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Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease

Annabel Biruete
Gabriela Leal-Escobar
Ángeles Espinosa-Cuevas
Luis Mojica
5 and
Brandon M. Kistler
Department of Nutrition Science, Purdue University, West Lafayette, IN 47907, USA
Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
Departamento de Nefrología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
Tecnología Alimentaria, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), Zapopan 45019, Mexico
Author to whom correspondence should be addressed.
Nutrients 2024, 16(5), 574;
Submission received: 19 January 2024 / Revised: 16 February 2024 / Accepted: 18 February 2024 / Published: 20 February 2024


Chronic kidney disease (CKD) disproportionately affects minorities in the United States, including the Hispanic/Latine population, and is a public health concern in Latin American countries. An emphasis on healthy dietary patterns, including the Mediterranean and the Dietary Approaches to Stop Hypertension (DASH) diets, has been suggested as they are associated with a lower incidence of CKD, slower CKD progression, and lower mortality in kidney failure. However, their applicability may be limited in people from Latin America. The Dieta de la Milpa (Diet of the Cornfield) was recently described as the dietary pattern of choice for people from Mesoamerica (Central Mexico and Central America). This dietary pattern highlights the intake of four plant-based staple foods from this geographical region, corn/maize, common beans, pumpkins/squashes, and chilies, complemented with seasonal and local intake of plant-based foods and a lower intake of animal-based foods, collectively classified into ten food groups. Limited preclinical and clinical studies suggest several health benefits, including cardiometabolic health, but there is currently no data concerning CKD. In this narrative review, we describe and highlight the potential benefits of the Dieta de la Milpa in CKD, including acid-base balance, protein source, potassium and phosphorus management, impact on the gut microbiota, inflammation, and cultural appropriateness. Despite these potential benefits, this dietary pattern has not been tested in people with CKD. Therefore, we suggest key research questions targeting measurement of adherence, feasibility, and effectiveness of the Dieta de la Milpa in people with CKD.

1. Introduction

Chronic kidney disease (CKD) affects >10% of the population worldwide, with a prevalence of 15% in the United States [1]. CKD disproportionately affects racial/ethnic groups in the United States, including the Hispanic (i.e., person from a country where the primary language is Spanish) and/or Latine (i.e., nongender-based term for people from Latin America) populations [2]. Moreover, CKD is a public health concern in Latin American countries due to the high prevalence of obesity, diabetes mellitus, and hypertension [3,4].
Medical nutrition therapy provided by a registered dietitian or international equivalent is a fundamental component in the management of CKD [5]. Current nutritional recommendations for people with CKD focus on the modulation of dietary protein, phosphorus, sodium, and potassium depending on the grade of kidney dysfunction and current clinical condition [6]. In clinical practice, this nutrient-focused strategy can create dilemmas between individual nutrients (for example, phosphorus and protein [7]) and conflicting guidance that may result in confusion and poor adherence to recommendations [8,9]. An alternative strategy, which considers nutrients as a part of foods and food matrices instead of in isolation [10], is to focus on overall dietary patterns [11,12].
Healthy dietary patterns have been associated with reduced incidence, slower progression, and reduced mortality in patients with CKD; therefore, dietary patterns are a topic of ongoing research [13,14]. Among these, there has been an increased emphasis on plant-dominant patterns characterized by high consumption of vegetables, fruits, whole-grains, nuts, legumes, low-fat dairy, and minimal consumption of animal-based products and ultra-processed foods [10,13,15]. The Mediterranean and the Dietary Approaches to Stop Hypertension (DASH) diets are the most widely recognized of these dietary patterns, and the Mediterranean diet has been recommended as the dietary pattern of choice for patients with CKD [12].
However, these dietary patterns may not be widely utilized in people from Latin American countries [16]. While dietary recommendations are often not dependent on race or ethnicity, usual dietary intake and patterns may be quite different [17]. Furthermore, the lack of cultural concordance is a source of anxiety for Spanish-speaking people with CKD in the United States [18,19]. Therefore, more culturally appropriate guidance may benefit people with CKD.
A dietary pattern for Mesoamerica (Central Mexico and Central America) called Dieta de la Milpa or Diet of the Cornfield was recently described [20]. This dietary pattern is characterized by a diet based on the consumption of corn/maize (Zea mays L.), common beans (Phaseolus vulgaris L.), a variety of pumpkins/squashes (Curcubita pepo maxima and moschata), and chilies (Capsicum annum and frutescens) [20,21]. The diet is complemented by a diet high in vegetables and fruits commonly grown in the Mesoamerican region, including tomatoes (Solanum lycopersicum L.), starchy vegetables (such as sweet potato and yuca), other whole grains and legumes, fish, water, and avoidance of ultra-processed foods, red meat, and artificial sweeteners [20]. In addition to the dietary pattern, there is a strong emphasis on a healthy lifestyle, promoting physical activity, and overall well-being [20]. While this dietary pattern follows similar characteristics as the Mediterranean and DASH diets, it may be more culturally concordant for people from the Mesoamerica region. Therefore, the objective of this narrative review is to summarize the characteristics of the Dieta de la Milpa and to describe the potential benefits for patients with CKD, including benefits on acid-base balance, sources of protein, potassium and phosphorus management, modulation of the gut microbiome, inflammation, and cultural appropriateness. To explore the impact of the Dieta de la Milpa in CKD, we conducted a literature search on PubMed and Google Scholar until December of 2023 for published articles including terms “dieta de la milpa”, “milpa”, ”Mexican diet”, “pre-Hispanic diet”, “pre-Hispanic foods”, “Mesoamerican foods”, and “Mesoamerican diet” with ”kidney disease”, “renal disease”, and “renal failure”. As we did not identify data in CKD, we propose key research questions to evaluate adherence, feasibility, and efficacy of this dietary pattern in CKD.

2. Components of the Dieta de la Milpa Dietary Pattern

The origins of this dietary pattern date back to pre-Hispanic times, when milpas or cornfields were utilized as a productive and sustainable agricultural system to grow local seeds [20,21]. Traditionally, the main crops were corn/maize, common beans, and pumpkins/squashes, which, along with chilies, are the basis of the Dieta de la Milpa [20]. These four foods have important nutritional characteristics and are often the base of the traditional Mexican diet [22]. Nixtamalized corn, or corn processed with calcium hydroxide, is considered a good source of energy, dietary fiber, and calcium [20,23]. Common beans are the main source of plant-based protein in this dietary pattern and provide dietary fiber, phosphorus, potassium, and bioactive compounds [20,24,25]. There are several types of pumpkins/squashes, but zucchini squash is common, and the flower, seeds, and pulp are used in traditional cuisine and are good sources of dietary fiber, vitamins A, E, and C, magnesium, calcium, phosphorus, and iron, making it a nutrient-dense food [20]. Finally, different types of chilies provide color, flavor, and spiciness to foods [20]. As observed in Figure 1, Table 1, and Supplementary Table S1 [26,27,28], the Dieta de la Milpa has ten components. This dietary pattern is plant-dominant but fundamentally omnivorous, with limited consumption of poultry, fish, eggs, and dairy and an avoidance of red meat and ultra-processed foods [20].

