Exam Room Nutrition: Where Busy Clinicians Learn About Nutrition

32 | How to Read a Nutrition Facts Label - with a Focus on Kidney Health

January 23, 2024 Colleen Sloan, PA-C, RDN Episode 30
Exam Room Nutrition: Where Busy Clinicians Learn About Nutrition
32 | How to Read a Nutrition Facts Label - with a Focus on Kidney Health
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Have you ever stared blankly at a nutrition facts label wondering what it all means? Or maybe your patient has asked you what they should look for on a food label? The nutrition facts label is an extremely useful tool for clinicians to use to educate their patients on making the best food choices. It is especially useful for patients following a therapeutic diet. Emily Campbell joins me today to unpack all the information that can be found on a nutrition facts label, in the context of kidney health.  Emily is a Registered Dietitian and Certified Diabetes Educator specializing in renal nutrition.  Emily dispels common myths about kidney-friendly diets and highlights the importance of personalized care.  The discussion emphasizes a food-first approach, allowing patients to enjoy a variety of foods while preserving kidney function.  You'll walk away today knowing exactly what's on a food label and how to explain it to your patients, whether you're counting calories, protein or sodium!

Main Discussion Points:

  • Interpreting nutrition labels for kidney health
  • Inclusion of plant-based proteins in renal diets
  • Understanding sodium, potassium, and phosphorus levels
  • Personalized care and goal-setting for kidney patients
  • The importance of a food-first approach in preserving kidney function

Connect with Emily:
Instagram | @kidneynutrition
Cookbook | https://kidneynutrition.ca/

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Disclaimer: This podcast is a collection of ideas, strategies, and opinions of the author(s). Its goal is to provide useful information on each of the topics shared within. It is not intended to provide medical, health, or professional consultation or to diagnosis-specific weight or feeding challenges. The author(s) advises the reader to always consult with appropriate health, medical, and professional consultants for support for individual children and family situations. The author(s) do not take responsibility for the personal or other risks, loss, or liability incurred as a direct or indirect consequence of the application or use of information provided. All opinions stated in this podcast are my own and do not reflect the opinions of my employer.

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Speaker 1:

How much do you know about the nutrition facts label? Do you know what nutrients are labeled and which ones aren't? Okay, pop quiz Is cholesterol listed? Is fiber? Is sodium on there? What about vitamin D? How about phosphorus? Would you be able to explain to your patient what a percent daily value is Okay? Did I get you thinking?

Speaker 1:

The nutrition facts label is an incredibly useful tool to make informed choices about the foods we eat, whether we're watching our calories, trying to minimize sodium or increase our protein intake, and this can be an extremely useful teaching tool for patients who follow a specific therapeutic diet as part of their treatment plan. But do you know how to explain reading a food label to your patients? I'm Colleen Sloan, a pediatric PA and registered dietitian, and this is the Exam Room Nutrition Podcast where, each week, I'm giving you the nutrition education you never got in school to help you become a more confident, compassionate clinician. So, seriously, when was the last time you looked at the nutrition facts label? Maybe you glance at total calories or grams of protein, but for patients who follow a therapeutic diet, the nutrition facts label becomes a goldmine of information. Today, you'll learn how to read a nutrition facts label in the context of individuals following a kidney-friendly diet.

Speaker 1:

Now, before you switch to another podcast because you're thinking, colleen, I don't work with kidney patients I promise this episode has something for you. We're not only sharing some surprising updates about a kidney-friendly diet, but you'll also learn exactly what's on a food label and how to clearly explain it to a patient, whether they follow a renal diet or not. So get comfy and join me in welcoming my guest, emily Campbell. Emily is a registered dietitian and certified diabetes educator, with a Master's of Science in Food and Nutrition. Over the years, she has experience working with individuals with a variety of kidney conditions to help them improve their eating and preserve their kidney function. She has been practicing as a renal dietitian for seven years and is also a two-time cookbook author, which I will link to in the show notes below. You can follow her on Instagram at kidneynutrition Emily. I cannot wait for this discussion. Thank you so much for your time and welcome to the show. Thanks so much for having me Colleen.

