A Plant-Based Diet: What Are The Pros and Cons

Recently I did a Broadcast on the Urban Health Outreach Media With Dr Blake Shusterman and Dr Shivam Joshi.

Dr. Blake Shusterman, the Cooking Doc strongly recommended some version of a plant-based diet. Dr. Blake Shusterman is President and Physician Partner at Carolina Nephrology, a twenty-two provider practice in Greenville, SC. He is also the creator and host of The Cooking Doc (www.thecookingdoc.co), and author of the book The Cooking Doc’s Kidney-Healthy Cooking: A Modern 10-Step Guide to Preventing and Managing Kidney Disease.  You can also subscribe to his newsletter there.

A board certified nephrologist, Dr. Shusterman serves as the medical director at multiple dialysis units. He is a Clinical Assistant Professor at the USC School of Medicine in Greenville and oversees the medical student nephrology rotations.

He is passionate about home dialysis, patient education and the importance of diet in the management of chronic kidney disease. His interest in diet and kidney disease led him to his role as an ambassador for the American Kidney Fund’s Kidney Kitchen.

Dr. Shusterman earned his medical degree from The Ohio State University and went on to complete his internal medicine residency and nephrology fellowship at the University of Virginia where he served as chief fellow. He holds a BA in Anthropology from Tufts University.

“During my years of practice, I have come to realize that many of my patients and their families live equally food-focused lives. So, I understand the furious looks I get from my patients when I tell them to give up their favorite foods.

Thus was born The Cooking Doc. Can you imagine having your doctor right next to you in the kitchen, telling you what delicious foods you need to try? Well, that’s me. I won’t tell you what tasty foods you need to give up, instead I’ll help you find creative ways to use new ingredients and together we’ll make them taste amazing. (Check out this summer squash soup with white wine and leeks)”

Our second nephrologist expert was Dr Shivam Joshi. Shivam Joshi, MD, is an internist, nephrologist, and plant-based physician practicing at NYC Health + Hospitals/Bellevue in New York City. He received his BS from Duke University and his MD from the University of Miami. He completed his residency at Jackson Memorial Hospital/University of Miami and his nephrology fellowship at the Hospital of the University of Pennsylvania. He is also a clinical assistant professor at the New York University School of Medicine with research interests in plant-based diets, fad diets, and nephrology. He has written numerous scientific articles and speaks nationally on these subjects. He is the youngest nephrologist to receive the NKF’s Joel D Kopple award, the highest award in renal nutrition. You can follow him on Twitter (@sjoshiMD).

“Dr. Joshi is incredibly impressive. Though he is still early in his career, he has already made important contributions to the field of renal nutrition and I can’t wait to see what will be next in his career,” said NKF President Dr. Paul Palevsky. “His dedication to patients and understanding kidney disease and its relationship to nutrition is of course evident, but also critical in understanding this disease that touches so many American lives”

What surprised me most about the interview was all of the scientific basis for Plant-based diets for Kidney Patients that exists, and has existed for a long period of time, and yet only recently has this information just begun to surface in the Kidney Community. Even more surprising was the number of views of the Broadcast, indicating a trend towards wide-ranging acceptance of at least some hybrid form of plant-based dieting from actual kidney patients.

That is the reason for this blog. I wanted to put the word out to Kidney Patients everywhere that this deserves their attention and serious consideration.

What Is A Plant-Based Diet?

A standard definition of a plant-based diet would be:  “A plant-based diet or a plant-rich diet is a diet consisting mostly or entirely of plant-based foods. Plant-based foods are foods derived from plants with no animal-source foods or artificial ingredients. While a plant-based diet avoids or has limited animal products, it is not necessarily vegan.”
https://www.health.harvard.edu/blog/what-is-a-plant-based-diet-and-why-should-you-try-it-2018092614760

According to the Harvard Health Blog,

“Plant-based or plant-forward eating patterns focus on foods primarily from plants. This includes not only fruits and vegetables, but also nuts, seeds, oils, whole grains, legumes, and beans. It doesn’t mean that you are vegetarian or vegan and never eat meat or dairy. Rather, you are proportionately choosing more of your foods from plant sources.”