3. Potential Benefits for People with CKD (Figure 2)

3.1. Dietary Patterns vs. Nutrient Intake

Dietary restrictions, particularly sodium, potassium, and phosphorus in moderate-to-severe grades of kidney dysfunction, have been the foundation of the nutritional approach to patients with CKD with and without kidney replacement therapy [35]. The main objective of these dietary recommendations in advanced CKD is to slow the progression of kidney disease and treat some of the complications derived from kidney dysfunction [5]. However, dietary prescription can become restrictive, and this may limit adherence [8,9]. Furthermore, dietary prescription without proper nutritional evaluation and monitoring can severely compromise the quality of the diet and the nutritional status of the patient [5,13,36].
Figure 2. Proposed benefits of the Dieta de la Milpa in CKD.
Figure 2. Proposed benefits of the Dieta de la Milpa in CKD.
Nutrients 16 00574 g002
An alternative to individual nutrients is to focus on dietary patterns. Healthy dietary patterns, particularly the Mediterranean and DASH diets, have been shown to confer benefits in CKD. The clinical benefit of these patterns may be explained by the impact they have on risk factors of incidence [14,37], the progression of CKD [38,39], and lower mortality [13,38]. In addition to hard outcomes, such as kidney disease progression and mortality, there may be an important benefit of healthy dietary patterns on patient-centered outcomes, including quality of life and a higher degree of satisfaction and adherence to the dietary prescription [40]. Overall, there seems to be a new perspective that the traditional renal diet needs to be revised and that a liberalized diet focused on dietary patterns may be more beneficial for patients with CKD [8,11,30].
The Mediterranean and DASH diets are plant-dominant, omnivorous dietary patterns that share many characteristics with the Dieta de la Milpa (Table 2). Some similarities among the three dietary patterns include a high intake of vegetables and fruits, whole-grains, legumes, and nuts, while limiting the intake of animal-based protein, sweeteners, and ultraprocessed foods. Dairy is strongly emphasized in the DASH diet, while the Mediterranean and Dieta de la Milpa diets recommend low-to-moderate consumption. Considering these characteristics, the Dieta de la Milpa may allow for greater plant-based diversity, adaptability, and eating viability by the Latin American population, including those with CKD (Table 2). However, to date, there is no clinical evidence to suggest whether the feasibility and efficacy are similar to other healthy dietary patterns.

3.2. Dietary Acid Load

In CKD, there is a reduced ability to excrete acids such as ammonium and titratable acids [41]. These alterations in acid-base balance increase the risk of developing acidosis and may lead to muscle wasting secondary to enhanced catabolic pathways, lower anabolism, insulin resistance, a higher risk of kidney stones, and a faster progression of CKD [41,42,43].
Diet is a significant contributor to acid-base balance in kidney disease. Nutrients can be classified as acid-forming or base precursors [41,44]. The acid-producing nutrients include phosphorus and sulfur-containing amino acids, such as cysteine, methionine, and taurine, while the base-forming nutrients include potassium, magnesium, and calcium [42,44,45]. Overall, it is considered that animal-based foods, such as meat products and ultra-processed foods are acid precursors, while fruits and vegetables are base-producers, with dairy and legumes often considered neutral [41,42]. Fruits and vegetables have been shown to correct metabolic acidosis and preserve kidney function to the same extent as bicarbonate supplementation [46,47,48]. In the Dieta de la Milpa, base-producing foods and neutral foods are emphasized, including vegetables, fruits, whole grains, legumes, and dairy. In contrast, animal-based foods and ultra-processed foods are recommended at lower quantities or to be avoided. These characteristics may positively impact patients with or at risk of metabolic acidosis, particularly those with CKD G3 and higher. However, trials that test the effectiveness of the Dieta de la Milpa in helping with acid-base balance are needed.

3.3. Dietary Protein Sources

Dietary protein quantity is a primary focus for patients with CKD. People with non-dialysis-dependent CKD (moderate and advanced) are recommended to consume lower dietary protein (0.55–0.6 g/kg/d or 0.28–0.43 g/kg/d with the use of keto acid analogs) to limit the progression of CKD, while people undergoing dialysis are recommended higher amounts (1.0–1.2 g/kg/d for hemodialysis and peritoneal dialysis) to account for higher requirements and losses in the dialysis treatment [6].
In addition to the protein quantity, there is a growing focus on dietary protein sources [49,50]. In the results of the ARIC cohort, Haring et al. [51] reported a high risk of incidence for CKD when there is a higher consumption of animal protein, specifically red meat and processed meat products (HR 1.23 [95% CI 1.06–1.42]; p < 0.01), whereas higher consumption of plant-based protein and dairy had a kidney-protective role. Additionally, in the same analyses, the daily substitution of a portion of red meat by a portion of low-fat dairy, nuts, or legumes was associated with a lower incidence of CKD, concluding that there was a strong association between the development of a CKD and the source of protein instead of just the total daily amount of protein [51].
In agreement with data demonstrating the value of considering protein source, there is growing support for plant-dominant diets [49,52,53]. However, one potential concern with the emphasis on plant-based protein, although primarily theoretical, is the potential for these patterns to worsen PEW due to the lower biological value of these proteins [54]. The Dieta de la Milpa emphasizes the use of complementary proteins through the combination of plant protein sources (i.e., legumes and grains), including the corn/maize + beans combination, improving the amino acid profile. Furthermore, this dietary pattern, while plant-dominant, remains omnivorous, with the consumption of dairy, eggs, fish, poultry, and insects, with a recommendation to avoid red meat. Therefore, it is plausible that the Dieta de la Milpa can be a dietary pattern that can be applied across the spectrum of CKD, focusing on the quantity, type, and combination of dietary protein sources, but this remains to be explored in clinical trials.

3.4. Phosphorus Management

CKD-MBD is a systemic disorder that is highly prevalent in patients with CKD, and its prevalence increases as kidney function declines [55]. Dietary phosphorus reduction is often recommended for patients with CKD, especially those with hyperphosphatemia [6,56]. The 2017 KDIGO guidelines recommend reducing the phosphorus intake with the objective of normalizing phosphorus [56]. Additionally, the guidelines suggest focusing on sources of dietary phosphorus and phosphorus bioaccessibility (i.e., the phosphorus available for absorption), limiting the intake of ultra-processed foods with phosphate-containing additives and preferring sources from plant-based foods, as most of the phosphorus is phytate-bound and less bioaccessible [33,56,57]. The implementation of this restriction may be challenging, as phosphorus additives are ubiquitous in manufactured foods [57].
In the Dieta de la Milpa, there is an emphasis on plant-based foods, which can contain most of the phosphorus in the form of phytate. Due to the limited expression of phytase, the absorption may be limited, particularly compared to phosphorus in animal-based sources and phosphate additives contained in ultra-processed foods [33]. However, it is important to note that while phosphorus may be bound to phytate, processes such as fermentation, soaking, and germination may release some of the phytate-bound phosphorus, allowing for its absorption [58]. Nonetheless, plant-based diets have been shown to reduce phosphorus excretion and circulating levels of phosphorus and fibroblast growth factor-23 (FGF23), suggesting a lower phosphorus absorption. For example, Moe et al. [59] showed that diets that contained the same amount of phosphorus but differed in the source of phosphorus (plant vs. meat) led to a lower phosphorus excretion and circulating fibroblast growth factor-23 (FGF23). Similarly, Moorthi et al. [60] showed that in people with CKD stage 3–4, a diet with 70% plant-based protein also led to lower urinary phosphorus excretion. Therefore, it is possible that the Dieta de la Milpa dietary pattern may reduce the risk of hyperphosphatemia and potentially reduce the need for phosphate binders [61]. However, the benefits of the Dieta de la Milpa on markers of CKD-MBD have not been assessed.

3.5. Potassium Management

Due to the central role of the kidney in maintaining potassium homeostasis, traditional dietary guidance has restricted potassium intake in people with CKD [35]. However, observational data have questioned the strength of the relationship between dietary and serum potassium, suggesting that other factors are involved in the risk for hyperkalemia [29,62,63]. As such, it is suggested to prioritize addressing possible non-dietary causes of hyperkalemia, including hyperglycemia, acidosis, constipation, recent medication changes, and use of potassium-sparing diuretics [64]. Taking this into account, recent guidelines are less restrictive in their guidance on potassium [6]. Dietary patterns like Dieta de la Milpa may further reduce the dietary risk of hyperkalemia by reducing the intake of potassium additives present in processed foods [65], increasing the consumption of foods with complex carbohydrates that can drive the release of insulin, increasing fiber intake which may support fecal potassium excretion [66], and by limiting transit time, especially when compared to increased intake of high-potassium and low-fiber foods such as meat [53,63]. Although concerns remain, especially related to postprandial kalemia [63], recent data supports the notion that liberalized plant-based diets can be tolerated by patients with CKD, but further research is needed [46,47,48].

