[00:00:00] Shireen: Podcasting from Dallas, Texas. I am Shireen and this is the Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

[00:00:32] Shireen: In today's episode, we welcome Dr. Melissa Prest, a renal nutritionist who has had years of clinical experience helping patients to improve kidney health via dietary strategies. We'll discuss the specific dietary elements that contribute to kidney health and how to use nutrition to tackle chronic kidney disease.

[00:00:52] Shireen: Stay tuned. Dr. Melissa Prest is a registered dietitian nutritionist who provides medical nutrition therapy for people living with chronic kidney disease and helps them navigate the kidney diet. She has experience as a health coach with clients worldwide, making behavior changes that allow them to reach their desired health goals.

[00:01:17] Shireen: Welcome, Dr. Prest. 

[00:01:18] Dr. Melissa Prest: Well, thank you so much for having me. It's great to be here. Great to have you on, Dr. Prest. So first things first, our classic question that we start every podcast episode with, why this, right? So what drew you to this field of renal nutrition? Yeah, it's. It's one that a lot of dieticians shy away from.

[00:01:35] Dr. Melissa Prest: They feel that it's a bit complicated and I'm sure most people living with chronic kidney disease feel like the diet is a bit complicated. I kind of fell into it in a way of, there was a job opening. I was like, I haven't done this before. Let me see what it's about. Let me try it. And it was something that I kind of fell in love with.

[00:01:56] Dr. Melissa Prest: Not so much the disease itself, but working with people one on one. For a period of time, my background prior was in hospitals. And so, you know, you might see someone, you just kind of talk to them quickly and you don't, there's really no relationship there. So what I enjoyed is that there's an actual relationship between yourself and the person you're working with.

[00:02:17] Shireen: So let's get into the basics first, Dr. Prest. So could you explain to us how diet actually impacts kidney health? Like what is that relationship that exists there or a sequence of series that could lead to that? And then what unique challenges those with chronic kidney disease today face? So a lot of people that have chronic kidney disease likely have other health conditions.

[00:02:41] Dr. Melissa Prest: So typically, it's not just kidney disease. It's kidney disease and something else. And so that becomes complicated in which they're managing two health conditions, three health conditions, whatever that might be. So high blood pressure, diabetes, those would be our leading causes of kidney disease. And so there's different diet recommendations for all three of the diets.

[00:03:05] Dr. Melissa Prest: And so for a lot of people, it's confusing and a little challenging to figure out which part of this diet fits with this diet, with this diet, what am I supposed to do? This says I'm supposed to do this. This says I'm not supposed to do that. So that is really challenging for people when they are initially diagnosed with chronic kidney disease, depending on what stage they're in.

[00:03:26] Dr. Melissa Prest: Some people. Do not know they're in kidney disease until stage five into those later stages. And then some know about that earlier. And so if they know about it earlier, they might get a little more information about the diet and are able to learn a little bit more about it and learn a little bit more about managing it.

[00:03:45] Dr. Melissa Prest: And then sometimes they kind of get on that end where now we have to manage it with dialysis. So in terms of that diet piece of it, there's a lot of different things that we do with the diet. Because we have to think a little bit for our kidneys because they aren't filtering as much waste and blood.

[00:04:03] Shireen: And so we need to help the kidneys kind of do what they would normally do by making some modifications with the foods that we're choosing. Now help us understand, what are some common misconceptions about the kidney diet specifically that you often address in your practice and the work that you do.

[00:04:23] Shireen: And again, help us maybe take us a step back to understand like, what are the types of things that lead to that? So that it sort of ties into the kidney diet itself. 

Dr. Melissa Prest: Sure. So I think one of the biggest thing, which kind of goes back into leads into it is that, um, Yeah, I think for a lot of people, they feel like there's a one size fits all for the diet and a lot of the information that's available on the internet they might find online or even sometimes in physician offices is maybe the most restrictive form of the diet and it's really not customized for them or differs by stages.

[00:04:58] Dr. Melissa Prest: So with kidney disease, we have five stages. Stage one would be. really the very beginning, stage 5, 5D, meaning that you're on dialysis. And so depending on where someone falls in that stage of kidney disease, there's different recommendations for what we're going to do with the diet. Salt, protein, potassium, phosphorus, there's a lot of P words.

