[00:00:00] Shireen: Renal dietitian Areli Gutierrez will discuss improving cultural competency in healthcare and how one can manage and maintain renal wellness through daily nutrition. This episode is for you whether you are someone managing chronic kidney disease or end stage renal disease for yourself or a loved one.

[00:00:22] Stay tuned.

[00:00:28] Areli Gutierrez is a bilingual registered dietitian who currently works as a kidney dietitian. And is passionate about making nutrition culturally inclusive for her patients. On her podcast, Food Culture Curious, she invites diverse healthcare professionals to discuss culturally inclusive nutrition and renal wellness.

[00:00:51] Welcome, Areli. 

[00:00:53] Areli Gutierrez: Thank you so much for having me.

[00:00:55] Shireen: Such a pleasure having you on. It's very rare that I get to do a podcast episode with someone else who has a podcast as well. So I'm glad to have you on. You're also a dietitian, which is where I actually want to get started is really understanding what sparked your interest in this area of nutrition and renal nutrition and, um, specifically around kidney care.

[00:01:16] What was that journey like and why this?

[00:01:19] Areli Gutierrez: It was a pretty long and, um, not a straight path because, uh, when I was in college, I was actually an English major. I was doing something completely unrelated, but I always had a, an interest in chemistry. So I was still taking, you know, my, my science electives. And at the time I had gained that, you know, freshman 15.

[00:01:43] So I started learning about nutrition for myself. And in learning about nutrition, I. Realized how much I liked it and how drawn I was to the chemistry aspects and the biology aspects of it So I just completely switched My life's path and I changed to nutrition And at the time I didn't really even know what a dietitian did.

[00:02:05] I think at the time I thought oh, you know dietitians Help people lose weight and that's all that they do and I didn't know until I got into my 20s clinical classes, just how much they can help in every aspect of wellness and all the different types of ways that we can help. Um, so it was quite a journey and I'll make it really short.

[00:02:25] It was quite a journey to become a dietitian because I am first generation. I did not have any financial support from my family. So I had to work for a few years to save up, um, to be able to do both the masters and the internship. I'm super grateful to the VA that they have a stipend, which helped a lot.

[00:02:46] Um, but because of that, I, it took me maybe what, five years before I was able to become a dietitian. And my first job as a dietitian was working at a maximum security prison in North Carolina. So they have a. basically in the state prison where all the offenders come to us. And from there we see them like, um, anyone that needs to see them, right?

[00:03:13] Dietitians, doctors, nurse, everyone is there. For those offenders. And from there, because I had to see so many different types of, um, medical issues, I realized that I enjoyed kidney nutrition because that, yeah, that the state prison had its own dialysis center. So that's when I started seeing, um, labs, medications, and just realizing how intricate it was.

[00:03:39] And the, it was a special place. great balance between um, acuity. So it was challenging and interesting, but you also, you know, saw the patients pretty regularly enough to see changes over time. So it wasn't just like a one and done, like it's something that takes time. It's something that's a process. And I really liked that.

[00:04:00] So when I finally moved to Texas, which is where we're originally from, um, I started working for DaVita Kidney Care and I've, I've been there ever since. I really have enjoyed just learning more about the medical complexity and also being able to build that rapport with the patients and seeing those changes happen over time, being able to still use motivational interviewing and such.

[00:04:25] And um, Working in DaVita and dialysis, I realized that a lot of patients can sometimes fall through the cracks, especially my Hispanic patients, because the recommendations that were being given, especially four years back or so before they updated the guidelines, did not include our cultural foods. So, thankfully, guidelines have updated, and now it's just about informing the patients, informing the doctors and nurses, like, Hey, I know that it used to be, um, oh, you have to avoid all the high potassium foods, you have to avoid beans and nuts and seeds, but that's not what the research is showing anymore, and so let's move toward this more plant based diet in a culturally inclusive way.

[00:05:12] And that's, that's where I'm trying to learn and grow and continue to help my population.

