somebody who has a phosphorus of like 5.7, like a
little high, not crazy, but it'sjust like a one off lab.
Like that's not the kind of problem we're looking at.

(45:36):
I'm talking about somebody who has a phosphorus level of like
7, which is quite high and they have sevens in their monthly
labs for like years. This is what we see.
And then what can happen over time is that we see their
calcium levels and their blood reports that drops because all
that calcium is binding to that phosphorus and so it's dropping
the calcium levels. So, so this is just this whole

(45:59):
thing and the, the bigger term for it is CKD, MB, D, mineral
bone disorder or mineral bone disease.
This is just kind of the school association of all this stuff
happening where phosphorus is building up causing these
problems. So and then also this calcium
change too is affecting the parathyroid that what we talked

(46:21):
about earlier, the PTH, because PTH is designed to control
calcium, but now PTH is freakingout because the calcium levels
are off and and then the count, the hormone, the sorry
parathyroid can't talk to the kidneys very well.
And so that can't, it's a whole mass.
It's very, very, very challenging.
It's very hard. And so in, in some cases there's

(46:42):
medication to help. There's parathyroidectomies
where people have surgery to remove some of the, some of the
glands so they're not producing the hormones so much.
I've even had a case where, man,this is back when I first
started dial, this is like 12 years ago, Somebody was
scheduled for a kidney transplant.
They got on the table. They were opened up and closed

(47:04):
up right away. They were the vascular
calcification was so bad they couldn't get the new kidney.
My goodness, the person woke up thinking they were going to have
a kidney transplant. Didn't happen.
There was no idea about this ahead of time that this was
potentially. No.
And it was, I can't remember allthe details.
It was a long time ago, but it was something related to some,

(47:27):
like they didn't have like the latest scans or something, but
it was just something that they didn't see, Yeah.
Wow, that's just like that's actually mind blowing.
They think it's that bad. And I want to reinforce the left
ventricular heart failure and for the audience to why this is
so critical as the left ventricle is where stroke volume
occurs and with poor stroke volume ejection fraction

(47:50):
changes, all these things lead to less blood going out to rest
of the body into all the organs creating even more of a mess.
That's which this is incredibly messy disease.
It is. I mean, it feels like it's just
like one hit after another afteranother on this.
So like a really serious condition.

(48:11):
Yeah. And I do want to put like a
little bit of silver lining. I'm, I'm not, I'm a very
positive person. I am not a Debbie Downer.
So I do want to say like a lot of these situations are not
typical. So this is, this is again, like,
I think a lot of the explanations and the examples I
gave, I would say like, you know, months and months and
months, This is like a long timeof not doing anything.

(48:33):
I have so many examples from clients and students who have
maintained or even improved their kidney filtration rate
just with like healthy diet and lifestyle changes.
There's, there's so many of those types of examples that are
there. And that's why like a lot of the
research coming out is saying like, if you have CKD, you you
need to have a dietitian becausewe see that it is very

(48:56):
important. Like we we acknowledge that this
does make a big difference. So yeah, I do want to just
highlight like there are a lot of great resources and
opportunities for people to be able to not get to those extreme
poor outcomes. So the recommendation is to to
have regular connection or consultation or sessions with a

(49:18):
dietitian if you have CKD. I didn't know that, that that
was the recommendation. Yeah.
Yeah, it's, it's on the international guidelines and
they they say that basically theDietetic consultation is it's
the the top tier, which I still,you know, I still hear doctors
telling people like, oh, you don't UFC KD3, you don't need a

(49:41):
dietitian, don't worry about it.Diet like they're not keeping up
what they say. Like just because they don't
know or I mean. They don't know, they don't
know. And and I will say a lot of
nephrologists like 90% of their patient population is dialysis.
So like they're really in the dialysis setting more so than

(50:02):
the the CKD setting. And then there's also they might
not even know we exist. Dietitians are not big.
We do not go through any type ofeducation about marketing or
even private practice. Like me creating my private
practice was wild to a lot of people.
But this is something that is becoming more on the forefront.
And now that we have those guidelines that support and back

(50:22):
nutrition and medical nutrition therapy, like now we're finally
being like, yay, we knew it. We're doing something.
So, So yeah, there, there are a lot of great benefits.
And I always tell people too, ifyour doctor says you don't need
an education, you let's say, OK,can you please chart that?
Can you please write that on thenote for today that I requested
this referral and you denied me the referral because I feel like

(50:44):
my insurance might need to know about this like just, and in
some cases denying A referral like that could be considered
malpractice. I'll just throw that out there
too. Wow, very interesting.
Well, as we're getting close to the end here, let's talk a
little bit. As you mentioned about I, I'm
the same way. I want, I want to find solutions
for people. I want to be positive about

(51:04):
things. Let's talk about some modifiable
factors outside of just nutrition that can be done to
help with chronic kidney diseasehere.
Yeah, yeah. And there are so many, truly.
Like I could, I could list a dozen just from the nutrition
side alone. But if we go even outside of
nutrition, some of the things that are incredibly important,
it's sleep. Like, you know, sleep is also

(51:27):
kind of having its moment, whichis really wonderful.
Yeah, People need good sleep. There are things that our body
is doing that it can only be done during sleep.
We need that restoration. And there is, there is a strong
connection, a strong associationwith chronic kidney disease and
sleep apnea or restless leg syndrome and like just sleep
health concerns. So focusing on, you know, what