Speaker 1:

I love remembering into topics that kind of make people squirm a little bit, and the kidney is one of them, right, and you know most of us like run for the hills when you talk anything nephrology and kidney because it can be so complex and it is. It really is a complex organ with complex dietary needs. So I'm super excited for you to really just break it down for us so it can be a little easier and really dig into the nutrition facts label, because there's so much goodness that I think we can use to educate our patients that they can make more informed choices when they're choosing their foods.

Speaker 2:

But you're so correct on that the nutrition facts table. It really does give us a lot of great information and I know when I was first starting in dietetics, renal nutrition was one of the areas I was most terrified of, so I'm really excited to be able to share this information with other clinicians.

Speaker 1:

So before we really jump into the nuances of the nutrition facts labels, you can really educate us on its components. I want you to give us just kind of a basics of a kidney-friendly diet. Play the foundations for us. What are we talking about when we say renal diet or kidney-friendly diet? What does that mean?

Speaker 2:

Yeah, that diet has been changing so much in the past few years in a really good way. The old kidney-friendly diet we used to say is like white rice no flavor, no fun. And now we're really moving into a diet that is full of protein from plant-based sources, full of fiber, you know, looking at whole grains, you know flavoring foods with herbs and spices and really customizing it to our patients' blood work and also their stage of kidney disease.

Speaker 1:

I'm so happy to hear that because I really haven't had any kidney nutrition education, probably since college, when I was pursuing my nutrition degree, and it really was just so bland and so boring and, you're right, like white rice was, I feel, like all we ever recommended. So I'm so excited to hear that it's much more of a liberalized diet. So I hope the clinicians that are listening can hopefully update what you've maybe learned and what you're recommending to your patients. Are the main components still the same, though? Are we still watching for protein, phosphorus, sodium and potassium?

Speaker 2:

We are, but I think what we learned over the years is that the bioavailability of potassium and phosphorus is not as much as we used to think. So we've been able to incorporate a lot more of these plant-based proteins, nuts and seeds, whole grains back into our diets, but also educate patients on how to prepare foods to leach out potassium so that they can be included.

Speaker 1:

Awesome and I know for those who have to follow a renal diet this is great news. You know this is so liberating for them that they can enjoy foods again. But I'm curious, you know, with these foods, do the foods have to be bland? So how can we increase flavor and pleasure in some of these diets? Because really there are certain foods that they still need to limit and to restrict. So what are some strategies that we can encourage our patients to do to just increase their flavor and pleasure?

Speaker 2:

of foods For sure, and I think one of the strategies is educating patients that it's not a no-salt diet, it's a low-salt diet and current recommendations anywhere from 1500 to 2300 milligrams of sodium per day, depending on any other conditions and blood pressure amounts. And when we think about that, that might mean, you know, flavoring our foods with herbs and spices, so you know if you're using fresh herbs or dried herbs. Maybe you use things like vinegars, like red wine vinegar, apple cider vinegar. You use citrus like lemon or garlic, I mean leeks, those really aromatic vegetables to add a bit of flavor. But no, it definitely doesn't need to be a bland diet anymore and a lot of that education piece comes from teaching patients how to flavor their food but also how to read food labels to find foods that they can include in their diet.

Speaker 1:

Beautiful transition because let's get into it. You know, the topic today really is about that food label, so I'm super excited for you to just break it down for us. I'm going to give you the floor, but I'm hoping that you're going to be covering what is a serving. How do we look at those key components of what a renal diet should be looking at? Where do they find those things? On the food label. So, emily, teach us all about the nutrition food label.