What is a plant-based diet and why should you try it?

https://www.health.harvard.edu/blog/what-is-a-plant-based-diet-and-why-should-you-try-it-2018092614760

Basically, a plant-based diet or some variety of a hybrid of a plant-based diet eliminates in full or in part meat or other animal products. Other versions of a hybrid plant-based diet may include the Mediterranean Diet (incorporates fish & poultry), Pescatarian(includes eggs, diary, fish and seafood, no meat or poultry)and Vegetarian(includes eggs, diary, no meats, poultry, fish or seafood) and Vegan(no animal foods) diets.

What is particularly striking about all of this is that studies have shown that plant-based products have been flying off of the shelves at the grocery while the sales of dairy and meat products may be declining.

A Word of Caution About the Keto Diet for Kidney Patients

In my interview with Drs Shusterman and Joshi, both nutrition expert did not reccommend the Keto Diet for Kidney Patients.

Borrowing heavily from the National Kidney Foundation of Hawaii’s article,
To Keto or Not to Keto, https://kidneyhi.org/dietitian-blog/to-keto-or-not-to-keto:

“The ketogenic diet, or “keto diet”, is one of a series of trendy low carbohydrate (“low carb”) diets that include the Atkins diet, the South Beach diet and the Zone diet. It was developed at the Mayo Clinic in 1924 as a treatment for epilepsy in children. In recent years the ketogenic diet has made a comeback and today, medical teams are once again using it as a therapy for epileptic kids whose seizures do not respond to medications. The medical ketogenic diet relies on precise ratios of fat to protein and carbohydrates so it requires careful monitoring by a medical team. This is because the diet is not balanced and can lead to nutrient deficiencies among other things.

The “keto diet” got its name from ketones, which are the source of energy that the body uses when it’s burning fat. The goal of the keto diet is to put the patient a state of ketosis through a diet that’s high in fat and ultra-low in carbs with moderate amounts of protein. In simple terms, ketosis occurs when there is a metabolic shift, where the body uses fat as the primary energy source instead of carbs.

The keto diet is NOT a high protein diet. It is a low-carb, high-fat diet typically containing a percentage of total calories as follows: 5% carbohydrates, 75% fat, 20% protein. By contrast, National Health Guidelines suggests intaking 45-65% carbohydrates, 20-35% fat, and 10-35% of protein.

Another Fad?

Because this diet is so restrictive and individualized, it isn’t a healthy option for the general population. You would be missing out on too many essential nutrients and probably experience unpleasant side effects as well. The effects of maintaining ketosis for long periods of time are unknown. There’s a lot of misinformation online about the ketogenic diet. Most people calling their diet a “keto diet” are simply following a low or very low carbohydrate diet. In other words, most keto diets are only keto-like, in that it replaces some of the carbs in a person’s diet with fat and protein. Ketogenic in the clinical sense limits carbs to as few as 10 grams a day. Low carbohydrate diets can be helpful in the short term for weight loss. However, as with the true medical ketogenic diet, most people can’t stick with a very low carbohydrate diet for the long term.

Nutrient Deficiencies

Any time you remove a macronutrient group like carbohydrates, your body is going to be losing some of the essential nutrients that come from that food group (B vitamins, vitamin C, phytochemicals and fiber). Although many people label carbohydrates as “bad”, not all carbs are created equal. The key is to choose smarter carbs: sweet potatoes, steel-cut oats, quinoa and fruit rather than white pasta, white bread, white rice, and pastries.

Long Term Effects?

People think, ‘Oh, this diet sounds great – I can eat bacon and cheese and I can still lose weight,’ then they drop pounds quickly and are instantly gratified. It’s true that cutting carbs often leads to rapid weight loss, but in the first week or two much of the loss is water weight, because our bodies store water with our carbs. However over the long term, a diet high in saturated fats increases the risk of heart disease and stroke. Keto diet or not, the fats we should be eating are unsaturated fats, which actually lower the risk of heart disease and stroke. Healthier fats include olive oil, canola oil, walnuts, avocados, and fish.