3.6. The Gut Microbiome

Diet has been shown to modulate the composition and function of the gut microbiota [67]. Two of the major nutrients that may modulate the composition and function of the gut microbiome in CKD are dietary fiber and protein [68]. In patients with CKD, dietary fiber consumption has been reported to be below the recommendations for healthy adults [69,70], while dietary protein is often higher in patients with non-dialysis CKD [71]. This lower dietary fiber intake may lead to reduced production of short-chain fatty acids (SCFAs), products of bacterial fermentation of dietary fiber that have been often associated with positive health outcomes [72], while microbiota-derived uremic toxins, indoxyl sulfate and p-cresyl sulfate, increase with kidney dysfunction, primarily due to a reduced ability to excrete these compounds as they are mostly protein-bound [73].
Foods emphasized in the Dieta de la Milpa that enhance the quantity and variety of types of dietary fiber, plant-based protein, and polyphenols may have the potential to impact gut microbiota composition and function, driving host effects [70,74]. Traditional Mexican foods have been associated with improvements in the gut microbiota in experimental studies in murine models of metabolic disease [75] and recently in patients with metabolic syndrome [76]. Specifically, maize (Zea mays L.), nopal (Opuntia ficus), and beans (Phaseolus vulgaris L.) have food matrices that may contain beneficial bacteria, prebiotic fibers, and polyphenols that may be beneficial for the gut microbiome [77]. For example, nixtamalized corn contains prebiotic compounds such as ferulated arabinoxylans, which can promote the growth of Bifidobacterium and increase the production of SCFAs [77]. Corn cobs are sources of xylooligosaccharides with prebiotic properties promoting the production of SCFAs and the growth of L. plantarum S2, which may have antimicrobial effects limiting pathogenic bacteria and maintaining gut homeostasis [77]. Nopal (Opuntia ficus) contains viscous, fermentable fibers (pectins and gums) and insoluble fibers (cellulose and lignin) that may have prebiotic and bulking effects, and it was shown to shift the gut microbiota composition and enhance the production of SCFAs in rats fed a high-fat diet [78,79]. Finally, common beans (Phaseolus vulgaris L.) increase Lactobacillus and Bifidobacterium and contain prebiotic oligosaccharides that may increase the bioavailability of minerals, including zinc and iron [77]. While the focus has mostly been on dietary fiber and protein, plant-based diets, including the Dieta de la Milpa, contain a variety of known and unknown compounds that also may be metabolized by the gastrointestinal microbiota, and further investigation is warranted [80].

3.7. Inflammation

CKD is described by a state of chronic low-grade inflammation, with elevated levels of both pro- and anti-inflammatory cytokines, due to a combination of reduced renal clearance as well as increased cytokine production potentially due to numerous diet-related factors, including advanced glycation, carbonyl stress, fluid overload, and acidosis [81,82,83,84,85]. Healthy behaviors, including healthy dietary patterns and physical activity, have been shown to reduce chronic inflammation [12,86]. Individual nutrients and foods may also modulate chronic inflammation, including dietary fiber, n–3 polyunsaturated fatty acids, and foods including fruits, vegetables, and legumes [10]. Dietary patterns that incorporate the intake of these foods and reduced intake of sugar and animal fats are associated with lower markers of inflammation [14]. In the Dieta de la Milpa, it is common for food preparations to be accompanied by sauces that contain a combination of tomatoes, chili peppers, and onion. The main ingredients used to prepare the sauces are tomato (Lycopersicum esculentum), tomatillo (Physalis ixocarpa), cilantro (Coriandrum sativum), onion (Allium cepa), garlic (Allium sativum), and chili (Capsicum annuum). These ingredients are sources of phenolic compounds, including phenolic acids, flavonoids, and capsaicinoids, which have antioxidant, antimicrobial, anti-inflammatory, and vasodilatory properties, among others [87]. Given these observations, it may be hypothesized that the Dieta de la Milpa could positively affect inflammation in people with CKD.

3.8. Cultural Appropriateness

One of the caveats with general nutritional recommendations for kidney disease is that these do not consider the diverse dietary patterns of people with CKD across the world. For example, countries that have a higher prevalence of plant-based eating patterns may have been at odds with previous nutritional recommendations due to the high intake of dietary potassium and total dietary phosphorus, without taking into consideration their effects on acid-base balance, blood pressure regulation, and differences in bioavailability. Similarly, the traditional Mexican and Central American diet, high in plant-based foods complemented with some animal products, may have been discouraged in individuals with CKD, again likely due to the high intake of total potassium and phosphorus [18]. However, the more recent positive narrative around plant-based dietary patterns has shifted, with the focus now on overall healthy dietary patterns, and this may provide an opening venue for the incorporation of culturally appropriate dietary patterns, such as the one described in the current manuscript [19].
Food intake relates to cultural identity and goes beyond the need to fulfill physiological needs. As nutrition professionals, we understand that what an individual eats goes beyond the nutrition prescriptions intended for CKD and that factors such as culture and the social environment impact an individual’s eating pattern and relates to satisfaction and adherence. Hence, integrating and promoting culturally appropriate dietary patterns within our practice may lead to better adherence and outcomes in patients with CKD [19]. This has been shown in other clinical populations, such as diabetes, but remains to be explored in CKD [88,89].

4. Key Research Questions to Evaluate the Measurement, Feasibility, and Effectiveness of the Diet a de la Milpa

While there may be theoretical benefits of the use of the Dieta de la Milpa due to the similarities with other healthy dietary patterns, research should focus on enhancing our understanding and evidence for the applicability of this dietary pattern in the context of CKD. We propose to focus on three main areas: (1) measurement of the dietary pattern, (2) evaluation of the feasibility and acceptability, and (3) evaluation of the effectiveness at improving clinical and patient-centered outcomes.

4.1. The Development or Adaptation of a Metric to Evaluate the Adherence to the Dieta de la Milpa

Cross-sectional and epidemiological studies provide important evidence to support the use of a specific dietary intervention. For the Mediterranean [90] and DASH [91] diets, scoring systems can be utilized and adapted for measuring dietary intake. Santiago-Torres et al. [92] developed a traditional Mexican diet score, which includes 12 food components (corn tortillas, beans, soups, Mexican mixed dishes, vegetables, whole fruits, rice, full-fat milk, full-fat Mexican cheeses, and low consumption of oils, solid fats, added sugars, processed meats, and refined grains), similar to the recommendations of the Dieta de la Milpa. Research should focus on the utilization of this traditional Mexican diet score or the development of a Dieta de la Milpa-specific diet score and outcomes related to CKD.

4.2. Evaluation of the Feasibility and Acceptability of the Dieta de la Milpa in People with CKD

Semi-structured interviews have highlighted the negative consequences of the traditional renal diet in people from Latin America [18]. However, there is no evidence of the acceptability of this dietary pattern by people affected with CKD (in the Mesoamerica region and elsewhere) as well as the feasibility of Dieta de la Milpa pattern consumption in countries outside of the Mesoamerica region. Moreover, while the four foundational foods (corn/maize, common beans, pumpkins/squash, and chilies) may be accessible outside the Mesoamerica region, several of the plant-based foods recommended may not. Therefore, the adaptability of the dietary pattern should also be explored.

4.3. Evaluation of the Effectiveness of the Dieta de la Milpa in CKD

There is evidence that a traditional Mexican diet can have cardiometabolic benefits [76,93]. However, the impact of consuming this dietary pattern on clinical and patient-centered outcomes is needed. Outcomes of interest include cardiometabolic health, kidney function, the gut microbiome, and quality of life.

5. Conclusions

The traditional renal diet is highly restrictive. Focusing on dietary patterns rather than the restriction of single or multiple nutrients may improve adherence across the CKD spectrum. However, commonly recommended dietary patterns, such as the Mediterranean diet, may limit foods that are staples consumed by people from Latin America and may lack cultural concordance. The recently proposed Dieta de la Milpa has many components that may benefit people with CKD while utilizing foods commonly utilized in this population. As this dietary pattern is plant-dominant yet omnivorous, there are plausible benefits that include improvement/maintenance of kidney function, the promotion of base-forming foods helping with acid base balance, improvement of the gut microbiome due to a higher quantity and diversity of dietary fiber, consumption of less bioaccessible phosphorus food sources helping with phosphorus management, consumption of foods with anti-inflammatory properties, and the benefit of being a culturally appropriate dietary pattern for people from the Mesoamerica region. These proposed benefits, however, currently lack evidence in the CKD context and should be tested in clinical trials to evaluate the feasibility and effectiveness of the adoption of the Dieta de la Milpa dietary pattern.