Speaker 2:

Yeah, the nutrition facts table is such a great resource for us as clinicians and for patients, and it really tells us what is in these packaged foods. And when we start at the top of the nutrition facts table, there's always going to be a serving size. Now, I always like to remind patients that this is going to be, you know, more or less than what you're actually eating, so we always kind of need to reflect on what that amount is. And as things have been changing, you know we're actually getting more standardized serving sizes so you can compare brand to brand, crackers to crackers or cereal to cereal. And when we're thinking about you know serving size, this is not the recommended amount that they need to eat. So also something to always remind patients. I love the nutrition facts table because now, especially here in Canada, where I am, we now have potassium on the label. We were a little bit slow to the market with that, but this is a big win for our renal patients because if you're following a low potassium diet, to be able to look on the nutrition facts table and see how many milligrams and how much percentage of daily value is there can be really impactful for managing your health. So, of course, the percent daily value is based on dietary reference amounts and it will always be a percentage. When we think about things like sodium, you know, usually foods that are about 200 milligrams or even 10% or less are a really great target for those kidney patients. Similarly, from a potassium standpoint, if it has 200 milligrams or 5% or less, we would consider that a low product.

Speaker 2:

The one thing that's not always here in the nutrition facts table is phosphorus. It's not a mandatory labeling thing, so some will have it in the top, others. We need to look in the ingredient list and for our kidney patients it's that added phosphorus. So that's where that pH OS is going to be hidden in the ingredient list. So you know, for example, you'll see the pH OS and that is that added phosphorus and we actually absorb 100% of that. So that is something we want to avoid when we have any kidney condition and it's often found in foods that we wouldn't expect. So, for example, cheerios Well, crapdyn are also having Coca Cola, some of those classic phosphorus things we think of. So the food label gives us a lot of information to see what foods we can include in our diet.

Speaker 1:

So so helpful. Let's take it way, way back to the basics with this food label. Packaged food only has this right, so we're not going to find it on fruits. We're not going to find it on vegetables. Correct, correct, yeah, okay. So how do we help our patients choose better fruits or vegetables? So are there any fruits or vegetables that they need to be avoiding?

Speaker 2:

considering potassium is kind of the big one, yeah so there's only one fruit that every single kidney patient needs to avoid and it is star fruit, and that's because it does release some neurotoxins in our body and when we have any kidney conditions we can't get rid of those.

Speaker 2:

The rest of them it's really just about portion size and frequency. So, goner the days, you know, when patients were on a low potassium diet and we told them they could never eat potatoes or banana or avocado or any of these really nutritious foods. Now we know that it's just portion size. So if you're following, you know a 2000 or even a 3000 milligram potassium restriction that we can still build our diet to include a variety of different foods. So, for example, you know one medium tomato that almost had 300 milligrams of potassium in it. But if we have a quarter of that tomato on our salad, you know that still fits in our potassium budget. So working with patients to understand what their blood work is and I think as dietitians we have that ability to really teach our patients how to interpret their blood work and how to utilize that for their benefit yeah, and I think that's super helpful, because it's not really a one size fits all right, like no tomatoes for everybody.

Speaker 1:

Well, if your potassium is fine, they might be able to enjoy more of the tomatoes than somebody else who maybe is having a higher potassium issue this month. So I think that is so important and I stress this in every episode how vital having a dietitian on your team is, especially for these therapeutic diets. So I love that you mentioned that, and dietitians are just so useful with looking at the specifics of the lab work and then matching that to portion sizes and appropriate foods that they can eat. All right, so we've talked to some produce. Now let's get back into the food label. What are some things that might be like red flags or things that if the clinician hears that the patient is eating a lot of that, we should probably provide a little bit of education. I'm thinking like packaged foods, like soups and pastas with sauce and that kind of stuff. So give us kind of some buzzwords that we should look out for or specific foods that they're finding and eating on the shelves that we might need to provide some more education for.

Speaker 2:

Yeah, one of the big things I would say is like condiments and flavor add-ins or broths right, these are often big sources of sodium. Our patients are eating soups. Can they look for the nutrient claim on the front of like low sodium or no added salt? Can we teach them to choose different brands of sauces that might have lower amounts of sodium in them? And, you know, even just within different types of salad dressing, there might be less sodium in one type than the other. I think the food skill aspect goes hand in hand with patients who may be using more of the packaged foods, which often are higher in sodium, and so teaching them easy swaps at the grocery store can be really helpful.