(51:49):
can you do related to your sleephealth, if it's related to
getting going to a sleep study or talking with your doctor
about some type of intervention or even medications or something
like that. There, there's a lot of, there's
a lot of areas for opportunity on what can be done just for
your sleep health. So developing a better bedtime
routine for yourself, shutting off the screens, like all that,

(52:10):
all that kind of like standard stuff you hear that nobody wants
to do, but like it's important, it's important.
So definitely focusing on sleep is important.
Another aspect that is incredibly powerful is physical
activity. Like really, really important.
And a lot of people with kidney disease, they're, they're scared
to be physically active one, because they might not have the

(52:31):
energy because like tie back into the beginning when I was
talking about calories and energy, but they need to
exercise. They, but they're, they're maybe
not feeling like they have a lotof energy, but also exercise is
very strongly associated with good outcomes for people with
kidney disease. And it doesn't have to be, I
think people, they, they again, think of it like in this all or
nothing mentality, but we're saying like a 10 minute walk

(52:55):
after lunch or after dinner or something.
Like it helps your digestion, itgives you some fresh air, 10
minutes. And even if even if you're not
outside, like just walking around your space, like just
walk around to get a little bit of movement.
And it's incredibly helpful. But physical activity,
particularly just walking is incredibly, incredibly helpful
for people. So setting a step goal, whatever

(53:16):
it is, plus 500 steps or whatever the case is, like take
those baby steps, get more physically active.
One of my clients, she, she was like, it's really hard for me to
get out. So I just took my spare room and
I turned it into a home gym. And so I'm seeing her log her
elliptical and her, her bike andher treadmill.
She's like logging the stuff in and she's doing so, so well.

(53:39):
So, you know, any kind of movement that like you enjoy and
not like feels good to you is going to be beneficial.
Even weightlifting, some people ask me about like, hey, what
about weightlifting and weight training and lifting heavy
weights? Like, yes, that's still great.
It will. If you you do like a heavy
intensive workout right before alab draw, it might impact your
labs a little bit. So either you just don't do a

(54:01):
heavy lift the day or two beforelabs or if you do it, make sure
your doctor knows. So when they're reviewing the
labs, they know that that's a factor involved.
But weightlifting is really fantastic too.
And I've had clients that have had great results in in doing
weightlifting. So any kind of physical activity
that you enjoy is really, reallygreat.

(54:21):
Aiming for the the 150 minutes of moderate activity per week is
awesome. If you're at 0 minutes, aim for
30 minutes per week. You know, set it, set a small
goal that feels really tangible and then and feels really good.
I always tell people like if yousay the goal and it already
scares you, then that's not yourgoal.
That's not your plan. You've got to think of something
that actually empowers you and makes you think about your life

(54:43):
and think about like, yes, thereis nothing standing in my way by
doing this and, and repeating it.
That's the key too. But but yeah, so I would say
that those two things are incredibly important.
Trying to think if there's any like any other kind of big ones.
Those are really the biggest ones that I can think of right
now. But nutrition, we've got a lot

(55:03):
too. Yeah, I know.
We had a lot on that. This is wonderful and and
clearly your passion and your knowledge on this is like
spilling out of you. You are.
It's. A problem.
It's a problem. It's like you're.
Saying Jen, I mean, and that's why I was so excited to have you
on. You just say this, you're
fluent, very fluent in this. And it's it's so recognizable.

(55:24):
So I just appreciate the education you're putting out
there for so many people. And there's lots in here that I
think it's going to be pretty eye opening to.
A lot of the people are going tolisten to this.
So I'm just so grateful for that.
And we'll have all your information in the show notes so
everybody can connect to Jen andon all the wonderful things
she's doing. But if you have any parting

(55:46):
wisdom, please feel free to share that you know.
I the only thing I can like off the top of my head right now is
I recently, just about two weeksago, published a book less than
two weeks ago. So I do have a book all about
the stuff that I've covered today and more.
There's a whole chapter on protein, There's a whole chapter

(56:06):
on phosphorus. There's a chapter on oxalates,
which is another big dietary kidney concern.
But if you're interested in likea resource for yourself or for
people with CKD, I've already had really great reviews on it.
So it's on Amazon and I do, I did provide a link so anyone can
learn more about the book. But I think it's just a matter
of giving people knowledge. And like, like you mentioned,

(56:27):
it's that positivity. It's it's, it's that like just
knowing that there are opportunities and resources
available that just a lot of people aren't aware of.
So that's my goal is people, people knowing that there's
these kinds of resources available.
Yeah, most definitely. And then you can get better.
And so much of the, our chronic illness that we have as a
society is they're modifiable and the things that we can get

(56:52):
done, it can feel overwhelming, especially, you know, when
people are dealing with chronic illness.
It's very depleting, you know, just having this on your
everyday, But it does get better.
It can get better. And, and hopefully this will
help anybody listen to this thatis experiencing this.
Hopefully this gives you some some hope and some some jet fuel

(57:13):
for you to just keep moving forward and and and and help
yourself too. Be the person you want to be
outside of this. You know so.
Yeah, yeah. That's it, That's it.
That's it. Thank you so much, Jen.
I appreciate you. Thank.
You so much for having me, Darren.
It's been a lot of fun.