[00:05:21] Dr. Melissa Prest: That we talk about with the kidney diet. And so that could be confusing too, where someone might say, I'm watching my phosphorus, I'm not eating these foods, but those foods are actually the potassium foods, not the phosphorus foods. So that could get really challenging and confusing as well. So there's a lot of little pieces someone has to kind of put together in this puzzle, which is where a dietician is really great at helping people put those pieces of the puzzle together.

[00:05:46] Shireen: That's helpful. And as you're sort of thinking through a dietician's role within addressing this, what are the types of things that a dietician is able to help someone with as they're sort of trying to manage it, regardless of what stage they're at when it comes to CKD or chronic kidney disease? How does a dietician's role really help that journey?

[00:06:06] Dr. Melissa Prest: So dieticians will You know, if I'm working with someone and most dietitians that work within the kidney space, we're gonna look at the labs. So, usually by the time someone's in stage three, they're getting labs drawn at least every quarter. If it's earlier, it might be annually with their regular visits.

[00:06:23] Dr. Melissa Prest: with their primary care doctor, but it's kind of taking a look at the labs and talking through particular changes in the diet to help them improve or maintain their labs. So, you know, a lot of times we're obviously talking about food, we're talking about what you're cooking at home, we're talking about putting together, you know, your meal plan, kind of helping you with creating a meal plan and talking through how you can fit the diet within your life.

[00:06:47] Dr. Melissa Prest: So it might be helping people who work on the road. They're traveling a lot for work and they're eating out a lot. And so then it's working with them, figuring out, you know, what are maybe some good choices that they can eat at a restaurant and then still kind of be within good, good, good, Guidelines are good places for them with their kidney foods, or maybe it's a holiday and helping them navigate the holiday.

[00:07:09] Dr. Melissa Prest: Or we're just kind of figuring out that day-to-day, what kind of things should I be making for myself? So meal plans are going to be really important and things that dietitians will work on. In addition to making some changes in terms of how much protein is in the diet, let's say, and that's going to be based on what stage of kidney disease you're at.

[00:07:29] Dr. Melissa Prest: How active you are, how old you are. So there's, you know, depending on just kind of your overall health, there'll be some recommendations and changes for that. So modifying the diet is something else that dietitians will help people with. And then also just kind of helping setting goals and helping on behaviors and helping on lifestyle, you know, it's not just necessarily like handing out a diet.

[00:07:51] Dr. Melissa Prest: I think a lot of people might feel like, Oh, they're just going to hand me a menu and then send me on my way. It's a little bit more involved than that. So it's kind of looking holistically at kind of that whole picture of what's going on in someone's life and then helping them with various lifestyle factors, the nutrition part of it, the cooking, the meal planning, grocery shopping, label reading.

[00:08:14] Shireen: So a whole host of things that dieticians help with. You know, and now diving into sort of the various stages of chronic kidney disease, can you explain the principles of renal nutrition and how dietary needs change depending on the stage of kidney disease? You talked about the peas earlier, so I want to double-click into that to understand how it varies across the different stages.

[00:08:35] Dr. Melissa Prest: Yeah, so usually in stage one and two, the recommendation is either a general healthy diet, whatever that kind of looks like for you. So kind of taking into consideration cultural preferences, what you like to eat, but you know, kind of keeping that within kind of that healthier framework, healthy, you know, kind of meaning fruits and vegetables, whole grains, whenever possible, kind of looking at those sources of protein.

[00:09:02] Dr. Melissa Prest: Yeah. Absolutely. Or, and, or looking at other health conditions. So as I said earlier, high blood pressure, diabetes, those two leading causes. So it may be working with you to make sure that those health conditions are well managed. So that's like stage one and two. So, you might be on Mediterranean-style diet, and that's gonna be great.

[00:09:20] Dr. Melissa Prest: You might be on something called a DASH diet, which is a dietary approaches to stop hypertension. So that would be something that might be prescribed if you have high blood pressure. Take care. So whatever type of diet you're following, you want to just kind of make a healthy plate and help you kind of manage those other health conditions.