Speaker 1:

Yeah, and you know, packaged foods are easy, they're convenient and you know, at some point in some season we've all been guilty of having them and they're not all inappropriate then they're not all harmful. So would you recommend that clinicians tell all renal patients to be looking at a food label before they purchase that food or eat that food item.

Speaker 2:

Oh, definitely. I think it is a great tool in our toolbox to help us manage our health. We live in a world where packaged foods are going to come into our diet right, we can't be unrealistic with our patients. With that I mean from a time standpoint, from a constant food. So they are going to use these convenience foods, but we need to educate them how to appropriately do that and how to safely do that. And that's where the food label comes into play.

Speaker 1:

And, in your experience, how appropriate or accurate is the labeling on the front of the package or the marketing on the front of the package to the actual food label? Can we trust what's said on the front when it says, hey, low sodium. Should they just feel comfortable buying that, or should they do a little bit more digging?

Speaker 2:

So great question, colleen. So here in Canada those nutrient content claims they mean different things sometimes. So when it says sodium reduced, that's actually only a 25% reduction from the original product and if that original product was really high in sodium it's still going to be high in sodium. So teaching patients to look for things that say like no added salt or low in sodium, those thresholds are a little bit better.

Speaker 1:

Awesome. Yeah, so really flipping it over and looking at the milligrams on the back of that food label is super important, yeah. So we talked a little bit about potassium and what to look for. You talked to where to find phosphorus on the food label. Let's dig in a little bit into protein and you know, that is kind of clear on the food label. We all understand how many grams of protein a food item has, but give us some parameters for helping our patients know if this is a too high protein, too low protein. And how would they know that?

Speaker 2:

Yeah, I think educating our patients on their protein, what I like to call budget, I think teaching them to them in practical terms. So if you know, we have a bank account, we have a budget similar with our protein throughout the day and whenever we eat a food we kind of deduct from that protein total. So if we have 60 grams of protein per day and you know this bread has 10 grams per slice, you know it might not be a good product for us to choose if we're going to still have two other meals in the day. So using that protein amount and you know talking about it in whether a meal target and a snack target whatever the patients are kind of eating can really help them to read the food labels and find out if something is helpful for them.

Speaker 1:

Now how different would following and paying attention to the things on the food guide label be for someone who is, you know, chronic kidney disease prior to dialysis versus someone who is currently on dialysis? So how important is really following your, your bank account when it comes to these different nutrients?

Speaker 2:

They're both the same. The big difference when we go on dialysis is that our protein needs are actually higher because we lose protein while we're on dialysis, whereas before dialysis we're following a low protein diet. So your protein budget might increase, but we're still looking for things like the added phosphorus, the potassium and then sodium.

Speaker 1:

Is there anything else that you think it's important for clinicians to know or to ask their patients when it comes to either protecting their kidneys or making sure that they are following a safe, kidney friendly diet?

Speaker 2:

I think understanding patients' goals is really important. We know that there's benefit to incorporating different dietary patterns like Mediterranean phall, the dash diet, plant-based eating have all shown really great benefit from a kidney protective standpoint. So understanding what their goal is and how we can modify their diet to kind of align with these dietary patterns is really important. But at the end of the day, we have to put the patient first, and so I think, while we have all of this knowledge and tools to support them, we also have to understand what their goal is.

Speaker 1:

Yeah, I agree, it's really working with them. You know, as clinicians it's really easy to just kind of spew out facts and give them the recommendations, give them a guidelines and hand them a handout. And here's your diet that you need to follow for the next six months. See it in a couple weeks. You know, and I think that's just. It's not very human, it's not very compassionate, it's not really personalized at all. So I would love to find out what do you think would be some of the best questions that clinicians can ask their patients to kind of dig a little deeper and just really find out what foods that they are really eating. What's some good verbiage that clinicians can use during, like your typical physical that's a really good question.