Kidney stones may also be an issue.  When you compare the annual rate of kidney stones to the annual rate normally found in the general population, the rate in those on the keto diet is 7-8 fold higher than in the general population!

https://pubmed.ncbi.nlm.nih.gov/34070285/#:~:text=Conclusions%3A%20The%20estimated%20incidence%20of,followed%20by%20calcium%2Dbased%20stones.

Sensible Eating is Best

The latest research shows that the ability to stick to a diet is key. If a low carbohydrate diet or keto diet is a practice that works for you and you are able to maintain it for as long as it takes to lose excess body fat and you are meeting your nutritional requirements, then science says that this should be encouraged. As of yet, there hasn’t been enough research into the ketogenic diet to support its use in some medical conditions like Polycystic Ovarian Syndrome, Alzheimer’s, Parkinson’s, and cancer. Eating a well-balanced, keto diet is costly. For most people, following a low carbohydrate diet, rather than a no carbohydrate diet, is much more practical as it will allow for the inclusion of fruit and all vegetables. This represents much better dietary balance and usually leads to people sticking with it for longer.

To Keto or Not to Keto?

As always with weight loss, it all comes down to taking less energy in than you burn. Rather than following a keto-like diet or other low-carb eating plans, focus on smart choices in all of the food groups while paying attention to portion sizes. You will not only be happier, you will be healthier too!

Remember that science involves being inquisitive and skeptical. This means we should all remain open to what high quality scientific research on the keto diet will show in the future, but we shouldn’t be jumping to conclusions that are not available yet. Work with an experienced Registered Dietitian and your medical specialist to help you sort through and make sense of the research and determine the best eating plan for your needs.”

Dr. Shusterman in his article, The Keto Diet and Your Kidneys, has said directly:

“While the data is still coming in on the long term effects of a keto diet, I believe there are too many risks and unknowns to safely advise this type of diet for most people with kidney disease. This is especially true for people with Stage 3-5 Chronic Kidney Disease, who already have significant dietary restrictions and who may benefit from a diet that is much lower in protein intake. Additionally, it remains to be seen if people can remain on a keto diet for many years, and this is an important part of any healthy, long term dietary pattern.”

Dr. Joshi has written in his article, Why You Should Say No to the Keto Diet,

https://www.forksoverknives.com/wellness/why-you-should-say-no-to-the-keto-diet/:

“Even if you believe the keto diet works for weight loss, there are plenty of other reasons to avoid it. In reviewing the literature of the documented side effects in epileptic children on the diet, I found that patients suffered from no shortage of side effects, including kidney stones, restricted growth, fatal cardiac arrhythmias, pancreatitis, higher cholesterol levels, and many more. The diet seems to be worth utilizing only if one happens to be a child with refractory epilepsy—and even then, children discontinue the diet because of its numerous side effects…

The ketogenic diet has swept the country up with the hope of a miracle diet, but, in the end, it may only bring us down with disappointment. Let food be thy medicine, but not if you need actual medicine to support thy food.”

The Pros and Cons of a Plant-Based Diet

There are more Pros than Cons to a plant based diet for Kidney Patients.

Pros

There are numerous positive benefits derived from eating a plant-based diet. A plant-based diet is:

• Rich in vitamins, minerals, fiber, antioxidants found in fruits, vegetables, and whole grains

• Heart-healthy, with lower cholesterol and saturated fats and higher in dietary fiber

• Disease prevention. Overall, plant-based diets are higher in antioxidants, helping to reduce chronic inflammatory diseases such as diabetes. Also, staying away from over-processed foods minimizes our exposure to chemical additives.

• Weight loss. Eating less animal fat and more vegetables, fruits, and dietary fiber keeps calories and fat consumption down and promotes better digestion and your metabolism.

• Contributes positively to the environment. The environmental impact of the livestock industry is affected through the use of chemical fertilizers, pesticides, and antibiotics; and depletion of fossil fuels, methane in the atmosphere.

• Animal preservation and ethics. Eating plant-based foods minimizes the exploitation and cruelty of animals. Those with ethical concerns can “vote” with their dollars and feel they are supporting what’s important to them morally.