Supplementary Materials

The following supporting information can be downloaded at:, Table S1: Nutrient composition of some foods recommended in the Dieta de la Milpa food pattern.

Author Contributions

Conceptualization, A.B. and G.L.-E.; writing—original draft preparation, A.B. and G.L.-E.; writing—review and editing, Á.E.-C., L.M. and B.M.K. All authors have read and agreed to the published version of the manuscript.


A.B. was funded by Indiana Clinical and Translational Sciences Institute KL2 and K12 Programs: KL2TR002530, UL1TR002529, and K12TR004415. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


Figures were created in (accessed on 17 February 2024).

Conflicts of Interest

A.B. has received honoraria from Amgen, research grants from Keryx Pharmaceuticals for work unrelated to the present manuscript, is part of the Next Generation Scientists Cohort of the National Dairy Council, and served as a scientific consultant for IGH Naturals, Inc. and Ardelyx. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. BMK has received research funding from the Academy of Nutrition and Dietetics Foundation, the National Kidney Foundation, and served as a scientific consultant or member of the Academy of Nutrition and Dietetics, International Society of Renal Nutrition and Metabolism, Journal of Renal Nutrition, Abbott Nutrition Health Institute, and Fresenius Medical Care.


  1. Kovesdy, C.P. Epidemiology of chronic kidney disease: An update 2022. Kidney Int. Suppl. 2022, 12, 7–11. [Google Scholar] [CrossRef] [PubMed]
  2. Desai, N.; Lora, C.M.; Lash, J.P.; Ricardo, A.C. CKD and ESRD in US Hispanics. Am. J. Kidney Dis. 2019, 73, 102–111. [Google Scholar] [CrossRef] [PubMed]
  3. Luxardo, R.; Kramer, A.; González-Bedat, M.C.; Massy, Z.A.; Jager, K.J.; Rosa-Diez, G.; Noordzij, M. The epidemiology of renal replacement therapy in two different parts of the world: The Latin American Dialysis and Transplant Registry versus the European Renal Association-European Dialysis and Transplant Association Registry. Rev. Panam. Salud Publica 2018, 42, e87. [Google Scholar] [CrossRef] [PubMed]
  4. Pecoits-Filho, R.; Sola, L.; Correa-Rotter, R.; Granado, R.C.-D.; Douthat, W.G.; Bellorin-Font, E. Kidney disease in Latin America: Current status, challenges, and the role of the ISN in the development of nephrology in the region. Kidney Int. 2018, 94, 1069–1072. [Google Scholar] [CrossRef] [PubMed]
  5. Beto, J.A.; Ramirez, W.E.; Bansal, V.K. Medical nutrition therapy in adults with chronic kidney disease: Integrating evidence and consensus into practice for the generalist registered dietitian nutritionist. J. Acad. Nutr. Diet. 2014, 114, 1077–1087. [Google Scholar] [CrossRef]
  6. Ikizler, T.A.; Burrowes, J.D.; Byham-Gray, L.D.; Campbell, K.L.; Carrero, J.J.; Chan, W.; Fouque, D.; Friedman, A.N.; Ghaddar, S.; Goldstein-Fuchs, D.J.; et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am. J. Kidney Dis. 2020, 76, S1–S107. [Google Scholar] [CrossRef]
  7. Shinaberger, C.S.; Greenland, S.; Kopple, J.D.; Van Wyck, D.; Mehrotra, R.; Kovesdy, C.P.; Kalantar-Zadeh, K. Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease? Am. J. Clin. Nutr. 2008, 88, 1511–1518. [Google Scholar] [CrossRef]
  8. Biruete, A.; Jeong, J.H.; Barnes, J.L.; Wilund, K.R. Modified Nutritional Recommendations to Improve Dietary Patterns and Outcomes in Hemodialysis Patients. J. Ren. Nutr. 2017, 27, 62–70. [Google Scholar] [CrossRef]
  9. Kalantar-Zadeh, K.; Tortorici, A.R.; Chen, J.L.; Kamgar, M.; Lau, W.L.; Moradi, H.; Rhee, C.M.; Streja, E.; Kovesdy, C.P. Dietary restrictions in dialysis patients: Is there anything left to eat? Semin. Dial. 2015, 28, 159–168. [Google Scholar] [CrossRef]
  10. Kant, A.K. Dietary patterns and health outcomes. J. Am. Diet. Assoc. 2004, 104, 615–635. [Google Scholar] [CrossRef]
  11. Campbell, K.L.; Carrero, J.J. Diet for the Management of Patients With Chronic Kidney Disease; It Is Not the Quantity, but the Quality That Matters. J. Ren. Nutr. 2016, 26, 279–281. [Google Scholar] [CrossRef]
  12. Chauveau, P.; Aparicio, M.; Bellizzi, V.; Campbell, K.; Hong, X.; Johansson, L.; Kolko, A.; Molina, P.; Sezer, S.; Wanner, C.; et al. Mediterranean diet as the diet of choice for patients with chronic kidney disease. Nephrol. Dial. Transpl. 2018, 33, 725–735. [Google Scholar] [CrossRef]
  13. Kelly, J.T.; Palmer, S.C.; Wai, S.N.; Ruospo, M.; Carrero, J.-J.; Campbell, K.L.; Strippoli, G.F.M. Healthy Dietary Patterns and Risk of Mortality and ESRD in CKD: A Meta-Analysis of Cohort Studies. Clin. J. Am. Soc. Nephrol. 2017, 12, 272–279. [Google Scholar] [CrossRef]
  14. Bach, K.E.; Kelly, J.T.; Palmer, S.C.; Khalesi, S.; Strippoli, G.F.; Campbell, K.L. Healthy Dietary Patterns and Incidence of CKD: A Meta-Analysis of Cohort Studies. Clin. J. Am. Soc. Nephrol. 2019, 14, 1441–1449. [Google Scholar] [CrossRef]
  15. Kistler, B.M.; Moore, L.W.; Benner, D.; Biruete, A.; Boaz, M.; Brunori, G.; Chen, J.; Drechsler, C.; Guebre-Egziabher, F.; Hensley, M.K.; et al. The International Society of Renal Nutrition and Metabolism Commentary on the National Kidney Foundation and Academy of Nutrition and Dietetics KDOQI Clinical Practice Guideline for Nutrition in Chronic Kidney Disease. J. Ren. Nutr. 2021, 31, 116–120 e1. [Google Scholar] [CrossRef]
  16. Sotos-Prieto, M.; Mattei, J. Mediterranean Diet and Cardiometabolic Diseases in Racial/Ethnic Minority Populations in the United States. Nutrients 2018, 10, 352. [Google Scholar] [CrossRef]
  17. Hiza, H.A.; Casavale, K.O.; Guenther, P.M.; Davis, C.A. Diet quality of Americans differs by age, sex, race/ethnicity, income, and education level. J. Acad. Nutr. Diet. 2013, 113, 297–306. [Google Scholar] [CrossRef]
  18. Cervantes, L.; Rizzolo, K.; Carr, A.L.; Steiner, J.F.; Chonchol, M.; Powe, N.; Cukor, D.; Hasnain-Wynia, R. Social and Cultural Challenges in Caring for Latinx Individuals With Kidney Failure in Urban Settings. JAMA Netw Open 2021, 4, e2125838. [Google Scholar] [CrossRef]
  19. Perez, L.; Biruete, A. Lack of Cultural and Language Concordant Nutrition Education for Hispanic/Latinx Individuals with Chronic Kidney Disease: A Call to Action. J. Am. Soc. Nephrol. 2022, 33, 1262–1264. [Google Scholar] [CrossRef]
  20. Almaguer-González, J.A.; García-Ramírez, J.H.; Padilla-Mirazo, M.; González-Ferral, M. Dieta de la Milpa: Modelo de Alimentación Mesoamericana Biocompatible; Secretaria de Salud: Ciudad de Mexico, Mexico, 2019. [Google Scholar]