Speaker 2:

I often say words like tell me a bit about your breakfast, because then they'll be like oh, I have, you know, oatmeal and I put these things in it and become a bit more specific about it. But we also, as clinicians, need to be asking about the add-ins, right? You know typical things like do you put butter or mayonnaise or peanut butter or anything like that on your bread when you have it? So asking for those little additional things where especially hidden sources of sodium might come from, and also asking them to elaborate on foods. One of the things I love the most is being a dietitian is getting to know more cultural foods and especially with the patients that I work with becoming more familiar, because then they teach me more things that I can then cook as well.

Speaker 1:

Yeah, so fun. And you're right, every culture is so different and I love a culturally diverse diet because you know, the American diet is just full of sodium. So it's really fun to hear of Indian cuisine and Haitian cuisine that pull in a lot of different herbs and different flavors, because it is a great way to season things. I want to back up a little bit, because you did mention something briefly and that was kind of the dash diet. I'm curious because in at least in the States, there's the flavorings or the salt seasoning packets that's kind of marketed under the dash. What are your thoughts on those things and alternative seasonings and everything like that? Are there like secret ingredients that we need to be leery of, or would those be appropriate to recommend to our patients? That's a great question.

Speaker 2:

So there are some good products out there that are just dried herbs and spices that have a great flavor profile and can be added. There are others, though, that they will remove the sodium chloride and add potassium chloride into it, and so that can be a concern for kidney patients. So I always recommend, if they are using dried herbs and spices, to make sure it's just the dried herbs and spices and not a low-sodium version so sneaky.

Speaker 1:

It's like we have to be a little food detectives when we're working with renal patients, right? Sometimes I feel like it. Yes, all right. I love to close by asking my experts what is one of the worst pieces of advice that clinicians either give to their patients or that you've heard clinicians give to their patients. That is just an absolute no. Please stop telling this to your renal patients.

Speaker 2:

I think the big one is that you can't have plant-based proteins. It's on every hand and note that you can't have them, and I think as clinicians, we know there's such a benefit with the kidneys and just in terms of filtration and preservation of kidney function, and we know how helpful plant-based diets can be, so we don't need to be scared of them anymore. We know that the bioavailability is a bit lower than what we thought in potassium and phosphorus, and so they can and should be included in moderation in kidney diets.

Speaker 1:

I love that and I think that's probably new, and some of my listeners are probably thinking oh gosh, that's me. I'm telling people to stop eating those plant-based proteins, and I might have some listeners that are like what are some examples of plant-based proteins? So, emily, could you give us just a list of some plant-based proteins that we should start recommending our patients to be consuming and to not be afraid of, for sure?

Speaker 2:

So the first is always legumes, so chickpeas, beans and peas, whether they're dried or canned so canned, of course, look for the ones that say no at itself. The canned ones are actually low in potassium because the potassium leaches out. While we can them, the dried ones, they still can soak them and cook them and reduce some of the potassium too. So even for patients that have high potassium, we can include these foods. Other things like tofu or nuts and seeds, and even among nuts and seeds, things like pecans and walnuts and pumpkin seeds, are a lot lower in potassium than something like an almond or a cashew. So we can still modify within the food groups if we need to, and that's why we personalize care, especially with renal patients.

Speaker 1:

What a great place to end with that personalized care, because I think that is the key. It's so important because what might be right for one patient might be completely wrong for the other, and you don't want to just be telling all patients that they must avoid tomatoes and oranges and potatoes and beans for everybody, because look at the healthful food items that now you're removing from their diet unnecessarily. So I think that was a really, really good take home point and really those nuts and seeds are great snacks too and they're a great source of protein. They've got great fat to kind of help control hunger throughout the day. So I'm super happy to hear that they can be eating those things, because I actually remember learning that beans and nuts and seeds are like in the like off limits list. So I'm so glad that you brought that up, because that's really encouraging to hear. Do you have any final thoughts or any tips for our clinicians who care for renal patients?