[00:05:18] Shireen: I absolutely love that. I think, um, even as I, even as I'm hearing you speak about this, that, that culturally affirming piece that, you know, we're, we're cracking the nut on, right? Um, with the work that we're doing at Yumlish with, of course, the work that you were doing in renal care, at the end of the day, it's really about what I'm hearing you say.

[00:05:34] It's about really meeting that individual where they are, right? It's not about know this and know that. It's really about. These are the inclusive things you can do, and these are the types of things that you can do around it and still enjoy your cultural foods, right? Like that's the key takeaway at the end of the day.

[00:05:49] Um, I do want to tie, you know, something that you mentioned with renal nutrition. Uh, I do want to take a step back actually first before that. Can you help us understand why this piece of renal nutrition is really so starkly different from what we hear about sort of in general nutrition? Like what is, what makes renal nutrition so starkly different. Um, and what are the types of things to consider when it comes to renal nutrition?

[00:06:12] Areli Gutierrez: Yes, absolutely. So, uh, renal nutrition, depending on where you are in your journey of CKD, it is vastly different. Like there's so many factors that impact renal nutrition. So if a patient is CKD, they're not on dialysis yet, their recommendations are going to be very different from a patient that is on dialysis versus a patient who's on, um, like chemo dialysis versus peritoneal dialysis.

[00:06:42] Everything changes because depending where you are, you could need extra protein, or you could be cutting back on your protein. You could need extra potassium or be. On a potassium restriction. Got it. You mentioned CKD. I just want to, um, unlock that acronym, if you wouldn't mind telling us what that stands for.

[00:06:59] Yeah. Yeah, chronic kidney disease. So, um, if you have chronic kidney disease, but you're not on dialysis yet, usually you're trying to restrict your potassium, sorry, you're trying to restrict your protein so that you can maintain as much function as you can versus once you're on dialysis, there's a lot of Protein wasting that happens in the dialysis process, so you'll have extra protein and that's just one example But there's a lot of labs that we look at specifically in dialysis.

[00:07:31] We look at potassium. We look at phosphorus calcium protein How much weight they gain because of the fluids how much weight they gain in between treatments? So it's just it's very particular to how the patient specific labs are doing 

[00:07:49] Shireen: That's incredibly helpful and I know we've, we've done a previous episode around this too and it's, and it comes down to those three P's, right?

[00:07:55] The potassium, the protein, and then the phosphorus. Is that correct?

[00:07:59] Areli Gutierrez: Mm hmm. Very important. Yes.

[00:08:02] Shireen: You know, as a renal dietitian, tell us more about the types of things that you're involved in on a day to day basis. You, you know, you mentioned your work that you are doing currently, the work that you've, uh, very interesting work that you've also done with the state prison there.

[00:08:16] How do you tailor your approach to meet specific needs of the patient, uh, with, uh, kidney issues or kidney challenges? 

[00:08:25] Areli Gutierrez: Yes, like I mentioned, it just, it really does depend on where their labs are at at the moment. So usually in dialysis, everything is very cyclical. Every month we draw the patient's labs, we review them, we discuss with the patient where they're at and what changes they need to make to reach their health goals.

[00:08:46] Um, we meet with their doctor once a month and discuss if there's any changes in medications that we need to be making for the patients. So it just depends on where they're Is this patient having issues with their potassium? We're going to address that. Are they having issues with their phosphorus? Um, have they started losing weight?

[00:09:04] Do we need to assess for malnutrition? Are they trying to lose weight because they're trying to get on the transplant list? It just depends what their specific goals are that we address that issue.

[00:09:19] Shireen: That's helpful. Uh, you know, we mentioned a little bit ago that you have your own podcast, which is exciting. Uh, it's called Food Culture Curious. We'll, by the way, link that up in the bottom of this, uh, this episode, the show notes itself. Um, but within your podcast, you discuss various aspects of food culture, uh, with other healthcare professionals as well.