[00:09:37] Dr. Melissa Prest: So that's one and two. So we're not necessarily modifying a lot for the kidneys. We may start doing some education and talking about those different P words or different things that are going to come up. Sodium or salt is probably one of the. First things that we talk about, even if you're at stage one or two, and that just helps the kidneys as they're not being able to filter and clear as much waste from our bodies.

[00:10:02] Dr. Melissa Prest: They're not able, you know, you're not producing as much urine as you would if your kidneys were working at a hundred percent. And so high salt typically attracts water. You retain water. It's just a little harder to get off hard for blood pressure management. So. We typically will start with that and just your general healthy diet.

[00:10:21] Dr. Melissa Prest: Once you get to stage three and four, that's when you can see a kidney specific doctor called a nephrologist. That is when Medicare will start paying to see a dietician and usually you'll be followed every quarter by the kidney doctor. You'll have labs drawn, they'll check in and see how things are going.

[00:10:43] Dr. Melissa Prest: And There aren't a lot of medications besides managing or other health conditions that is going to slow or stop the progression of kidney disease. There is some new ones that are particularly geared towards managing blood sugar that have some really great promise and slowing that progression of kidney disease.

[00:11:01] Dr. Melissa Prest: But there isn't. A kidney specific medication that someone can take like we have for high blood pressure or insulin for our blood sugars. There's nothing like that. So what we do have is diet and lifestyle, and those are going to be two really important things to really help slow that progression of kidney disease.

[00:11:18] Dr. Melissa Prest: And so with that, we continue with that sodium. We continue kind of talking about things like potassium and phosphorus. and protein. That's three Ps. But we'll start to kind of modify your protein. So we'll look at the amount of protein that you're eating. And we can also talk about the type of protein. So initially we had some recommendations come out in 2020.

[00:11:44] Dr. Melissa Prest: Again, reinforcing for practitioners who've been working in the kidney disease space for non dialysis to continue doing lower protein. It's just easier for the kidneys to function. Our kidneys are involved in clearing kind of these end products of metabolism from protein when we eat protein foods. So it's helpful for them to not have as much protein, but then also kind of looking at the type of protein.

[00:12:09] Dr. Melissa Prest: So those guidelines just had said either type is okay. There were some international guidelines recently released that kind of mentioned maybe the type of protein is important too. So stage one and two, we're kind of focusing on healthy diet, sodium, we get to three and four. Continue with sodium, and now we start talking about proteins.

[00:12:28] Dr. Melissa Prest: We'll talk about the amounts and the type of protein. So I typically would encourage people to get a mix between animal and plant proteins. It doesn't have to be all or nothing, and either way, just kind of whatever works for them. I've had some patients do really well going all plant based, and then I have others that eat animal proteins mostly, and They've done great too.

[00:12:51] Dr. Melissa Prest: So just kind of depends on you, but the total amount of protein is what we really focus on. And then the other things that we talk about, but you're likely not going to be seeing changes in your blood work are things like phosphorus and potassium. They're going to become a little bit more important for people if they progress to dialysis, but in kind of these middle stages, early stages, you're likely not going to see a change in your blood work for those labs, but we still talk about.

[00:13:20] Dr. Melissa Prest: food sources of those and ways to look at things like additives in the food. So phosphorus additives, potassium additives. So phosphorus additives are in our foods for a variety of reasons. Shelf stability to help things melt that maybe wouldn't melt normally or easily. make things taste better. So, you know, a variety of reasons why we have that in our food supply and then also potassium additives as well.

[00:13:47] Dr. Melissa Prest: It's kind of a replacement for salt and our lower salt products. We have a potassium chloride added or other potassium additives, which for many people is fine, but if our kidneys aren't working as well, that could be a problem. So I like to, you know, start that conversation and provide some information about that.

[00:14:04] Dr. Melissa Prest: About those additives so people can kind of start getting used to them to look for them in their foods and start making other choices, but we're not really modifying high potassium foods, high phosphorus foods in the diet at that point. So we're still just kind of focusing on sodium and protein. And then when we kind of get towards dialysis, we might start seeing then these changes in our potassium levels, our levels for anemia, like hemoglobin, phosphorus, we might start seeing some changes.

[00:14:33] Dr. Melissa Prest: So typically the kidney doctor will likely add some medication to help manage those changes. Kind of what's going on with that. Our kidneys are involved in making red blood cells, so if they're not functioning as well, it's harder for the body to make these healthy red blood cells. So there's medication that can be added that someone can take to help with that.

