A Disconnect Between Patients and Providers about Obesity Care Worsens the Problem.
Obesity is a risk factor for end-stage kidney disease (ESKD), and it can prevent an ESKD patient from becoming eligible for a life-saving kidney transplant. New findings from researchers at Drexel’s College of Medicine, School of Public Health and College of Nursing and Health Professions – in conversations with patients and clinical teams – suggests that critical weight management conversations between patients and their care teams simply aren’t happening, and the communication breakdown doesn’t end there.
Although Medicare covers nutritional care by renal dietitians for ESKD patients and United States transplant programs must also include nutrition experts on their multidisciplinary teams, patients report that support for weight management is usually insufficient and sometimes non-existent in dialysis and other ESKD healthcare settings. Providers admitted to often feeling uncomfortable talking to patients about weight and nutrition and described many communications-based challenges that prevent patients from learning how to lose the weight they need for a life-saving transplant.
The team’s insights, recently published in the journal AJKD, came from 40 adult ESKD patients with obesity (BMI >30 kg/m2) who were currently on dialysis about their experiences with obesity and weight loss, and 20 ESKD health professionals about their care for ESKD patients.
During 90-minute interviews, patients described many weight loss challenges, such as trying to balance differences between “kidney-friendly” and popular weight loss diets. Patients described how fatigue from dialysis hurt their food and nutrition choices and how they felt pressure and unrealistic expectations from health professionals to lose weight before a transplant.
In 60-minute interviews with dieticians, surgeons and nephrologists, respondents often reported a lack of training, comfort and time to counsel patients about obesity and weight loss.
Both patients and clinical teams perceived a lack of transparent and honest communication about obesity and said roles and responsibilities for obesity counseling were unclear.
“It’s apparent that efforts to address obesity must be tailored to each individual patient,” said lead author Meera Harhay, MD, an associate professor in the College of Medicine. “Responsibilities of nutritionists, surgeons, nephrologists pertaining to obesity care must be more clearly defined and explained to patients, so they receive the support they need.”
Obesity can increase risks associated with kidney transplant, such as wound complications, poor outcomes and needing dialysis after the procedure.
“More than four of 10 U.S. patients on dialysis have obesity,” said Harhay. “Unfortunately, though kidney transplant is associated with longer life for these patients compared to dialysis, the additional risks of the procedure with obesity mean that many patients will get turned down for transplant unless they can lose weight.”
Improving weight-loss care can also help reduce health disparities in patient populations nationwide.
“Because both obesity and end stage kidney disease are borne more heavily by minoritized and low resource populations in the United States, lowering barriers and improving access to kidney transplantation are important strategies for addressing health disparities in chronic disease,” says co-author Ann Carroll Klassen, PhD, a professor in the Dornsife School of Public Health.
Using a research technique known as “free listing,” the team received more detailed feedback related to weight loss from patients to get to the heart of the obstacles they’re facing.
“Because we are asking participants to spontaneously name anything and everything that comes to mind (about a particular topic), the responses are often not what the researcher may have expected,” said co-author Brandy-Joe Milliron, PhD, an associate professor in the College of Nursing and Health Professions. “We can then explore these spontaneous responses in more depth, so in the end, the activity can lead to the collection of more in-depth qualitative information.”
The team compiled patient feedback into three themes.
(We included a snapshot of responses below.):
Patients shared how difficult weight loss really is. Dialysis left patients feeling too tired to cook healthy meals and instead satiate their hunger with high calorie, high-sugar, processed foods: Some patients also reported eating as a coping mechanism while stressed.
For example:
“[After dialysis] I got to get home and get something to eat. I have to eat.”
Patients reported receiving insufficient counseling about weight loss but several health professionals felt patients weren’t being forthcoming or honest about what they were eating.
“[Patients] claim to not be eating anything at all…and then their phosphorus is through the roof…I think it’s a lot of lying.”
Disagreement was common among transplant surgeons, nephrologists and renal dieticians about which professionals should lead efforts that advise patients about weight loss.
Patients said they seldomly heard from their clinicians about obesity and anytime it was mentioned, it was pertaining to reaching a proper BMI for transplant eligibility. Clinical teams feared that discussing weight loss would embarrass patients. Dietitians in dialysis facilities reported feeling overwhelmed with other tasks and felt transplant dietitians are better positioned to advise patients, whereas transplant dietitians felt that dialysis-based dietitians are better suited to counsel patients because they interact with patients more frequently.
Overall, the findings illuminated how many constraints on ESKD patients are antithetical to healthy weight loss. Patients should restrict water intake, but many weight loss programs encourage water intake. Patients strive to minimize calories – but can fail to eat sufficient protein needed to prevent malnutrition.
Some patients said that although they were motivated to lose weight to ensure eligibility for a transplant, they felt unwanted pressure from their health care team to undergo bariatric surgery.
“That surprised me and underscores the dire need for non-surgical, non-pharmaceutical tailored behavioral weight loss approaches for people with ESKD and obesity,” said Milliron.
All interviews took place from April to July 2021. The researchers believe future studies would benefit from caregivers’ perspectives. The study offered in-depth insights from patients from 24 states but may not be generalizable for ESKD patients in all states.
“Healthcare professionals, including clinicians, researchers, and educators, must become better versed in helping people with ESKD and obesity optimize their quality of life,” said Milliron. “Dialysis is extremely taxing – physically, emotionally, and cognitively. It’s hard on caregivers and families too. Further, not all patients desire weight loss surgery or medications to achieve their goals. Our findings serve as a reminder of the importance of person-centered care, where care is guided by the patient’s values, needs, and desired health outcomes, within and beyond the dialysis setting.”
Media interested in talking to Harhay should contact Greg Richter, assistant director, News and Media Relations, at gdr33@drexel.edu or 215.895.2614, or for Milliron, contact Annie Korp, assistant director, News and Media Relations, at amk522@drexel.edu or 215.571.4222.