[00:09:40] What inspired you one to start this podcast, which is always exciting to hear what that, what that journey looks like. And then what are some of the most. So what are some surprising enlightening things that you've learned about over, you know, over time of doing, doing your podcast itself, uh, that you find that may be helpful to our listeners here today, learning about renal nutrition.

[00:10:00] Areli Gutierrez: Absolutely. Um, one specific moment that I remember, I was in one of my plan of care meetings with one of the nephrologists and we had a patient who had a high potassium. And my nephrologist looked over at me and he said, Okay, well, this patient is from Bangladesh. Like, what do they eat over there? Like, how can we help him get his potassium down?

[00:10:23] And I remember my response being, I'm not sure. I'm not sure what they eat in Bangladesh. Like, I'm going to have to look into that to be able to, to help him, um, to help him better. And just That just got me thinking into, okay, we really need to dig into the patient's culture when we're, um, cause usually there's, you know, the lists that we're using or we're using at the time, um, as far as the low, medium, high potassium foods.

[00:10:50] But if those aren't the foods that they're eating, um, then that's not going to be very helpful for them. So really learning about the patient's culture is important. I started talking to other kidney dietitians of different backgrounds and asking them Hey, so if I have a patient who's Vietnamese like what recommendations would you make like if I'm talking to a Vietnamese

[00:11:11] dietician, what recommendations would you make? What are some things that I need to take into consideration with their, um, with their seasonings, with their holidays? Like what are some things I should know? And just having those questions, I felt if other people heard this, that would be really helpful for them too, especially other healthcare providers.

[00:11:31] So I just, I started my first few episodes just with my friends. And then from there, starting inviting other people. And every time I learn. More and more and more and it just really opens my eyes to different things because We don't know what we don't know, right? So if i'd never thought of it that way never considered that aspect I would have never known so the more I learned the more i'm like wow, this is like A lot that I need to learn and that I want to share.

[00:12:01] So I really really enjoyed doing it. Um, And I like going beyond just talking about specifically, you know You What we eat, but other factors that we need to know that impact a patient's nutrition care. So I always ask about barriers. What are some barriers that your population faces in nutrition care? Um, what are some stigmas?

[00:12:24] What are some cultural health beliefs? What are like the social determinants of health that affect your population, because all of that has to be considered when we're making nutrition recommendations. So digging into that with these, um, dieticians and healthcare providers and healthcare professionals has been really eyeopening.

[00:12:46] Shireen: Wanted to dive into, uh, with something that you mentioned. There's just, you know, sort of going through the experience, learning from others around you. And I think that's the, that's sort of the theme here, right? When you learn from others around you. You don't know what you don't know, unless you know it, you don't know it, right?

[00:13:02] Um, but when you're looking at that and sort of looking at when it comes to renal nutrition, specifically, a little bit ago, you also mentioned about like plant based diet. What are the types of things that a person who's listening to this episode here today, be it someone who's, you know, CKD stage, perhaps further along in ESRD, what are the types of things that they should keep in mind as their health is probably progressing toward ESRD or they just, you know, want to try to maintain at a certain level?

[00:13:31] What are the types of considerations they should have for themselves or again for a caregiver too?

[00:13:37] Areli Gutierrez: Absolutely. So if you're earlier on in your chronic kidney disease journey, a big recommendation is to try to do as much plant based as you can. This is something if you want to aggressively approach That that's actually fine because the sooner you switch over to plant based, the more you're going to be able to slow this progression of kidney disease.

[00:14:05] Um, but if you want to do it one meal at a time, that's okay too. You know, everything is going to be beneficial. Um, so usually a lot of dieticians are working with CKD patients on addressing their blood pressure again, to slow down that progression of kidney disease. Um, so. Thinking about lower sodium options and then thinking about more plant based because animal protein puts a lot of stress on the kidneys.