[00:14:54] Dr. Melissa Prest: So I typically see that in people that are later stage four into stage five, not on dialysis. And then again, sometimes we'll see phosphorus creep up. So in addition to the foods. We might also start someone on a medication we call a phosphorus binder. And so that acts like a sponge or a magnet with the food as you eat it, to help keep that phosphorus level in goal.

[00:15:15] Dr. Melissa Prest: And so that's non dialysis. Once we get to dialysis, things change up a little bit, particularly with fluid. So we start really watching how much fluid someone's drinking. Because again, by the time you're on dialysis, you might not be producing any urine. And so then that's gonna just have some swelling and buildup of fluids in your body.

[00:15:34] Dr. Melissa Prest: We likely start seeing these changes in potassium and phosphorus. So have to make changes in the diet for that. And we, end up needing more protein than we did before dialysis because you lose a little bit of that with the treatment. So we want to focus on more protein for that. And often we'll do a kidney specific vitamin as well because we lose some nutrients in the dialysis treatment.

[00:15:56] Dr. Melissa Prest: And then the very last thing would be transplant. And you know, that's always kind of like our first line of treatment, if that would be great, if everyone just can get a transplant and not end up on dialysis. But once someone goes through the transplant process and their post transplant, usually the diet's just a regular diet.

[00:16:12] Dr. Melissa Prest: There really aren't any modifications unless there needs to be something, if there's high blood sugar or something else that's going on. I know that was a lot. Yeah, I know. That was quite in depth. And one thing that really resonates strongly is like, there's a lot within kidney disease, like, based on the stage.

[00:16:28] Shireen: You have different considerations or those considerations evolve drastically as it progresses, you know, what are which takes me to my next question, which is, you know, as you start looking at that, are there any dietary restrictions that need to be kept in mind for patients with CKD? And, uh, How does one sort of help navigate that?

[00:16:48] Dr. Melissa Prest: So specifically when it comes to foods, what are the types of foods that are, I know it's a broad question and even as I'm asking it, I understand that it changes depending on the stage, but if you have to provide, especially to our listeners who either are caregivers for someone who has CKD, have CKD themselves, perhaps in the earlier side.

[00:17:05] Dr. Melissa Prest: What are the types of things they should? So I generally just encourage people to make sure they're choosing foods that are kind of as close to the farm as possible. So limiting foods that are ultra processed and mainly because they're usually high in salt and a lot of times they're going to have these added phosphorus additives, potassium additives in there.

[00:17:27] Dr. Melissa Prest: So really trying to modify your diet to be more kind of. Whole foods, more fresh foods, whether that's like a fresh fruit or vegetable or something that's frozen or, you know, even like a low sodium canned food, something like that. So trying to have it as close to like the farm as possible, the minimally processed, is kind of the one thing just to focus on in general.

[00:17:47] Dr. Melissa Prest: So I guess in terms of like limiting, it's kind of limiting more of these ultra processed foods. And that goes for like your protein options. So if you're doing something like Chicken, right? So you want to do maybe like a chicken breast thigh that's fresh and not necessarily like a chicken nugget or a chicken patty.

[00:18:05] Dr. Melissa Prest: So you really want to be mindful of that. And it goes the same for even our kind of like processed plant foods when we think of like a veggie burger or a veggie chicken nugget, something like that. Oftentimes they can be really high in salt. So you got to kind of compare the labels of the foods. So I always kind of start from that processing piece and think about your beverages.

[00:18:27] Dr. Melissa Prest: So trying to do more of like water or tea or even just some coffee and limiting things like sodas, right? You have added sugars in there, in things like colas, fruit punches, there's often a lot of added phosphorus in those. So a lot of times we're Patients are recommended to have clear sodas or even things in a glass bottle.

[00:18:49] Dr. Melissa Prest: So like a iced tea in a glass bottle versus a can. There's less phosphorus in the glass bottle ones. They can heat treat it when you can't do that in a can. So beverages would be the second thing I would say to kind of take a look at and make some changes with that. And then again, it just depends on your labs.

