Managing Key Nutrients in Patients With Renal Disease
In this podcast episode, Lisa Jones, MA, RDN, LDN, FAND, interviews Kimberly Snodgrass, RDN, LD, FAND, a renal care coordinator at Fresenius Medical Care, on how dietitians can help patients with renal patients manage minerals—such as potassium—in the their diet, how certain minerals affect renal patients, and what strategies can be implemented by dietitians to help manage key nutrients in the person's diet. This episode is part one of a four-part series.
Listen to part two of this four-part series here.
Listen to part three of this four-part series here.
Listen to part four of this four-part series here.
TRANSCRIPTION:
Moderator: Hello and welcome to Nutrition411: The Podcast, a special podcast series led by registered dietitian and nutritionist Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.
Lisa Jones, MA, RDN, LDN, FAND: Hello and welcome to Nutrition411, the podcast where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's podcast is part of a series of short episodes on renal nutrition realities featuring a Q and A with Kimberly Snodgrass. But first, hi Kim. How are you doing today?
Kimberly Snodgrass, RDN, LD, FAND: I'm doing wonderful. How about yourself?
Lisa Jones: I am good. I'm so happy to have you with me today. But before we jump into the fun questions, I want to share your bio with our audience. So Kimberly Snodgrass is a renal care coordinator at Fresenius Medical Care. She is the vice president of the Graduate Students of Color at the University of Michigan, a student mentor in the University of Michigan's Mentor Collective program and a member of the Advisory Board for the Ursuline College Nutrition and Dietetics program. Snodgrass has held many leadership roles in the nutrition and dietetics profession and has won numerous awards, including the 2021 Francis G. Ballentine Memorial Scholarship from the Academy Foundation. Congratulations Kim.
Kimberly Snodgrass: Thank you so much.
Lisa Jones: <laugh> and Snodgrass is a graduate of Marygrove College and is pursuing a master's degree in public health at the University of Michigan. So Michigan is where you call home? I'm assuming.
Kimberly Snodgrass: That is correct. Yeah, Michigan is where I call home.
Lisa Jones: Beautiful state. All right. Well again, thank you for being here and first we're going to be talking about, in this particular segment we're going to be talking about the basics of renal nutrition, understanding kidney health and diet. And so my first question for you, Kim, is how do you, does sodium, potassium and phosphorus specifically impact kidney health? And more specifically, what strategies can you share with us that dietitians can use to manage these minerals in renal patients? Because it's a lot to manage. I hear.
Kimberly Snodgrass: It definitely is. Well, just to give a little bit of background, I've worked in the realm of renal nutrition for about 15, 16 years. And as you said, managing sodium, potassium and phosphorus is pretty hard when dealing with the patients. So with the sodium, you have to work with patients on making sure that they eat a low sodium diet. So we have to teach them how to read labels. So definitely we want to stay with lower sodium food. So anything that's over 201 milligrams per serving is considered a high sodium food. So we try to limit them with their sodium. The reason we want to do that is we don't want them coming in with fluid overload, which can cause swelling in their feet, their ankles and their face, which is not good. It can cause discomfort. While they're on a dialysis machine like cramping or headaches or abdominal bloating, it can cause them to have high blood pressure due to those excessive fluids and shortness of breath.
So too much sodium is really bad for renal patients. So we do try to stress a low sodium diet. We want them to see them, their food with herbs and spices. To me, herbs and spices make your food taste just as good as salt, if not better. I like oregano, I like garlic powder, onion powder, anything of that nature. I like things a little bit more hotter, so I like a little bit of crushed red pepper flakes. So anything that they can use to replace sodium in their diet, that's what we try to get them to. And typically if we can show them how to make things taste good, they'll follow the regimen. So that's one thing we work on with the sodium. And then in terms of the potassium, that's really a hard issue for us to control too because too much potassium is not a good thing for a dialysis patient.
And when we look at their labs, if the potassium gets too high in their blood, it can affect their heart and we don't want that. And so we try to caution the patients to follow a low potassium diet. Some of the foods that are high in potassium are like potatoes or beans, things that people typically eat. So with those foods, we tell them to soak those foods and then to pour that water off and cook them in fresh water. So that process is called leaching. It takes out some of the potassium, not all, but some. So it's not like they can go to a restaurant and request French fries because most likely they're not soaking those potatoes to make those French fries. But if you want potatoes, you have to soak those potatoes yourself. So you can do a boiled potato, a mashed potato or fry those yourself.