• Wide variety of food choices. There are lots of options for what to eat, unlike many other diets where you have to deny yourself certain foods you like or that require you to carry a checklist to the grocery store to make sure you’re purchasing the “right” items.

• Plant-based meals can be prepared more quickly – or just as quickly – as other foods. You can even find them already prepared, for instance, in the grab-and-go sections of grocery stores. Examples include bagged produce like washed leafy greens, and semi-prepared entrees and sides in the produce section.

• Less expensive. While eating fresh foods might seem more expensive – especially if they’re organic – some costs can be offset by eliminating meat, poultry, and/or fish and buying bulk dried foods. Plus, beans, nuts, seeds, and grains are relatively inexpensive and filling. Also, fresh foods go a long way in feeding yourself and your family compared to packaged foods in terms of quantity and price.

Cons

What could possibly be negative about eating a plant-based diet?

• Fresh produce can be very perishable, so buy just as much as you need to minimize waste.

• Possibly a protein-deficient diet. Animals, milk, and eggs contain necessary amino acids for protein. Plant-based proteins are an incomplete protein source unless properly combined. Make sure you’re eating plants that can supply the appropriate quantity and combination of amino acids.

• Possibly deficient in certain nutrients such as iron calcium, and B12. Plant-based iron is not as bio available to the body as animal-based iron, but you can improve your body’s absorption by eating foods containing vitamin C, vitamin A, meat, fish, and poultry during your meals. Getting enough calcium from plants is also more difficult, so pair it with high vitamin D foods like mushrooms which help absorption, and dark leafy vegetables, which contain more calcium. And plants don’t contain Vitamin B12, so you need to add foods fortified in B12, soy, and nutritional yeast to prevent anemia and/or take a B12 supplement. More time for meal planning and preparation – but hey, anyone preparing meals from scratch knows it’s worth the wait. But as plant-based foods become more mainstream, the convenience factor will likely improve.

• If you decide to go vegetarian or vegan, it could be challenging to give up eating animals. But a plant-based diet doesn’t have to exclude animals. Each person can find their happy medium.

According to the experts, the potential big Con is the lack of good protein in a plant-based diet. Dr Joshi in his article, Adequacy of Plant-Based Proteins in Chronic Kidney Disease, https://www.jrnjournal.org/article/S1051-2276(18)30154-7/fulltext,
concludes:

“Concerns regarding protein and amino acid deficiencies with plant-based proteins have precluded their use in chronic kidney disease (CKD) patients. Many of these concerns were debunked years ago, but recommendations persist regarding the use of “high-biological value” (animal-based) proteins in CKD patients, which may contribute to worsening of other parameters such as blood pressure, metabolic acidosis, and hyperphosphatemia. Plant-based proteins are sufficient in meeting both quantity and quality requirements. Those eating primarily plant-based diets have been observed to consume approximately 1.0 g/kg/day of protein, or more. CKD patients have been seen to consume 0.7-0.9 g/kg/day of mostly plant-based protein without any negative effects. Furthermore, those substituting animal-based proteins for plant-based proteins have shown reductions in severity of hypertension, hyperphosphatemia, and metabolic acidosis. Plant-based proteins, when consumed in a varied diet, are not only nutritionally adequate but have pleiotropic effects which may favor their use in CKD patients.”

Not only then are there sufficient proteins in a plant-based diet, but the over all effect may be to slow or reverse the effects of Diabetes and High Blood pressure, and therefore, slow or reverse the effects of the number 1 and 2 causes of Kidney Disease.

Dr. Joshi also reccommends that if your blood levels are not being checked, you should consider taking a Vitamin B12 supplement, low dose, daily.

Conclusions

Both experts recommended that Kidney Patients consider the benefits of a plant based diet/hybrid plant-based diet.