Speaker 2:

Yeah, I think there's lots of renal dieticians out there and we are more than happy to share information about what's happening in the literature. So if you do have renal patients and you're not sure, feel free to connect with us, because the guidelines are changing in a good way and you know, we want to take a food first approach to preserving our kidney function.

Speaker 1:

Oh, so good, Emily, thank you so much for coming on. And, like she said, there are renal dieticians just like Emily out there that are willing and ready to help, and most of them do offer virtual counseling. And you can connect with Emily on Instagram at Kidney Nutrition, and you can also find me on Instagram at exam room nutrition. Emily, I'm so grateful for your time. I can't give this time back to you, but I really appreciate you coming on and just sharing your wisdom and advice with us. Thank you so much. Thanks for having me, colleen. All right, guys, now it's time for my nutrition notes. In this section, I will leave you with a nutrition tip and encouraging quote or an interesting case that I think might add value to your day. So today I wanted to leave you with a few more facts about the nutrition facts label and clear up some common misconceptions that either you might have or your patients might have. So the next time they ask you something about the nutrition label, you'll be ready. So, like Emily said, at the very top you're going to see the serving size. This is very important that you remind your patients to look at, because this tells you how many calories and how much of each nutrient is in each serving. So, for example, for a bag of chips and a serving is two thirds of a cup and there's 200 calories in that serving, it doesn't mean that that entire bag of chips is 200 calories. It means that there are 200 calories in two thirds of a cup, so 200 calories in one serving. So be sure to tell your patients to look at serving size and pay attention to how much they're actually having, because a lot of us are having more than two thirds of a cup of whether it be chips or cereal or anything else like that, so they might need to double the calories and everything else that's listed on the food label. The next somewhat confusing thing is that percent daily value, which is going to be listed to the right of the different nutrients that are listed and this doesn't mean that they should equal 100%. The daily value refers to the overall amount of each nutrient that's recommended to eat in a whole day and how much is found in one serving of that item. The percent daily value is just telling you how much of your total percentage of an item is coming from this serving. So, for example, if a cereal says that it's 25% daily value of your total calcium needs. That means that in one serving of the cereal you're meeting 25% of your daily needs of calcium for that day found from this cereal. This is really important for renal patients to pay attention to because, as Emily had discussed, we want to make sure that they are monitoring those foods that contain potassium and sodium in it, that they keep that percent daily value below 5%.

Speaker 1:

The other thing that can get a little tricky is carbohydrates, because there are a few things that are also listed underneath there. So total carbohydrates includes sugars, added sugars and fiber. So when you're looking at total carbohydrates you want to pay attention to where that carbohydrate is coming from. So you'll first see total carbohydrates and then kind of like a sub note underneath it is going to say dietary fiber. Then below that we now have listed in there total sugars. Then below that you are also going to be seeing added sugars. So that's going to say includes this many milligrams of added sugars and this will just help you know whether the carbohydrates that you're consuming if they contain primarily naturally occurring sugar, like those found in fruit, or if it comes from added sugar that you can find in, like the processed foods, like white sugar.

Speaker 1:

The next thing that's also listed under total carbohydrates is going to be dietary fiber, because this tends to come from carbohydrate type foods like beans, fruits, vegetables and grains, and if you've been listening to this podcast for any amount of time, you'll know that most of my experts recommend foods that are high in fiber. Fiber has so many health benefits for you. The Dietary Guidelines for Americans recommends that you receive 14 grams of fiber per 1,000 calories, so that's why we're typically recommending anywhere between 25 and 30 grams of fiber per day. I hope this content was valuable to you and you guys. I cannot express how thankful and grateful I am that you're spending this time with me. I really and truly hope to provide you with helpful nutrition information and just maybe give you the courage to start talking about nutrition with your patients. Well, that's all I have for you today, guys, and, as always, let's continue to make our patients healthier, one exam room at a time. I'll see you next time.

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