But I don't try to promote frying foods. But everything in moderation. Potassium is important to control. And then for phosphorus, that's always one of the biggest challenges for us because if the phosphorus is in control, it will affect your bones. And so people who have higher phosphorus are weakening their bones. So if they fall, they're more susceptible to breaking something. So some of the high phosphorus foods we try to have them avoid are cheese, chocolate, too much dairy, colas. And so what we try to do is to say, you know, instead of having, you know, like a cola have like a lighter color beverage, like a Sprite or a Seven Up or something like that. And so, and with the dairy products, they're only to receive four ounces of dairy. So I always tell patients to make a choice.
If you're going to your grandkids birthday party later on in the evening, that means you can't have milk and cereal, you'll probably have a scoop of ice cream. So you have to make a choice because four ounces of dairy is not a whole lot. And I feel like dietitians can make a really big impact by spending that quality time with their patients. We get a lot more time with our patients usually than doctors do, just because we're assigned a certain caseload and the doctors see all the patients. We have a certain caseload that we tend to. So sitting down, really going through the diet with the patients, sometimes the family, it really helps a lot.
Lisa Jones: Yeah, that's a lot. It's a lot to management I'm sure. Like it's overwhelming, especially if you have not only being, I guess there's two sides of it. Having new dietitians that like you've been doing it for, you have a lot of experience in it, but like a dietitian that's fresh into like say a dialysis unit, they start working and then you have the patients that are new. That must be kind of a, it's a lot. Sounds like it's a lot to manage because you have to keep every, a lot of things in mind. It's not just one thing, like if it's kind of like diabetes, you're watching out for their blood sugars amongst other things. But with this, it's more compounded if you will.
Kimberly Snodgrass: So definitely is. And I'm glad you spoke to that because we have to manage so many things and we all know that people are on dialysis for two main reasons: Uncontrolled diabetes or uncontrolled hypertension. So not just managing their phosphorus, their potassium and their salt, but we're also looking at their blood sugars and their blood pressure. So being a renal dietitian is really a specialization. It takes a lot of training and so the academy does a really good job at making sure we're ready and prepared for this profession.
Lisa Jones: I'm glad that you mentioned that. So any other suggestions for, say there's somebody that's not quite in renal right now, maybe they're in another area and they want to transition. Any recommendations that you would give to somebody that wants to come over and say, Hey, this sounds good. I want to try like, I want to be challenged. because obviously what you do is challenging and I want to come over there. Like what would you suggest for new dietitians who want to come over to your area?
Kimberly Snodgrass: So for new dietitians, I always say it's nice to have a mentor. It's nice to have somebody that can kind of take you under their wings and kind of guide you. And then the academy also has a lot of materials that people can read to become more familiar with the kidney diet. They have coursework or certificates that you can work on. They even have a specialization in renal that you can sit for that exam. And so they tell you which materials that you can study to become more knowledgeable about kidney disease and nutrition. I would say take any things that the, um, academy offers as coursework and then just have somebody that can mentor you, somebody that may already work in dialysis or the renal realm, reach out to them and say, "Hey, you know, this is something that I'm interested in." Or you can join the renal dietetic practice group, which I'm a part of. And someone in that group can mentor you if you're really interested in working in dialysis. So there's pretty much a lot of avenues that you can take if that's something that you're interested in.
Lisa Jones: Yes, thank you for sharing that. And the renal group sounds like a really great place because that's, you can most likely get a mentor there. They probably have programs like that and then they can help you kind of in your transition and then the process of learning. because it just sounds overwhelming at the beginning, right?
Kimberly Snodgrass: It is, it's a lot. It's really a lot to know. And actually I have a meeting with a group today. We're actually working on some renal-related material for different populations. So say for instance the Latino population or the Black population, we don't all eat the same way. And so we want to tailor that diet information to fit different populations because it's not a one size fits all diet. So we're actually working on some educational materials that we can put out there. It really is a good group if you want to learn more about renal disease and nutrition.
Lisa Jones: Yeah, that sounds fantastic, Kim, because I remember like back in the day I did work in dialysis and it was like, there wasn't anything like that and there that was something that was a need. So I'm glad that you're addressing that and filling that gap. Well done.