[00:14:32] And even for patients that are on dialysis, they can still benefit a lot from plant based because usually when you're eating phosphorus, eating potassium, if it's coming from a plant, you're only absorbing 50 percent of that phosphorus or potassium or less versus if it's coming from animal based, Then you're absorbing 60, around 60%, maybe a little bit more.

[00:14:55] And then if it's coming from processed foods, deli meats, pre packaged items, you absorb about 90 to a hundred percent of that phosphorus and that potassium, because it's usually coming from potassium additives, which is what food companies use to keep food fresh and many other things. Um, so the most general advice I would say, um, if you're struggling with high phosphorus, high potassium is actually to include more plants.

[00:15:24] Shireen: Can you walk us through on a plant based diet, what are the types of things to consider, the types of foods to consider? 

[00:15:30] Areli Gutierrez: Yeah, so fruits, vegetables, and then plant based sources of protein would be like beans, nuts, seeds, tofu, depending what your culture is. You're going to, um, be more amenable to one over the other.

[00:15:46] I was actually just talking with a, um, a dietician from Taiwan, who was also a kidney dietician. And we were comparing notes and we were talking about how for my Hispanic population, when I talk about using beans as a plant based source, they're all for it because we're familiar with it. Versus if I say, have you tried something different like tofu?

[00:16:07] Then they're like, Oh, I don't know if that's for me. I'm not that adventurous. And for her culture, they don't use beans in savory dishes. They use beans in desserts. So for her talking about using beans in a plant based diet, they hesitate a little bit more to use it in savory dishes because they usually just use it in desserts.

[00:16:29] So 

[00:16:31] Shireen: Look at that. How, how interesting is that? Just learning like how the same food is used so differently. you know, in another culture. And so when, as a dietitian, I would imagine that translates into like when you're providing those types of recommendations to be very mindful as to how can you incorporate, for instance, protein, but incorporated not so much on the savory side, but perhaps on the, on the sweet side.

[00:16:52] That's so interesting. Um, you know, as you're, as you're sort of even talking right now, you know, we're thinking about Um, certain dietary changes or modifications that one needs to make, um, often to maintain a certain healthy lifestyle, right? Uh, when it comes to kidney function specifically, and you know, you said, uh, the sooner perhaps when someone is diagnosed with something like CKD, the sooner they're able to sort of transition into the plant based, the better.

[00:17:20] Um, some of that comes from, you know, what you mentioned in sort of even absorbing those nutrients from, let's say, fresh foods versus processed foods. Um, what are some other key considerations that one should have when it comes to kidney disease? Um, especially now I want to switch the. the conversation for caregivers.

[00:17:39] What are the type of things that caregivers should keep in mind as they are someone who make the food decisions in the household, um, make the cooking decisions in the household as well? What are the types of things they should consider when it comes to kidney disease for a loved one?

[00:17:54] Areli Gutierrez: Absolutely. Um, like I mentioned, if it's still CKD, then the biggest thing other than, you know, of course going plant based is To make sure we know how to read our nutrition labels so that we can gear more towards the lower sodium options to help with the blood pressure one and two, if the patient has diabetes to make sure that we're trying to manage those blood sugars because that's another major reason that our patients progress in their kidney disease and ultimately end up on dialysis.

[00:18:24] So addressing the blood pressure, addressing those blood sugars, very important. And even when they're already on dialysis. It's still very important to address those blood sugars because having high blood sugars actually leads to high potassium. Even more possibly, this is what new research is coming out, um, possibly even more than dietary potassium.

[00:18:44] So it affects your labs. It's very important when you're making those decisions, know how to read a nutrition label, know that we're supposed to look at the portion size and everything that's in that label. is according to the portion, knowing how to find those phosphorus and potassium additives underneath and the ingredients.

[00:19:02] Um, all of that's going to be really important for, for picking which, which foods to buy.

[00:19:09] Shireen: Could you talk about some common misconceptions that exist today or that people might have about a diet and kidney health? 

