Dietitians should take the lead in weight management for patients with kidney disease
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Registered dietitian nutritionists caring for patients with chronic kidney disease are frequently challenged to help address multiple chronic diseases, comorbidities and acute issues to achieve goals for health and well-being.
Obesity in patients is associated with increased risk for CKD progression, both independently and through its association with diabetes and hypertension, the leading causes of CKD and end-stage kidney disease. Obesity is also associated with nephrolithiasis in patients with diabetes and frequently presents as a barrier to eligibility for kidney transplant.
While obesity is a risk factor for CKD progression in earlier stages of CKD, in CKD stages 4 and 5, the relative risk of death decreases as BMI increases, even into ranges historically defined as overweight, obese or morbidly obese. Theories attempting to explain this “obesity paradox” have focused on the associations between weight, protein-energy wasting and inflammation. The direction of causality has not been established, and the interplay between factors may be complex.
Relative importance of weight management
Although addressing excess weight in patients with CKD is important, weight loss may not always be the first clinical priority for complex patients with multiple comorbidities. The interdisciplinary team may prioritize weight differently in the dialysis population than in patients with earlier stages of CKD or the general population. Thorough assessment should inform an individualized weight management plan that includes the patient’s goals and those of the team. At all stages of CKD, it is critical to consider risks of malnutrition/protein-energy wasting in addressing obesity.
The possibility of kidney transplant may elevate weight management as a priority for intervention. While each transplant center determines its own eligibility criteria, weight and, more specifically, central adiposity are generally included due to increased risk of poor surgical outcomes.
Behavior modification
Behavior-based strategies for addressing obesity center around educating and supporting patients in modifying both dietary intake and physical activity level.
An individualized approach is key to supporting patients to be successful with sustainable, incremental change. Understanding and applying theories of health-related behavior change, such as the transtheoretical model, can help facilitate adoption of new habits. Motivational interviewing techniques support assessment of readiness to change and patient-driven goal setting. While not developed as a tool for weight management, intuitive eating is another approach that may support patients in increasing their awareness of hunger, satiety and eating behaviors.
Beyond behavior
The reality is sustained behavior change is hard. Patients with advanced CKD may encounter barriers to lifestyle changes, such as limited mobility, fatigue from delayed recovery between dialysis treatments, and limited access to nutrient-dense foods. It may be necessary to consider other tools in developing the plan of care.
Bariatric surgery to reduce the gastric pouch and, thereby, food intake, has become more commonly used in the CKD and ESKD populations, particularly in preparation for kidney transplant.
Incretin-based therapies, such as glucagon-like peptide-1 receptor agonists, for weight loss have added complexity and controversy to the weight management conversation. Increased demand for drugs such as semaglutide has created shortages for patients with type 2 diabetes who depend on GLP-1s for glycemic control. Some dietitians fear the availability of GLP-1s creates a “quick fix” mentality that may displace the role of lifestyle modifications, including medical nutrition therapy provided by a registered dietitian nutritionist (RDN).
The Academy of Nutrition and Dietetics recently published a position paper underscoring the important role that RDNs and medical nutrition therapy play in obesity management for patients on incretin-based therapies. RDNs caring for patients with CKD and on dialysis have the opportunity to take a lead role in educating both patients and clinicians. RDNs must be competent in understanding the implications of GLP-1 use in formulating their interventions and patient education.
“Research shows that effective obesity care should include counseling from an RDN to support the adoption of lifestyle changes that optimize weight loss maintenance, prevent and/or reduce medication side effects, and achieve long-term health. RDNs offer essential services, including screening and assessment, medication support and guidance on a nutrient-dense eating plan. They encourage healthy lifestyles, support positive body image and promote physical activity to help maintain lean body mass during weight loss,” according to the position paper.
The landmark FLOW trial, a randomized controlled trial of semaglutide in people with type 2 diabetes and CKD, demonstrated a 24% decrease in primary kidney-related outcomes with the medication. These findings elevate the role and efficacy of semaglutide in reducing the risk for adverse kidney outcomes and death from cardiovascular causes in patients with type 2 diabetes and CKD. Clinicians caring for people with CKD should expect GLP-1 receptor agonists to become a standard of care for this subpopulation and should develop competence in their use.
Dietitians and the care team
Given the influence of excess body weight on chronic conditions and on kidney function, dietitians can play a key role in the care of patients with kidney disease across all stages.
Dietitians can take the lead in educating patients, as well as other clinicians, in the complexities of obesity and weight management across the spectrum of CKD. An interdisciplinary approach — developing individualized goals, plans of care and interventions with involvement of the patient — increases chances for success.
Avoiding stigmatizing body size or placing a moral value on body weight helps us to build and maintain credibility and trusting relationships with patients. Care should be taken to carefully plan nutrition interventions to prevent or minimize the risk of protein-energy wasting and micronutrient deficiencies. Monitoring should be frequent, particularly when pharmacologic or surgical interventions are included in the weight management plan of care.
Working together, the interdisciplinary team can provide compassionate, individualized care to support patients in achieving their goals for weight management, health and quality of life.
- References:
- Gigliotti L, et al. J Acad Nutr Diet. 2024;doi:10.1016/j.jand.2024.10.023.
- Perkovic V, et al. N Eng J Med. 2024;doi:10.1056/NEJMoa2403347.
- For more information:
- Rory C. Pace, MPH, RD, CSR, FAND, FNKF, is a nutrition therapy consultant with Patient Care America and a Healio | Nephrology News & Issues Editorial Board member. She can be reached at rpace@pcacorp.com.
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