[00:19:06] Dr. Melissa Prest: So there's definitely like kidney. org has a list of foods that would be high or low in potassium or high or low in phosphorus. But I would say really focus on the additives in the foods before restricting like fresh fruits and vegetables. We're not as like a country and as a whole, whether there's kidney disease or not, even meeting kind of our basic minimum for fruits and vegetables.

[00:19:31] Dr. Melissa Prest: So likely that's not what's causing, you know, changes in like, say your potassium level. So let's make sure you're eating our fruits and vegetables, but let's look at the really ultra processed foods. So that might be the biggest change for people with kidney disease is kind of less reliance on these convenience processed foods and really kind of looking at more whole food sources.

[00:19:50] Shireen: I know we're coming up at time here, Dr Prest. I quickly want to sneak in this question, which is to say, how does as we're talking about the different types of foods, how does proper nutrition contribute to slowing that progression of kidney disease? Could you share perhaps some success stories? Yeah.

[00:20:09] Dr. Melissa Prest: I mean, I've definitely have had patients. I've had one patient who was very, like I said, very dedicated to being on a plant based diet. And he went from a stage three to basically a stage one or two with his kidney numbers. And again, he was cooking things from home. He was exercising. He was really limiting salt.

[00:20:29] Dr. Melissa Prest: He was just doing herb seasonings. There is actually a shot. That has kidney disease and does a lot with the kidney community. And he as well had just made some really big kind of diet changes. More plant foods really is kind of the common theme here. Some more fruits and vegetables and plant proteins and very low salt and kind of changed how he was cooking.

[00:20:49] Dr. Melissa Prest: And he also basically. Went down to like stage one, no blood pressure medications, lost weight. So had done really well with that. I had someone else who stage three, I think she went to stage two, not necessarily plant proteins, but just improved her diet, made those changes with protein and sodium and just kind of more balanced on that plate.

[00:21:10] Dr. Melissa Prest: And she also had some success. And then I had an older gentleman. Who was in Alaska and really liked his game meats and his desserts and so forth. But his wife was his caregiver and was really pretty diligent about things that she was doing and cooking for him. And we had a lot of different conversations on, you know, which type of meat, how much to have, maybe let's mix in some veggie dishes in there.

[00:21:33] Dr. Melissa Prest: And he also had some improvements from stage. Four or five to like stage three. So, you know, really kind of having a healthier plate in general, and that's going to always include more fruits and vegetables on the plate and just really kind of, you know, working with a dietitian, you know, as able definitely has some benefits, but even if you don't have access to a dietitian, just trying to find ways to get more fruits and vegetables on the plate, less processed foods might be the easiest.

[00:22:01] Dr. Melissa Prest: Kind of place to start. I absolutely love the message there and as plant based and I think the default answer is if you can get 

[00:22:08] Dr. Melissa Prest: as close as possible to plant based you'll do your health a favor. And it's I think also very promising to hear that a lot within our nutrition which is within our control, can impact our health, right?

[00:22:20] Shireen:: So CKD being a great example of that and seeing to what you're saying with folks being able to, you know, go or stage or two back there. Thank you so much for your time here, Dr. Prest. I would like for our listeners to hear from you about how they can just connect with you and learn more about your work after this episode.

[00:22:37] Dr. Melissa Prest: Sure. So I am on Instagram and Facebook, but you can also just go to my website, which is knsdietitians. com. That would be the easiest way. You can email me there and connect with me. Lovely. And to all of our listeners, thank you so much for tuning in to another episode of the of the Yumlish podcast. You know, it is that time to head over to our social media and answer this quick question based on the episode.

[00:23:02] Shireen: And when you learn today, what are the types of things that you will do to take care of your kidney health? So head over to our social media at Yumlish on Facebook, as well as on Instagram. And again, find this podcast post and answer below to tell us, how would you take care of your kidney based on what you learned here today on the podcast?

[00:23:21] Shireen: We will continue the conversation there with that. Dr. Prest. Thank you so much again. Thank you. Thank you for listening to the Yumlish podcast. Make sure to follow us on social media at Yumlish underscore on Instagram and Twitter and at Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspective.

[00:23:47] Shireent: You can also visit our website. site, yumlish. com for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you liked this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time.

[00:24:08] Shireen: Remember, your health always comes first. Stay well.

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