  21. Sánchez-Velázquez, O.A.; Luna-Vital, D.A.; Morales-Hernandez, N.; Contreras, J.; Villaseñor-Tapia, E.C.; Fragoso-Medina, J.A.; Mojica, L. Nutritional, bioactive components and health properties of the milpa triad system seeds (corn, common bean and pumpkin). Front. Nutr. 2023, 10, 1169675. [Google Scholar] [CrossRef] [PubMed]
  22. Ojeda-Granados, C.; Panduro, A.; Gonzalez-Aldaco, K.; Sepulveda-Villegas, M.; Rivera-Iñiguez, I.; Roman, S. Tailoring Nutritional Advice for Mexicans Based on Prevalence Profiles of Diet-Related Adaptive Gene Polymorphisms. J. Pers. Med. 2017, 7, 16. [Google Scholar] [CrossRef]
  23. Gwirtz, J.A.; Garcia-Casal, M.N. Processing maize flour and corn meal food products. Ann. N. Y. Acad. Sci. 2014, 1312, 66–75. [Google Scholar] [CrossRef]
  24. Turco, V.L.; Potortì, A.G.; Rando, R.; Ravenda, P.; Dugo, G.; Di Bella, G. Functional properties and fatty acids profile of different beans varieties. Nat. Prod. Res. 2016, 30, 2243–2248. [Google Scholar] [CrossRef] [PubMed]
  25. Hernández, D.F.; Mojica, L.; Berhow, M.A.; Brownstein, K.; Cervantes, E.L.; de Mejia, E.G. Black and pinto beans (Phaseolus vulgaris L.) unique mexican varieties exhibit antioxidant and anti-inflammatory potential. Food Res. Int. 2023, 169, 112816. [Google Scholar] [CrossRef] [PubMed]
  26. Sumida, K.; Biruete, A.; Kistler, B.M.; Khor, B.-H.; Ebrahim, Z.; Giannini, R.; Sussman-Dabach, E.J.; Avesani, C.M.; Chan, M.; Lambert, K.; et al. New insights into dietary approaches to potassium management in chronic kidney disease. J. Ren. Nutr. 2023, 33, S6–S12. [Google Scholar] [CrossRef]
  27. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Tables of Composition of Mexican Foods and Food Products (Condensed Version; 2015); Departamento de Ciencia y Tecnología de los Alimentos: Ciudad de México, México, 2016. [Google Scholar]
  28. Instituto de Nutrición de Centro América y Panamá (INCAP) y Organización Panamericana de la Salud (OPS). Tabla de composicion de alimentos de Centroamérica; INCAP/OPS: Apartado, Guatemala, 2007. [Google Scholar]
  29. Perez-Lizaur, A.B.; Palacios-Gonzalez, B. Sistema Mexicano de Alimentos Equivalentes, 5th ed.; Fomento de Nutrición y SaludÑ: Mexico City, Mexico, 2022. [Google Scholar]
  30. Sussman, E.J.; Singh, B.; Clegg, D.; Palmer, B.F.; Kalantar-Zadeh, K. Let Them Eat Healthy: Can Emerging Potassium Binders Help Overcome Dietary Potassium Restrictions in Chronic Kidney Disease? J. Ren. Nutr. 2020, 30, 475–483. [Google Scholar] [CrossRef]
  31. Bazzano, L.A.; Green, T.; Harrison, T.N.; Reynolds, K. Dietary approaches to prevent hypertension. Curr. Hypertens Rep. 2013, 15, 694–702. [Google Scholar] [CrossRef] [PubMed]
  32. Chen, Y.; Sang, Y.; Ballew, S.H.; Tin, A.; Chang, A.R.; Matsushita, K.; Coresh, J.; Kalantar-Zadeh, K.; Molnar, M.Z.; Grams, M.E. Race, Serum Potassium, and Associations with ESRD and Mortality. Am. J. Kidney Dis. 2017, 70, 244–251. [Google Scholar] [CrossRef]
  33. Biruete, A.; Gallant, K.M.H.; Lloyd, L.; Meade, A.; Moe, S.M.; St-Jules, D.E.; Kistler, B.M. ‘Phos’tering a clear message: The evolution of dietary phosphorus management in chronic kidney disease. J. Ren. Nutr. 2023, 33, S13–S20. [Google Scholar] [CrossRef]
  34. Avesani, C.M.; Cuppari, L.; Nerbass, F.B.; Lindholm, B.; Stenvinkel, P. Ultraprocessed foods and chronic kidney disease-double trouble. Clin. Kidney J. 2023, 16, 1723–1736. [Google Scholar] [CrossRef]
  35. K/DOQI, National Kidney Foundation. Clinical practice guidelines for nutrition in chronic renal failure. Am. J. Kidney Dis. 2000, 35 (Suppl. S2), S1–S140. [Google Scholar]
  36. Asghari, G.; Momenan, M.; Yuzbashian, E.; Mirmiran, P.; Azizi, F. Dietary pattern and incidence of chronic kidney disease among adults: A population-based study. Nutr. Metab. 2018, 15, 88. [Google Scholar] [CrossRef] [PubMed]
  37. Huang, X.; Jiménez-Moleón, J.J.; Lindholm, B.; Cederholm, T.; Ärnlöv, J.; Risérus, U.; Sjögren, P.; Carrero, J.J. Mediterranean diet, kidney function, and mortality in men with CKD. Clin. J. Am. Soc. Nephrol. 2013, 8, 1548–1555. [Google Scholar] [CrossRef] [PubMed]
  38. Wai, S.N.; Kelly, J.T.; Johnson, D.W.; Campbell, K.L. Dietary Patterns and Clinical Outcomes in Chronic Kidney Disease: The CKD.QLD Nutrition Study. J. Ren. Nutr. 2017, 27, 175–182. [Google Scholar] [CrossRef]
  39. Banerjee, T.; Crews, D.C.; Tuot, D.S.; Pavkov, M.E.; Burrows, N.R.; Stack, A.G.; Saran, R.; Bragg-Gresham, J.; Powe, N.R.; Hsu, C.-Y.; et al. Poor accordance to a DASH dietary pattern is associated with higher risk of ESRD among adults with moderate chronic kidney disease and hypertension. Kidney Int. 2019, 95, 1433–1442. [Google Scholar] [CrossRef]
  40. Piccoli, G.B.; Di Iorio, B.R.; Chatrenet, A.; D’alessandro, C.; Nazha, M.; Capizzi, I.; Vigotti, F.N.; Fois, A.; Maxia, S.; Saulnier, P.; et al. Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: A multicentre study with long-term outcome data (TOrino-Pisa study). Nephrol. Dial. Transpl. 2019, 35, 790–802. [Google Scholar] [CrossRef]
  41. Raphael, K.L. Metabolic Acidosis in CKD: Core Curriculum 2019. Am. J. Kidney Dis. 2019, 74, 263–275. [Google Scholar] [CrossRef]
  42. Osuna-Padilla, I.; Leal-Escobar, G.; Garza-García, C.; Rodríguez-Castellanos, F. Dietary Acid Load: Mechanisms and evidence of its health repercussions. Nefrologia 2019, 39, 343–354. [Google Scholar] [CrossRef]
  43. Betz, M.V.; Penniston, K.L. Primary Contributors to Dietary Acid Load in Patients with Urolithiasis. J. Ren. Nutr. 2023, 33, 53–58. [Google Scholar] [CrossRef]
  44. Brown, L.; Luciano, A.; Pendergast, J.; Khairallah, P.; Anderson, C.A.; Sondheimer, J.; Hamm, L.L.; Ricardo, A.C.; Rahman, M.; Miller, E.R.; et al. Predictors of Net Acid Excretion in the Chronic Renal Insufficiency Cohort (CRIC) Study. Am. J. Kidney Dis. 2019, 74, 203–212. [Google Scholar] [CrossRef]
  45. Scialla, J.J.; Asplin, J.; Dobre, M.; Chang, A.R.; Lash, J.; Hsu, C.-Y.; Kallem, R.R.; Hamm, L.L.; Feldman, H.I.; Chen, J.; et al. Higher net acid excretion is associated with a lower risk of kidney disease progression in patients with diabetes. Kidney Int. 2017, 91, 204–215. [Google Scholar] [CrossRef]
  46. Goraya, N.; Simoni, J.; Jo, C.H.; Wesson, D.E. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney Int. 2014, 86, 1031–1038. [Google Scholar] [CrossRef]
