Patients with obesity, ESKD have unique dietary needs
The prevalence of obesity is growing worldwide among children, adolescents and adults.1-6 People with obesity in the general population are at an increased risk of various adverse health concerns, including diabetes mellitus, hypertension, cardiovascular disease, depression and kidney disease.7-13 Kovesdy, Furth and Zoccali published a review in 2017 of numerous studies that demonstrated the association between measures of obesity and the development and progression of chronic kidney disease. They indicated recommendations appear to be justified for lifestyle modifications to reduce body weight in obese people at risk of CKD and those with early stages of CKD (particularly for the control of diabetes and hypertension).13
While the risk between obesity and worsening of CKD to ESKD may be unclear,7,13 achieving a goal BMI for transplantation status remains important for patients with ESKD. The American Society of Transplantation recommends a supervised weight loss regimen to achieve a goal BMI of less than 30 km/m2 prior to transplantation.15
Patients with obesity and ESKD have a unique need to balance dietary requirements and allowances, alongside other comorbid conditions that can present challenges with traditional weight loss attempts. Traditional weight loss recommendations for the general population tend to include increased intake of fruits and vegetables, increased intake of fluids and increased intake of plant-based proteins, which may cause issues with serum potassium and phosphorus levels for the patient with ESKD. Balancing the implementation of weight loss recommendations with ESKD dietary allowances highlights the importance of the role of the renal dietitian in weight loss. Renal dietitians typically have an established relationship with their patients, regular patient contact and access to their patients’ medical history, lab results and fluid gains, all of which can be used to develop individualized patient goals, while considering nutritional likes and dislikes to determine the best weight loss approach.
It is critical to consider possible psychological barriers and implement behavior modification strategies as a part of a patient’s individualized weight loss approach. Depression is a psychological barrier that can influence nutritional choices and warrants partnership with the social worker to assist the patient in obtaining the right resources to address more complex mental health needs. Dietitians may benefit from behavior modification strategy training to enhance their professional practice and communication skills.
Motivational interviewing is a counseling strategy involving the use of open-ended questions, affirmations, reflections and active listening to encourage a patient to engage in “change talk.” Motivational interviewing, in particular, has been demonstrated to enhance weight loss in overweight and obese patients, per a 2011 systemic review and meta-analysis of randomized controlled trials.14, 16 More information about motivational interviewing can be found through the Motivational Interviewing Network of Trainers.17
Patients who are obese with CKD who progress to ESKD have multiple considerations in weight loss plans. Renal dietitians play a vital role. Weight loss approaches should include patient-centric goals, which may be enhanced by the use of behavior modification strategies. There are online tools available to assist patients and renal dietitians in the creation of a healthy meal plan to support weight loss.
- Miller EO, et al. J Community Health. 2016; doi:10.1007/s10900-016-0213-7.
- Ogden CL & Carroll MD, (2010) Prevalence of obesity among children and adolescents: United States, trends 1963-1965 through 2007-2008. Atlanta, Georgia:CDC, National Center for Health Statistics.
- Ogden CL, et al. JAMA. 2014;doi:10.1001/jama.2014.6228.
- Ogden CL, et al. Prevalence of obesity among adults and youth: United States, 2011-2014. 2014; NCHS Data Brief; 219: 1-8.
- Ogden CL, et al. JAMA.2014;doi:10.1001/jama.2014.732.
- Ogden CL, et al. JAMA.2012;doi:10.1001/jama.2012.40.
- Lin TY, et al. Am J Clin Nutr.2018;doi:10.1093/ajcn/nqy200.
- Iseki K, et al. Kidney Int. 2004;doi:10.1111/j.1523-1755.2004.00582.x.
- Hsu CY, et al. Am Intern Med. 2006; doi:10.7326/0003-4819-144-1-200601030-00006.
- Reynolds K, et al. Am J Kidney Dis. 2007;doi:10.1053/j.ajkd.2007.08.011.
- Munkhaugen J, et al. Am J Kidney Dis. 2009;doi:10.1053/j.ajkd.2009.03.023.
- Vivante A, et al. Arch Intern Med. 2012;doi:10.1001/2013.jamainternmed.85.
- Kovesdy CP, et al. Canadian Journal of Kidney Health and Disease. 2017;doi:10.1177/2054358117698669.
- Armstrong MJ, et al. Obes Rev. 2011;doi:10.1111/j.1467-789X.2011.00892.x.
- Kasiske BL, et al. The evaluation of renal transplant candidates: clinical practice guidelines. Am J Transplant. 2001; 1 (suppl 2): 3-95.
- Chru-Hansen A. Nutrition and Dietetics. 2012;doi:10.1111/j.1747-0080.2012.01645.x.
- For more information:
- Jane Wheeler MS, RD, LDN, is the clinical protocols development director for the clinical improvement team at DaVita Inc. She can be reached at firstname.lastname@example.org or 267-984-8493.
Disclosure: Wheeler reports no relevant financial disclosures.