Addressing the challenges of obesity and kidney disease

Introduction

Obesity is an expanding public health threat, which heightens risk of multiple chronic diseases, including kidney diseases. Within the past two decades, the percentage of US adults with a body mass index (BMI) ≥30 kg/m2 has increased from 30.5% to 41.9%. The incidence of Class 3 obesity (BMI ≥40 kg/m2) is now increasing faster than other classes (and has almost doubled from 4.7% to 9.2%). For the patient living with both obesity and kidney diseases, weight loss can improve psychosocial functioning, including better mood; heighten quality of life; and slow kidney disease progression. Effective management of obesity in patients with kidney diseases remains challenging and requires a multidisciplinary team that includes kidney health professionals. Obesity can be treated with lifestyle modifications, such as diet and exercise. A recent article in the Journal of the American Society of Nephrology studied this topic and offered some guidelines on how to treat this problem. This post does not contain our information, it contains excerpts from that article.

Psychosocial Considerations for the Management of Persons Living with Obesity and Kidney Disease

To effectively treat obesity, clinicians should support patients by addressing health-related social needs and identifying and treating common mental health comorbidities.

Health-Related Social Needs

Health-related social needs (i.e., social determinants or drivers of health) contribute to approximately half of the observed variation in health outcomes across the United States. Food and nutrition insecurity, housing insecurity, health literacy, and economic and transportation instability can interfere with the effective treatment of obesity and chronic diseases, including kidney diseases, and impede access to nutritious foods, medications, and health care

Mental and Behavioral Health

Obesity and its associated comorbidities are often compounded by a substantial psychosocial burden for many, but not all, individuals. A range of life experiences and psychosocial issues likely influence the decision to seek weight loss interventions. Many patients with obesity report low self-esteem and greater body image dissatisfaction than those persons with a lower BMI. Persons with more severe forms of obesity often report poor physical functioning, such as walking or climbing stairs, which can impede employment and also increase the need for medical disability.

Stigmatization of Patients with Obesity and Kidney Diseases

Persons with obesity are frequently stigmatized, if not subjected to discrimination in many settings, including educational, employment, and medical settings, which may lead to avoidance of clinical care and worse health outcomes. Weight stigma and internalized weight bias, in which individuals apply negative beliefs about body weight to themselves, are associated with negative mental health outcomes and, in some cases, worse physical health outcomes.

While clinicians may avoid conversations about obesity because of concerns of patient embarrassment, patients commonly report a desire for more engagement with their clinicians about obesity, including helping them disentangle conflicting nutritional advice, select goals and treatment, and follow-up on success.22,23 Clinicians should advocate for training on obesity management, adequate clinic time to address obesity, and establishment of interdisciplinary care teams to best facilitate comprehensive person-centered weight management.

Most patients experience profound improvements in psychosocial functioning with weight loss. On the other hand, after weight loss, some patients may struggle with maintaining weight loss and/or experience depression and self-injurious behavior, substance abuse, body image dissatisfaction, and experience difficulties with romantic relationships. All care team members should be aware of these potential complications and refer patients for additional mental health assessment and treatment if warranted. Preferably, nephrology clinics should have ready access to a mental health professional who can assess mental health, help determine appropriateness of obesity treatments, and provide support during and after obesity treatment.

Core Skills	Components
Self-monitoring	• Daily recording of food intake • Daily or weekly exercise tracking • Regular self-weighing
Goal setting	• Set specific, measurable, achievable, relevant, and time-bound goals in collaboration with a clinician • Progress assessment at follow-up visits
Stimulus control	• Self-identification of environmental cues triggering unhealthy eating and low physical activity • Create an environment that makes healthy behaviors the default
Problem solving	• Identify a problem in detail • Create potential solutions • Consider the pros and cons of each option • Choose a solution • Develop an implementation plan • Evaluate the effectiveness of the chosen solution once the behavior has been implemented

Table 1 -  Core skills to facilitating behavioral modification skills

Lifestyle Modification and Weight Loss

Lifestyle modification includes long-term adjustments in dietary intake, physical activity, and other daily habits.24 It is first-line therapy for weight management because it is a safe, noninvasive, and potentially sustainable way to treat obesity and its associated comorbidities and improve overall health. Lifestyle modifications, such as whole-food plant-dominant diet, portion control, mindfulness, physical activity on most days, stress reduction, and adequate sleep, serve as the foundations to long-term weight loss success. Individuals with obesity should be provided education and support to implement lifestyle modifications regardless of use of other therapeutic options to manage obesity.

Efficacy of Lifestyle Modification on Weight Management in Persons Living with Kidney Diseases

The interaction of several individual-level factors (e.g., age, sex, comorbidities, and psychosocial circumstances) and environmental factors contribute to a person's ability to lose weight. Physical activity combined with dietary change leads to more sustained weight loss than dietary change alone.25,26 Clinical practice guidelines for the evaluation and management of kidney diseases recommend that adults with kidney diseases engage in at least 150 minutes of moderate intensity physical activity per week27 and guidelines for management of obesity in adults recommend 200–300 minutes or more per week to prevent weight regain after intentional weight loss.28,29 Baseline physical abilities and dietary patterns vary between individuals, but success can be augmented through participation in a structured intensive lifestyle intervention program, which consists of multiple sessions with a health care professional to establish goals, identify barriers to behavior change, problem solve, and track progress. MyRenalRehab is and excellent choice for getting your baseline information and for finding plans to keep you going on your path to better health.

Observational weight loss studies using a variety of diets, exercise training, or a combination of exercise and diet have demonstrated that people with kidney disease stages 1–4 can lose a substantial amount of weight and maintain this weight loss for up to 24 months, but whether these results can be extrapolated to individuals with more advanced kidney diseases remains untested. Lifestyle interventions may lead to improvements in BP, physical function, and other markers of health independent of weight loss.

Safety Considerations

Nonserious adverse events, including musculoskeletal concerns (pain, fatigue, etc.), may occur with lifestyle interventions, but serious adverse events seem to be rare, even in people with kidney diseases.37,38 Safety may be improved by following current clinical guidelines related to nutrition and physical activity in kidney diseases,27,28,39,40 such as when discussing diets that may contain high levels of protein and certain electrolytes like potassium or phosphorus. Consultation with professionals, such as registered dietitians and exercise physiologists, can help ensure the safety and effectiveness of lifestyle changes.

Health and weight goals should be individualized and aim for sufficient weight loss to facilitate kidney transplant waitlisting. Weight loss interventions may also delay or prevent kidney failure and/or cardiovascular disease by stabilization or improvement in kidney function, albuminuria, glucose control, and/or BP.

By maintaining an appropriate weight and staying active a person can minimize the incidence as well as manage diseases, including kidney disease. Using MyRenalRehab.com is and excellent resource to help you with your journey.

Ikizler, T. Alp1; Kramer, Holly J.2; Beddhu, Srinivasan3; Chang, Alex R.4; Friedman, Allon N.5; Harhay, Meera N.6; Jimenez, Elizabeth Yakes7; Kistler, Brandon8; Kukla, Aleksandra9; Larson, Kristin10; Lavenburg, LindaMarie U.11; Navaneethan, Sankar Dass12; Ortiz, John13; Pereira, Rocio I.14; Sarwer, David B.15; Schauer, Philip R.16; Zeitler, Evan M.17;  for the ASN Kidney Health Guidance Workgroup on Obesity and Kidney Diseases. ASN Kidney Health Guidance on the Management of Obesity in Persons Living with Kidney Diseases. Journal of the American Society of Nephrology ():10.1681/ASN.0000000512, September 18, 2024. | DOI: 10.1681/ASN.0000000512