  47. Goraya, N.; Munoz-Maldonado, Y.; Simoni, J.; Wesson, D.E. Fruit and Vegetable Treatment of Chronic Kidney Disease-Related Metabolic Acidosis Reduces Cardiovascular Risk Better than Sodium Bicarbonate. Am. J. Nephrol. 2019, 49, 438–448. [Google Scholar] [CrossRef]
  48. Goraya, N.; Munoz-Maldonado, Y.; Simoni, J.; Wesson, D.E. Treatment of Chronic Kidney Disease-Related Metabolic Acidosis with Fruits and Vegetables Compared to NaHCO. J. Ren. Nutr. 2021, 31, 239–247. [Google Scholar] [CrossRef]
  49. Joshi, S.; Shah, S.; Kalantar-Zadeh, K. Adequacy of Plant-Based Proteins in Chronic Kidney Disease. J. Ren. Nutr. 2019, 29, 112–117. [Google Scholar] [CrossRef]
  50. Burstad, K.M.; Cladis, D.P.; Wiese, G.N.; Butler, M.; Gallant, K.M.H. Effects of Plant-Based Protein Consumption on Kidney Function and Mineral Bone Disorder Outcomes in Adults With Stage 3-5 Chronic Kidney Disease: A Systematic Review. J. Ren. Nutr. 2023, 33, 717–730. [Google Scholar] [CrossRef]
  51. Haring, B.; Selvin, E.; Liang, M.; Coresh, J.; Grams, M.E.; Petruski-Ivleva, N.; Steffen, L.M.; Rebholz, C.M. Dietary Protein Sources and Risk for Incident Chronic Kidney Disease: Results from the Atherosclerosis Risk in Communities (ARIC) Study. J. Ren. Nutr. 2017, 27, 233–242. [Google Scholar] [CrossRef]
  52. Chauveau, P.; Koppe, L.; Combe, C.; Lasseur, C.; Trolonge, S.; Aparicio, M. Vegetarian diets and chronic kidney disease. Nephrol. Dial. Transpl. 2019, 34, 199–207. [Google Scholar] [CrossRef]
  53. Carrero, J.J.; González-Ortiz, A.; Avesani, C.M.; Bakker, S.J.L.; Bellizzi, V.; Chauveau, P.; Clase, C.M.; Cupisti, A.; Espinosa-Cuevas, A.; Molina, P.; et al. Plant-based diets to manage the risks and complications of chronic kidney disease. Nat. Rev. Nephrol. 2020, 16, 525–542. [Google Scholar] [CrossRef]
  54. Tallman, D.A.; Khor, B.-H.; Karupaiah, T.; Khosla, P.; Chan, M.; Kopple, J.D. Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients. J. Ren. Nutr. 2023, 33, 249–260. [Google Scholar] [CrossRef]
  55. Moe, S.M.; Drüeke, T.; Lameire, N.; Eknoyan, G. Chronic kidney disease-mineral-bone disorder: A new paradigm. Adv. Chronic Kidney Dis. 2007, 14, 3–12. [Google Scholar] [CrossRef]
  56. Ketteler, M.; Block, G.A.; Evenepoel, P.; Fukagawa, M.; Herzog, C.A.; McCann, L.; Moe, S.M.; Shroff, R.; Tonelli, M.A.; Toussaint, N.D.; et al. Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann. Intern. Med. 2018, 168, 422–430. [Google Scholar] [CrossRef] [PubMed]
  57. Uribarri, J.; Calvo, M.S. Hidden sources of phosphorus in the typical American diet: Does it matter in nephrology? Semin. Dial. 2003, 16, 186–188. [Google Scholar] [CrossRef]
  58. Gupta, R.K.; Gangoliya, S.S.; Singh, N.K. Reduction of phytic acid and enhancement of bioavailable micronutrients in food grains. J. Food Sci. Technol. 2015, 52, 676–684. [Google Scholar] [CrossRef]
  59. Moe, S.M.; Zidehsarai, M.P.; Chambers, M.A.; Jackman, L.A.; Radcliffe, J.S.; Trevino, L.L.; Donahue, S.E.; Asplin, J.R. Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin. J. Am. Soc. Nephrol. 2011, 6, 257–264. [Google Scholar] [CrossRef]
  60. Moorthi, R.N.; Armstrong, C.L.; Janda, K.; Ponsler-Sipes, K.; Asplin, J.R.; Moe, S.M. The effect of a diet containing 70% protein from plants on mineral metabolism and musculoskeletal health in chronic kidney disease. Am. J. Nephrol. 2014, 40, 582–591. [Google Scholar] [CrossRef]
  61. Cupisti, A.; Kalantar-Zadeh, K. Management of natural and added dietary phosphorus burden in kidney disease. Semin. Nephrol. 2013, 33, 180–190. [Google Scholar] [CrossRef]
  62. Noori, N.; Kalantar-Zadeh, K.; Kovesdy, C.P.; Murali, S.B.; Bross, R.; Nissenson, A.R.; Kopple, J.D. Dietary potassium intake and mortality in long-term hemodialysis patients. Am. J. Kidney Dis. 2010, 56, 338–347. [Google Scholar] [CrossRef]
  63. St-Jules, D.E.; Fouque, D. Etiology-based dietary approach for managing hyperkalemia in people with chronic kidney disease. Nutr. Rev. 2022, 80, 2198–2205. [Google Scholar] [CrossRef]
  64. MacLaughlin, H.L.; Friedman, A.N.; Ikizler, T.A. Nutrition in Kidney Disease: Core Curriculum 2022. Am. J. Kidney Dis. 2022, 79, 437–449. [Google Scholar] [CrossRef]
  65. Sherman, R.A.; Mehta, O. Phosphorus and potassium content of enhanced meat and poultry products: Implications for patients who receive dialysis. Clin. J. Am. Soc. Nephrol. 2009, 4, 1370–1373. [Google Scholar] [CrossRef]
  66. Clase, C.M.; Carrero, J.-J.; Ellison, D.H.; Grams, M.E.; Hemmelgarn, B.R.; Jardine, M.J.; Kovesdy, C.P.; Kline, G.A.; Lindner, G.; Obrador, G.T.; et al. Potassium homeostasis and management of dyskalemia in kidney diseases: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2020, 97, 42–61. [Google Scholar] [CrossRef]
  67. David, L.A.; Maurice, C.F.; Carmody, R.N.; Gootenberg, D.B.; Button, J.E.; Wolfe, B.E.; Ling, A.V.; Devlin, A.S.; Varma, Y.; Fischbach, M.A.; et al. Diet rapidly and reproducibly alters the human gut microbiome. Nature 2014, 505, 559–563. [Google Scholar] [CrossRef]
  68. Evenepoel, P.; Meijers, B.K.; Bammens, B.R.; Verbeke, K. Uremic toxins originating from colonic microbial metabolism. Kidney Int. Suppl. 2009, 76, S12–S19. [Google Scholar] [CrossRef]
  69. Luis, D.; Zlatkis, K.; Comenge, B.; García, Z.; Navarro, J.F.; Lorenzo, V.; Carrero, J.J. Dietary Quality and Adherence to Dietary Recommendations in Patients Undergoing Hemodialysis. J. Ren. Nutr. 2016, 26, 190–195. [Google Scholar] [CrossRef]
  70. Biruete, A.; Shin, A.; Kistler, B.M.; Moe, S.M. Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis. Semin. Dial. 2021. [Google Scholar] [CrossRef]
  71. Kalantar-Zadeh, K.; Moore, L.W.; Tortorici, A.R.; Chou, J.A.; St-Jules, D.E.; Aoun, A.; Rojas-Bautista, V.; Tschida, A.K.; Rhee, C.M.; Shah, A.A.; et al. North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease. BMC Nephrol. 2016, 17, 90. [Google Scholar] [CrossRef]
  72. Alexander, C.; Swanson, K.S.; Fahey, G.C., Jr.; Garleb, K.A. Perspective: Physiologic Importance of Short-Chain Fatty Acids from Nondigestible Carbohydrate Fermentation. Adv. Nutr. 2019, 10, 576–589. [Google Scholar] [CrossRef]
  73. Vanholder, R.; Schepers, E.; Pletinck, A.; Nagler, E.V.; Glorieux, G. The uremic toxicity of indoxyl sulfate and p-cresyl sulfate: A systematic review. J. Am. Soc. Nephrol. 2014, 25, 1897–1907. [Google Scholar] [CrossRef]
  74. Su, G.; Qin, X.; Yang, C.; Sabatino, A.; Kelly, J.T.; Avesani, C.M.; Carrero, J.J. Fiber intake and health in people with chronic kidney disease. Clin. Kidney J. 2022, 15, 213–225. [Google Scholar] [CrossRef]
