An Updated Approach to Managing Obesity in Patients With CKD

Obesity or a higher body mass index (BMI) is frequently cited as a risk factor for the development of chronic kidney disease (CKD). Those with CKD hoping to get a transplant may have to comply with BMI requirements to be active on the transplant list.  A recent Cochrane Review of interventions for weight loss in people with CKD concluded that when considering all types of weight loss interventions (including weight loss surgery, medications, dietary and/or lifestyle changes) compared with no weight loss interventions, there was little to no difference seen in BMI, waist circumference, proteinuria, or blood pressure. It was also noted that none of the studies reported outcomes on death or cardiovascular events. Additionally, no individual dietary intervention was found to be more efficacious than another for weight loss or lower BMI.¹   While this review may seem to contradict much of the body of research already available, it can illuminate some of the shortcomings in the general perception of obesity and current interventions. 

Studies repeatedly find that individuals with obesity experience weight stigma from doctors, nurses, dietitians, and mental health professionals. Multiple studies have demonstrated that individuals with obesity repeatedly put off medical care or are unwilling to seek medical treatment for non-weight related issues because of weighing procedures, medical equipment being too small to be functional, or being treated poorly.² These seem to be strong contributing factors to obesity being associated with negative outcomes that have nothing to do with the clinical aspect of the disease itself.   

Common management for obesity such as increased physical activity and reduced caloric intake is based on the prevalent yet still unproven suppositions that body weight is an indicator of health and is entirely manageable by lifestyle choices and self-control.³ Meanwhile, evidence-based approaches to obesity management show that factors such as hormone imbalance, inflammation, chronic stress, poor diet quality, inadequate sleep, loss of lean muscle mass, gut microbiome imbalance, various micronutrient deficiencies, genetics, and toxins from food and the environment are all critical considerations when managing obesity.³

The Cochrane Review’s conclusion that no single dietary or lifestyle intervention was more impactful than another and that other important outcomes were not improved (eg, reduced proteinuria) supports the idea that obesity needs to have an individualized, root cause approach. This allows providers to focus on improving overall health and nourishing the body rather than the reduced-calorie approach that increases the risk of malnutrition (a compounded risk for those with CKD following a low-protein diet),⁴ eating disorders, and mental health issues,⁵ not to mention an exacerbation of whatever underlying issue continues to go unaddressed. Indeed, since the actual benefits of achieving reductions in proteinuria, blood pressure, diabetes risk, and many other health benefits are not actually weight dependent but can be achieved through diet and lifestyle changes, the focus on weight loss can be distracting and hinder the patient’s progress.⁵  

Nephrology providers may not always have time outside of addressing kidney health or the obesity management specific training that allows them to help their patients with weight loss or weight loss resistance. Collaborating with other providers as well as making small, simple changes can make a difference to patients. 

According to a paper by Fruh et al in the Journal for Nurse Practitioners,² nephrology providers can help their patients with obesity by:

• Identifying and correcting their own weight bias.
• Humanizing patients with obesity by not labeling them by their disease in conversation and charting and scholarly writing. (Consider the difference of referring to a patient as cancerous vs a patient with cancer.)
• Implementing appropriate weighing procedures. Consider if weight actually needs to be a part of the patient’s check in, weigh patients in a private location, and document weight without commentary.
• Ensuring a supportive environment, such as large chairs without arm rests and appropriately sized medical equipment.
• Emphasizing success with behavior changes rather than numbers on a scale.
• Exploring all causes of a patient’s problems, not just their weight.
• Asking questions about a patient’s health history outside of kidney specifics. This can help narrow down the type of support they need, the best type of provider referral, or additional testing needed.
• Referring to dietitians and other health providers that can help them correct issues contributing to weight loss resistance.

Health and disease occur across the weight spectrum. When providers recognize this and provide a collaborative root cause approach to managing obesity, they empower patients to make positive changes that benefit all aspects of their health.

References

1. Conley MM, McFarlane CM, Johnson DW, Kelly JT, Campbell KL, MacLaughlin HL. Interventions for weight loss in people with chronic kidney disease who are overweight or obese. Cochrane Database Syst Rev. 2021;3(3):CD013119. Published 2021 Mar 30. doi:10.1002/14651858.CD013119.pub2
2. Fruh SM, Nadglowski J, Hall HR, Davis SL, Crook ED, Zlomke K. Obesity stigma and bias. J Nurse Pract. 2016;12(7):425-432. doi:10.1016/j.nurpra.2016.05.013
3. Rubino F et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020;26:485-497. doi.org/10.1038/s41591-020-0803-x
4. Ko GJ, Obi Y, Tortorici AR, Kalantar-Zadeh K. Dietary protein intake and chronic kidney disease. Curr Opin Clin Nutr Metab Care. 2017;20(1):77-85. doi:10.1097/MCO.0000000000000342
5. Weight science: Evaluating the evidence for a paradigm shift.  Nutr J. 2011;10:9. doi.org/10.1186/1475-2891-10-9