Dr Joshi in the NKF article Plant-Based vs. Animal-Based Diets: The Jury is in!
https://www.kidney.org/newsletter/plant-based-vs-animal-based-diets-jury, states:

It’s been shown that patients with CKD who obtain food from plant sources may actually demonstrate improvement in several of the complications of CKD like hypertension, metabolic acidosis, and hyperphosphatemia…We want the general public to reconsider their stance on plant-based proteins in CKD and know that plant-proteins, when consumed in a varied diet, are a great source of amino acids for patients. These foods are rich in healthy substances, like fiber, antioxidants, phytonutrients, vitamins, and minerals that contribute to improved overall health…  “The renal community has had no shortage of reasons to avoid plant-based foods in the past,” Dr. Joshi said. “However, over the years, we’ve seen these concerns fall by the wayside in response to an ever-expanding body of literatures documenting their safety and benefit for patients with CKD…

“Other disciplines of the health care field have used plant-based diets to their benefit in treating heart disease, diabetes, and obesity,” he said. “Food can be seen as being complementary to pharmacologic therapies for patients with CKD. Instead of running away from these foods, and perhaps incurring harm by doing so, we should be embracing these foods to our collective benefit.”

Both experts recommend if you have CKD, talk to your nephrologist about plant-based protein diets and schedule an appointment with a renal dietitian.

References

1. Dr. Shusterman and Dr. Joshi’s Websites

Dr. Shusterman

The Cooking Doc
https://www.thecookingdoc.co/

To Order a Copy of His Book,  The Cooking Doc’s Kidney-Healthy Cooking,  A Modern 10-Step Guide to Preventing & Managing Kidney Disease
https://www.thecookingdoc.co/kidney-healthy-cooking-book/

To Subscribe to His Newsletter
https://www.thecookingdoc.co/

Check out His Blog
https://www.thecookingdoc.co/blog/

Recipies & Videos
https://www.thecookingdoc.co/videos/

American Kidney Fund’s Kidney Kitchen
http://www.kitchen.kidneyfund.org

Dr. Schusterman Bio
GET TO KNOW THE COOKING DOC®
https://www.thecookingdoc.co/about/

Dr. Joshi

AFTERNOONROUNDS, Plant-Based Diets in Kidney Disease
https://afternoonrounds.com/2020/04/28/plant-based-diets-in-kidney-disease/

Dr. Joshi on FORKS OVER KNIVES WEBSITE
Plant-based eating simplified.

Shivam Joshi, MD

Dr. Joshi on Kidney News 360
https://www.kidneynews.org/view/news/careers/perspectives/dr-shivam-joshi-speaks-about-plant-based-diets-and-the-relationship-with-ckd-in-recent-study.xml

THE PROOF IS IN THE PLANTS
https://plantproof.com/nutrition-for-healthy-kidney-function-with-nephrologist-dr-shivam-joshi

Dr. Joshi on Food Is Medicine(Bio)
Plant-Based Diets in Kidney Disease
https://foodasmedicinephilly.com/shivam-joshi

Dr. Joshi Bio on Neph.Org
Shivam Joshi, MD
https://nephu.org/about/team/shivam-joshi/

Nephrologist from NYC Health + Hospitals to Receive NKF’s Kopple Award

https://www.kidney.org/news/nyc-health-hospitals-to-receive-nkf-s-kopple-award

Shivam Joshi, MD, on Plant-Based Diets to Treat and Prevent Kidney Disease

https://www.consultant360.com/podcast/nephrology/chronic-kidney-disease/shivam-joshi-md-plant-based-diets-treat-and-prevent

Podcasts360 · Shivam Joshi, MD, on Plant-Based Diets to Treat and Prevent Kidney Disease

2.  Definition of a Plant-Based Diet

What is a Plant-Based Diet?
https://nunm.edu/2019/04/plant-based-diets/

What Is a Plant-Based Diet? Food List, 7-Day Meal Plan, Benefits, and More
https://www.everydayhealth.com/diet-nutrition/plant-based-diet-food-list-meal-plan-benefits-more/

What is a plant-based diet and why should you try it?
https://www.health.harvard.edu/blog/what-is-a-plant-based-diet-and-why-should-you-try-it-2018092614760

Plant-Based Diet for Beginners: Your Guide to Getting Started
https://www.eatingwell.com/article/7775696/plant-based-diet-for-beginners-your-guide-to-getting-started/

Vegetable-Based Diets for Chronic Kidney Disease? It Is Time to Reconsider
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6627351/