  75. Avila-Nava, A.; Noriega, L.G.; Tovar, A.R.; Granados, O.; Perez-Cruz, C.; Pedraza-Chaverri, J.; Torres, N. Food combination based on a pre-hispanic Mexican diet decreases metabolic and cognitive abnormalities and gut microbiota dysbiosis caused by a sucrose-enriched high-fat diet in rats. Mol. Nutr. Food Res. 2017, 61, 1501023. [Google Scholar] [CrossRef]
  76. Guevara-Cruz, M.; Flores-López, A.G.; Aguilar-López, M.; Sánchez-Tapia, M.; Medina-Vera, I.; Díaz, D.; Tovar, A.R.; Torres, N. Improvement of Lipoprotein Profile and Metabolic Endotoxemia by a Lifestyle Intervention That Modifies the Gut Microbiota in Subjects With Metabolic Syndrome. J. Am. Heart Assoc. 2019, 8, e012401. [Google Scholar] [CrossRef]
  77. Torres-Maravilla, E.; Méndez-Trujillo, V.; Hernández-Delgado, N.C.; Bermúdez-Humarán, L.G.; Reyes-Pavón, D. Looking inside Mexican Traditional Food as Sources of Synbiotics for Developing Novel Functional Products. Fermentation 2022, 8, 123. [Google Scholar] [CrossRef]
  78. Remes-Troche, J.M.; Taboada-Liceaga, H.; Gill, S.; Amieva-Balmori, M.; Rossi, M.; Hernández-Ramírez, G.; García-Mazcorro, J.F.; Whelan, K. Nopal fiber (Opuntia ficus-indica) improves symptoms in irritable bowel syndrome in the short term: A randomized controlled trial. Neurogastroenterol. Motil. 2021, 33, e13986. [Google Scholar] [CrossRef]
  79. Moran-Ramos, S.; He, X.; Chin, E.L.; Tovar, A.R.; Torres, N.; Slupsky, C.M.; Raybould, H.E. Nopal feeding reduces adiposity, intestinal inflammation and shifts the cecal microbiota and metabolism in high-fat fed rats. PLoS ONE 2017, 12, e0171672. [Google Scholar] [CrossRef]
  80. Wiese, G.N.; Biruete, A.; Moorthi, R.N.; Moe, S.M.; Lindemann, S.R.; Gallant, K.M.H. Plant-Based Diets, the Gut Microbiota, and Trimethylamine N-Oxide Production in Chronic Kidney Disease: Therapeutic Potential and Methodological Considerations. J. Ren. Nutr. 2020, 31, 121–131. [Google Scholar] [CrossRef]
  81. Amdur, R.L.; Feldman, H.I.; Gupta, J.; Yang, W.; Kanetsky, P.; Shlipak, M.; Rahman, M.; Lash, J.P.; Townsend, R.R.; Ojo, A.; et al. Inflammation and Progression of CKD: The CRIC Study. Clin. J. Am. Soc. Nephrol. 2016, 11, 1546–1556. [Google Scholar] [CrossRef]
  82. Suliman, M.E.; Heimbürger, O.; Bárány, P.; Anderstam, B.; Pecoits-Filho, R.; Ayala, E.R.; Qureshi, A.R.; Fehrman-Ekholm, I.; Lindholm, B.; Stenvinkel, P. Plasma pentosidine is associated with inflammation and malnutrition in end-stage renal disease patients starting on dialysis therapy. J. Am. Soc. Nephrol. 2003, 14, 1614–1622. [Google Scholar] [CrossRef]
  83. Aveles, P.R.; Criminácio, C.R.; Gonçalves, S.; Bignelli, A.T.; Claro, L.M.; Siqueira, S.S.; Nakao, L.S.; Pecoits-Filho, R. Association between biomarkers of carbonyl stress with increased systemic inflammatory response in different stages of chronic kidney disease and after renal transplantation. Nephron Clin. Pract. 2010, 116, c294–c299. [Google Scholar] [CrossRef]
  84. Ori, Y.; Bergman, M.; Bessler, H.; Zingerman, B.; Levy-Drummer, R.S.; Gafter, U.; Salman, H. Cytokine secretion and markers of inflammation in relation to acidosis among chronic hemodialysis patients. Blood Purif. 2013, 35, 181–186. [Google Scholar] [CrossRef]
  85. Carrero, J.J.; Kistler, B.M.; Stenvinkel, P. Inflammation in Chronic Kidney Disease, 4th ed.; Kopple, J.D., Massry, S.G., Kalantar-Zadeh, K., Fouque, D., Eds.; Nutritional Management of Renal Disease; Academic Press: Cambridge, MA, USA, 2022. [Google Scholar]
  86. Woods, J.A.; Wilund, K.R.; Martin, S.A.; Kistler, B.M. Exercise, inflammation and aging. Aging Dis. 2012, 3, 130–140. [Google Scholar]
  87. Perales-Vázquez, G.D.C.; Mercado-Mercado, G.; Rosa, L.A.; Sáyago-Ayerdi, S.G. Bioaccesibilidad y cinética de liberación in vitro de compuestos fenólicos en algunas salsas de la cocina mexicana. Rev. Espec. Cienc. Químico-Biológicas 2020, 23, 1–9. [Google Scholar] [CrossRef]
  88. Goody, C.M.; Drago, L. Using Cultural Competence Constructs to Understand Food Practices and Provide Diabetes Care and Education. Diabetes Spectr. 2009, 22, 43–47. [Google Scholar] [CrossRef]
  89. Edwards, C.; Orellana, E.; Rawlings, K.; Rodriguez-Pla, M.; Venkatesan, A. Changes in Glycemic Control Following Use of a Spanish-Language, Culturally Adapted Diabetes Program: Retrospective Study. JMIR Form. Res. 2022, 6, e40278. [Google Scholar] [CrossRef]
  90. Aoun, C.; Papazian, T.; Helou, K.; El Osta, N.; Khabbaz, L.R. Comparison of five international indices of adherence to the Mediterranean diet among healthy adults: Similarities and differences. Nutr. Res. Pract. 2019, 13, 333–343. [Google Scholar] [CrossRef]
  91. Folsom, A.R.; Parker, E.D.; Harnack, L.J. Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease. Am. J. Hypertens 2007, 20, 225–232. [Google Scholar] [CrossRef]
  92. Santiago-Torres, M.; Tinker, L.F.; Allison, M.A.; Breymeyer, K.L.; Garcia, L.; Kroenke, C.H.; Lampe, J.W.; Shikany, J.M.; Van Horn, L.; Neuhouser, M.L. Development and Use of a Traditional Mexican Diet Score in Relation to Systemic Inflammation and Insulin Resistance among Women of Mexican Descent. J. Nutr. 2015, 145, 2732–2740. [Google Scholar] [CrossRef] [PubMed]
  93. Santiago-Torres, M.; Kratz, M.; Lampe, J.W.; Tapsoba, J.D.D.; Breymeyer, K.L.; Levy, L.; Villaseñor, A.; Wang, C.-Y.; Song, X.; Neuhouser, M.L. Metabolic responses to a traditional Mexican diet compared with a commonly consumed US diet in women of Mexican descent: A randomized crossover feeding trial. Am. J. Clin. Nutr. 2016, 103, 366–374. [Google Scholar] [CrossRef]
Figure 1. Dieta de la Milpa description by food groups. Adapted with permission from [20].
Figure 1. Dieta de la Milpa description by food groups. Adapted with permission from [20].
Nutrients 16 00574 g001
Table 1. Components of the Dieta de la Milpa.
Table 1. Components of the Dieta de la Milpa.
ComponentExamples [20]Characteristics and Recommendations [20]Considerations for People with CKD
(1) VegetablesNopal (cactus), tomatoes, green beans, quelites, quintile, verdolagas (purslane), romeritos, huazontle, green tomatoes, chilies, bell peppers, squash, chayote squash, chilacayote, colorines, izote flower, jicama, watercress, chaya, huitlacoche, achiote, epazote, vanilla, Mexican pepperleaf, mushrooms, and others.Eat a combination of these daily in high quantities; make them the base of your plate.