Kimberly Snodgrass: Definitely. Yeah. Awesome.
Lisa Jones: And then the other thing I wanted to ask you about is, so now that you have these patients, you're balancing all these key nutrients, how would you say, how can the dietitians, how can they help patients with the key nutrients in their diets? Like what's like three biggest takeaways that you can think of that we can, that dietitians can help?
Kimberly Snodgrass: So one way is just to be making sure that you're sensitive to the patient's needs because when people first start dialysis, it's a really hard transition. You're coming three times a week. Um, some people who are working have to stop working. Some people are scared of needles, some people are scared you're taking all their pleasurable foods away. So just being tentative to the patient's needs and taking baby steps and remembering that this is a big transitional change for them it's something I think that the dietitian has to keep in mind because if you're going to see them, the social worker, the doctor, the nurse, the patient can become overwhelmed. Anyone could. So I try to look at it as, you know, I know I have to see them within a certain timeframe, but I want to catch them at just the right moment.
So they're receptive to learning and I try to break my diet education off into small chunks so that I feel like they retain it better. If I tell them 20 things. I don't really think they're going to remember all that at one time. And of course they always get a diet book, but I like to take baby steps. I think that's one of the biggest things that you can do in educating a new renal patient. Also, explaining to them the importance of the lab. So I just don't go to a patient and say, "Oh, your potassium is high." Well, they need to know what that means. What range? So different companies use different ranges. When you look at the potassium, typically is usually the three to five of the 3.5 to 5.5 when you're looking at the potassium, the goal range for a dialysis patient.
But we like to tell them, you know, there's a couple ways that we can try to get your potassium to stay within range. One is coming into your dialysis treatment, not cutting it short or don't come in late. You need to stay your duration, whether that's three hours, three and a half, or whatever your doctor prescribes. Um, you definitely want to control the potassium in your diet. So you know, that means you may not be able to have that slice of pizza because it has that red sauce in it, so we may have to have a different fun food option for you. We try to educate them on a diet and then the importance of why we want to keep it in control because if your potassium gets too high, it can severely affect your heart. And so we don't want to play with your heart. So just showing them the importance of why they're there, why that lab is important, why the dietitian is there every month to go over it to make it understandable to them. I think that's an important way. And I don't really have a third thing to add to that, but those are my big two, if you will.
Lisa Jones: Yeah, well there was kind of a third thing and it was great information there, so thank you. Yeah, there's a, there's a lot to unpack there. And the other thing I was thinking too, when you were talking, and I remember, I'm going to date myself, but, and things have changed. I know a lot since, you know, over a decade ago by now, but I remember some of the challenges and we're going to talk about challenges in a future segment, but I want to touch on, you were talking about handing out labs and reviewing the labs when you give their labs, like how do you like the people that are sleeping? There would always be like a couple patients at every single time, monthly labs and I'd have to be persistent and just keep going back and trying to catch them when they were awake, even though it was sometimes difficult. So I'm sure you experienced that as what I'm trying to, to make sure that they're...
Kimberly Snodgrass: Yeah, and you know what I do, if they're sleeping during the treatment and I see that they historically sleep during the treatment, I like to catch them right when they get on the machine before they fall asleep. And so, "Oh, you just got on the machine, this is the perfect time to talk to you before you take your nap." And that usually works. So yeah.
Lisa Jones: Yeah.
Kimberly Snodgrass: Always a workaround.
Lisa Jones: And are they, what is the status now with the eating? I remember the one guy brought, this was back in the day, brought like a whole bucket of chicken and he would eat it during. Are they off food now? Are they, what is the policy for food now?
Kimberly Snodgrass: We do not recommend eating food on the dialysis machine. And I'm with you. I had a patient sneak in food and was eating it and I, everyone said, "oh, what's that smells so good in here." And I found it and I'm like, oh no, we can't do that. It is too risky. I mean it can cause drops in the blood pressure, you know, just too many different things. We had to put out a memo for it. But yeah, no eating on the machine.
Lisa Jones: All right. So it's still okay. I figured it was probably, yeah.
Kimberly Snodgrass: Still stands.
Lisa Jones: Yeah. Well, thank you so much. This episode, the basis of renal nutrition. Thanks for being on today.
Kimberly Snodgrass: You're most welcome. It was a pleasure being with you.
Moderator: For more nutrition content, visit consultant360.com