Aleix Cases, Secundino Cigarrán-Guldrís, […], and Emilio Gonzalez-Parra

What You Should Know About A Plant-Based Diet
https://health.clevelandclinic.org/is-a-plant-based-diet-right-for-you/

General Plant-Based Diet Articles

Ameliorating Chronic Kidney Disease Using a Whole Food Plant-Based Diet

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230354/

Plant-based dietary approach to stage 3 chronic kidney disease with hyperphosphataemia

https://casereports.bmj.com/content/12/12/e232080

Open Access

Plant-Based Diets in CKD
https://cjasn.asnjournals.org/content/14/1/141

Plant-Based Diets and Kidney Disease
https://kidneyhi.org/dietitian-blog/plant-based-diets-and-kidney-disease

How A Plant-Based Diet Helped Me Restore Kidney Function

How a Plant-Based Diet Helped Me Restore Kidney Functioning

Plant-Based vs. Animal-Based Diets: The Jury is in!
https://www.kidney.org/newsletter/plant-based-vs-animal-based-diets-jury

PLANT-BASED DIET AND KIDNEY HEALTH
https://www.kidney.org/atoz/content/plant-based

3.  Caution on Keto Diets

To Keto or Not to Keto,
https://kidneyhi.org/dietitian-blog/to-keto-or-not-to-keto:

The Ketogenic Diet for Obesity and Diabetes—Enthusiasm Outpaces Evidence
Shivam Joshi, MD1,2; Robert J. Ostfeld, MD, MSc3; Michelle McMacken, MD1
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2737919

Incidence and Characteristics of Kidney Stones in Patients on Ketogenic Diet: A Systematic Review and Meta-Analysis
Prakrati Acharya et al. Diseases. 2021.
https://pubmed.ncbi.nlm.nih.gov/34070285/

Keto diets are a ‘disease-promoting disaster,’ researchers warn
https://wgno.com/news/health/keto-diets-are-a-disease-promoting-disaster-researchers-warn/

Analysis: Keto diets place pregnant women and kidney disease patients at risk of adverse health effects
https://www.news-medical.net/amp/news/20210803/Analysis-Keto-diets-place-pregnant-women-and-kidney-disease-patients-at-risk-of-adverse-health-effects.aspx

Keto Diet Downsides May Outweigh Benefits, Review Suggests
https://www.everydayhealth.com/ketogenic-diet/keto-diet-downsides-may-outweigh-benefits-review-suggests/

Review finds keto diet ups heart risks, cancer risk, dangers to pregnant women and kidney patients
https://scienceblog.com/524530/review-finds-keto-diet-ups-heart-risks-cancer-risk-dangers-to-pregnant-women-and-kidney-patients/

kidneys

The Super-Trendy Keto Diet Is A Recipe For Bad Health-This Is Why
https://www.theladders.com/career-advice/the-super-trendy-keto-diet-is-a-recipe-for-bad-health-this-is-why

This ‘Popular’ Diet is Doing More Harm Than Good to Your Health, Says New Study
https://www.india.com/health/this-popular-diet-is-doing-more-harm-than-good-to-your-health-says-new-study-4881239/

The popular diet that could lead to seven life threatening illnesses – a new study shows
https://www.express.co.uk/life-style/health/1473843/keto-diet-increase-risk-cancer-diabetes-alzheimers-heart-disease-kidney-failure

Dr. Shusterman’s You Tube Video on the Keto Diet
https://youtu.be/wRMooWmj2ZI

4.  The Pros and Cons of a Plant-Based Diet

https://www.vitruviamd.com/the-pros-and-cons-of-plant-based-diets/

https://crystalgeyser.com/blogs/news/pros-and-cons-of-a-plant-based-diet

Adequacy of Plant-Based Proteins in Chronic Kidney Disease

https://www.jrnjournal.org/article/S1051-2276(18)30154-7/fulltext

5. Conclusions

Plant-Based vs. Animal-Based Diets: The Jury is in!
https://www.kidney.org/newsletter/plant-based-vs-animal-based-diets-jury

Jim Meyers
Guest Author