Nutrient-dense foods, high in dietary fiber, vitamins, and minerals.
Consider potassium content per portion and cooking methods to reduce potassium content [29].

Consider the use of potassium binders, as described by Sussman et al. [30] in order to liberalize the diet in those at risk of hyperkalemia.
(2) Starchy vegetablesSweet potatoes, yuca, chayotextle.2–4 times per week considering physical activity.
Combine them with legumes and vegetables
Consider potassium content per portion [29].

Consider carbohydrate content and its impact on insulin release, as this may limit the rise in serum potassium [29,31,32].
(3) FruitsGuanabana (soursop), tuna, papaya, black zapote, chicozapote, mamey, guava, tejocote, capulin, pineapple, anona, xoconostle, chirimoya (custard Apple), nance, berries, yellow plum, dragon fruit.Consume daily according to physical activity.

These foods are high in dietary fiber, vitamins, minerals, antioxidants and should not be consumed with added sugar.

Whole fruit consumption is recommended rather than juice.
Consider potassium content per portion [29].

Consider carbohydrate content and its impact on insulin release, as this may limit the rise in serum potassium [29,31,32].

The objective is to maintain serum potassium < 5.5 mmol/L (ideal < 4 mmol/L) [32].
(4) Legumes and (5) nutsCommon beans, lima beans, squash seeds (pepitas), chickpeas, lentils, chia seeds, peanuts, and pine nuts.Consume daily ½ to 1 cup, prioritize daily consumption if animal-based proteins are not consumed.

These foods are high in plant-based proteins, dietary fiber, iron, fat, and B-vitamins.
Consider cooking methods to reduce potassium and phosphorus in beans [29,33].

Consider portion control [29,33].
(6) Healthy fatsAvocado.Not more than ¾ of an avocado daily.

High in dietary fiber, potassium, vitamin E, vitamin C, and monounsaturated fats.
Consider potassium content per portion [29].
(7) Whole grainsCorn/maize, amaranth.Daily according to physical activity; consider sources without added sugars and animal-based fats.

High in energy, dietary fiber, calcium, iron, folic acid, phosphorus (phytate-bound), potassium.
Consider potassium content per portion [29].

Consider carbohydrate content and its impact on insulin release, as this may limit the rise in serum potassium [29,31,32].
(8) Animal protein
a. Eggs and seafood

b. Poultry

c. Insects

Eggs, catfish, trout, white fish, bass, mojarra, sierra, crab, mussels, oysters, acamayas, octopus, shrimp.

Local chicken and turkey.

Crickets, maguey worms, chinicuiles, chicatana ant, honey ant, jumiles.

With poultry and insects, 3–4 times per week.

Moderate consumption of these foods is recommended. Combine with vegetables.

Sources of protein and phosphorus. Insects are also sources of dietary fiber.

Consider protein depending on the stage of CKD [6].

Limited research on insects in CKD.
(9) DairyRequesón≤2 portions per week.

Source of protein, phosphorus, calcium, and probiotic strains.
Consider sodium, potassium, and phosphorus content per portion [8,29,33].
(10) Honey and sweetenersHoney, agave nectar, piloncillo.
Not more than 2 teaspoons of piloncillo or honey in healthy individuals. Consider sugar content [34].
Water and fermented beveragesWater, pozol, aguamiel of maguey, chocolate, tesgüino.Prefer water consumption.

Limit consumption of fermented beverages high in sugar.
Consider sugar content [34].
Table 2. Advantages and Disadvantages of Dietary Patterns in Chronic Kidney Disease.
Table 2. Advantages and Disadvantages of Dietary Patterns in Chronic Kidney Disease.
Mediterranean Diet
  • High consumption of fruit, vegetables, legumes, nuts, whole grains, olive oil and fish
  • Low-to-moderate consumption of dairy
  • Low consumption of ultra-processed foods, saturated fats, red meat, and poultry
  • Regular consumption of wine
  • Key nutrients: monounsaturated and polyunsaturated fatty acids, potassium, and dietary fiber
  • Low consumption of sodium
  • The main sources of protein are plant-based proteins and white meats
  • Low consumption of red meat and ultra-processed foods
  • Lower consumption of sodium, inorganic phosphorus, and added potassium
  • Evidence of improvement in endothelial function, lipid profile, inflammatory parameters, and blood pressure
  • Dietary pattern of choice for CKD
  • It does not take Mesoamerican food items into consideration, which may increase costs for Latin American countries
  • Not designed to reduce the progression of CKD, resulting in some authors suggesting the customization of eating patterns to avoid the risk of hyperkalemia as a result of a high intake of fruits and vegetables
  • High consumption of fruits, vegetables, and low-fat dairy
  • Low consumption of ultra-processed foods, saturated fat, sodium, artificial sweeteners, and other added sugars
  • Key nutrients: potassium, calcium, magnesium, and dietary fiber
  • Low consumption of sodium
  • High consumption of dietary fiber and potassium
  • Higher consumption of plant-based products with suggested lower potential renal acid load
  • Evidence of improvement in blood pressure, lipid profile, and cardiovascular risk
  • It does not take Mesoamerican food items into consideration, which may increase cost for Latin American countries
  • Not designed to reduce CKD progression, resulting in some authors suggesting the customization of eating patterns to avoid the risk of hyperkalemia as a result of plant-based food consumption
Dieta de la Milpa
  • Base of the diet: corn/maize, common beans, pumpkins/squashes, and chilies
  • High consumption of fruits and vegetables
  • Moderate consumption of dairy and natural sweeteners
  • Low consumption of ultra-processed foods and red meat
  • Key nutrients: potassium, dietary fiber, and organic sources of phosphorus
  • Low consumption of sodium
  • Fits regional and economic environment by incorporating local food items
  • Viable eating pattern, even for patients with food/nutrient insecurity
  • No studies assessing its efficacy on potential cardiovascular, metabolic, and kidney-related outcomes
  • Observational or intervention studies to evaluate the impact on patients with CKD are not available
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MDPI and ACS Style

Biruete, A.; Leal-Escobar, G.; Espinosa-Cuevas, Á.; Mojica, L.; Kistler, B.M. Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease. Nutrients 2024, 16, 574.

AMA Style

Biruete A, Leal-Escobar G, Espinosa-Cuevas Á, Mojica L, Kistler BM. Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease. Nutrients. 2024; 16(5):574.

Chicago/Turabian Style

Biruete, Annabel, Gabriela Leal-Escobar, Ángeles Espinosa-Cuevas, Luis Mojica, and Brandon M. Kistler. 2024. "Dieta de la Milpa: A Culturally-Concordant Plant-Based Dietary Pattern for Hispanic/Latine People with Chronic Kidney Disease" Nutrients 16, no. 5: 574.

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