[00:19:18] Areli Gutierrez: Yes. The biggest one, I think my biggest pet peeve is, um, that we need to cut out beans, nuts, seeds. Tomatoes, mangoes, avocados, all, there's an entire list, right? Where patients tell me like, no, no, no, I can't have, I can't have potatoes, I can't have this, I can't have that.

[00:19:39] And what I try to remind them and remind, cause I've heard healthcare providers. I've heard nurses, I've heard even recently saying, you have high potassium, you can't be eating tomatoes, you can't be eating bananas, you can't be eating, I still hear it. So reminding them that it's not, the food doesn't suddenly become toxic because they have kidney disease.

[00:20:01] With the exception of star fruit, star fruit actually is toxic if you're on dialysis. But other than that, everything we need to consider the cooking method, right? If it's being cooked in water, that's going to leach out some of the potassium. Um, we need to consider the portion we need to consider. Are we compare, are we having tomato juice or are we having a slice of tomato?

[00:20:21] That's a very different concentration of potassium. So it's not that the food is off limits. It's let's talk to a dietician, see how we can incorporate it safely, right? That's if you have a high potassium, if you have a high phosphorus. If your labs are great, then you can keep going, and if there's an issue, like, we'll address it.

[00:20:43] So that's, that's my biggest misconception, is that a lot of kidney patients think that they're supposed to be avoiding surgery. These foods completely. 

[00:20:54] Shireen: And what I'm also hearing you say is that it's almost like data informed decision making, right? The more you learn about like where your labs are a certain point, the better you can work with a dietitian to then come up with a plan to adjust accordingly.

[00:21:05] And I find that the role of a dietician in, in, in overall in general health is just. It's incredibly important, but it seems like all the more important when it comes to renal health itself. Um, when we're talking about, uh, sort of our kidney health, uh, for ourselves, um, for someone who wants to start working with a dietitian, where do we begin without feeling completely overwhelmed?

[00:21:30] Areli Gutierrez: There are a few sources. Um, the national kidney foundation has a register where they keep track of a different dieticians, renal dieticians. Um, and then of course there's, you know, health profs are in the, um, I should be more familiar with the different databases. Um, but there are certain databases where you can check to see, you know, do they take your insurance or, um, are they cash pay?

[00:22:02] And then of course there's websites and Instagram where you can Google renal dietitian and you can find some there as well. You'll find me there as well. 

[00:22:12] Shireen: Great. Which actually takes me to my next question. We are unfortunately out of time on this episode. Um, Areli, tell us how we can even just continue the conversation with you.

[00:22:22] How do we connect with you on social media outside of that? And just continue to keep in touch with your work and your podcast. 

[00:22:29] Areli Gutierrez: Absolutely. So, uh, my kidney Instagram is. At Latina Kidney Dietician, that's also my website, ww dot latina kidney dietician.com. Um, I'm also on TikTok, same name. And then as you mentioned, my podcast is Food Culture Curious, which is on, uh, Spotify, apple and Amazon Podcast.

[00:22:51] Shireen: Lovely. Thank you so much, Areli we'll, we'll link up everything in the show notes, send folks over your way with that. Areli, it has been such an immense pleasure talking to you here today. I feel there's so much more, uh, within kidney health that we could certainly talk about. Perhaps we'll do a follow on episode sometime in the future, but thank you so much for joining us on the podcast today to our listeners who listened to another episode of the podcast here today.

[00:23:14] Thank you so much for joining us. We will continue the conversation on our social media, over to our social media. Find this podcast post to comment below to tell us what are some ways you can incorporate kidney friendly foods. Remember we talked about plant based foods into your diet. So what are some small steps you can take starting today to incorporate those foods into your diet?

[00:23:35] We'll continue the conversation at Yumlish on Instagram and on Facebook. Again, find this podcast post comment below to tell us again, what are some ways to incorporate kidney Kidney friendly or plant based foods into your diet. We will see you there. And with that, Areli, thank you so much again. 

[00:23:53] Areli Gutierrez: Thank you.

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