Expert Q&A: The State & Future of Nutrition in Kidney Health

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Welcome to the first of many expert-led Q&As from Signals slated for 2024 that asks community leaders to weigh-in on pitfalls, progress, and potential in their respective corners of the Kidneyverse.

As the title suggests, today's conversation explores the vital role of nutrition in kidney health, as told through the firsthand perspectives of frontline clinicians across the care landscape. My goal is to use these group formats to shine a bright, balanced light on the most pressing topics in the kidney community today.

Many of you know that nutrition plays a vital (if not central) role in helping people manage their kidney health, from the earliest stages of kidney disease to those living with kidney failure. Recent clinical practice guidelines make that point clear. And still, despite its benefits, we can see just how far we have left to go to bring individualized nutrition to those who need it most.

Without further ado, let’s meet our guides for today’s journey to this delicious, nutritious, and bittersweet corner of the Kidneyverse.

Meet Our Experts

Our guests today represent a broad range of insights and experiences. They have worked as independent practice owners and on multidisciplinary care teams, within large health systems and in rural community clinics, for non-profits and Fortune 500s. I’m grateful to each of these experts for sharing their earned wisdom and insights with all of us.

• Rory Caswell Pace , MPH, RD, CSR, FAND, FNKF
• Bethany Keith , MS, RDN, LD, CNSC
• Karla Rippchen , MBM, RDN
• Jill Sher , RDN, LD
• Cory Zenner , RD

What you’ll learn

• Current approaches to nutrition management in CKD/ESRD
• Barriers to effective management at multiple levels
• Role and impact of individualized nutrition planning
• How policy and systemic changes might improve access
• Where technology and innovation support better care
• Emerging trends and their potential impact
• Personal insights and anecdotes
• Resources & discussion

Q&A

Under each question below you'll find a TLDR summary of responses from our experts. To read the full article, including individual responses and our group discussion, please open the full article on Substack .

Q1. Thinking big picture here. How would you describe your approach to nutrition management for people with kidney disease?

TLDR: Our experts underscore the strategic importance of a personalized approach. They advocate for individualized goals and using Medical Nutrition Therapy (MNT) not just as a treatment modality, but as a fundamental part of a broader strategy to enhance kidney health. Their approaches balance clinical insights with a focus on understanding each patient's unique dietary preferences and lifestyle, moving away from rigid food restrictions towards a more nuanced understanding of nutrition's role in kidney health. (See their responses )

Q2. What do you see as the biggest barriers to effective nutrition management in kidney care today?

TLDR: Our experts identify several key barriers to effective nutrition management in kidney care, including lack of awareness about the impact of Medical Nutrition Therapy (MNT), limited access to dietitians, insurance complexities, and low utilization of available resources. They stress the importance of provider and patient education, early intervention, and recognizing the critical role nutrition plays in delaying or managing kidney disease. (See their responses )

Q3. Let’s get specific and talk about the role of individual nutrition planning. Why is it important within kidney care compared to a one-size-fits-all approach?

TLDR: Experts unanimously agree on the vital importance of individualized nutrition planning in kidney care. Emphasizing the diversity of dietary needs across different stages of kidney disease and (often) coexisting health conditions, they highlight the necessity of tailoring nutrition plans to each patient's unique clinical status, lab values, and personal factors like food preferences and access. It's about translating nutritional science into tangible, daily practices that resonate with and adapt to the unique circumstances of each patient. (See their responses )

Q4. What policy or systemic changes are needed to improve access to nutrition therapy in kidney care? Where do current measures fall short?

TLDR: Our experts advocate for policy reforms like expanded Medicare coverage across all CKD stages, uniform insurance billing, and better integration of dietitians in early kidney care. They highlight these as key steps to improve accessibility and effectiveness of nutrition therapy in kidney care. (See their responses )

Q5. Has recent technology innovation helped you deliver nutrition therapy treatments for your patients? If so, how?

TLDR: Technology, particularly telehealth, plays a varying role in delivering nutrition therapy for kidney patients. Experts note its benefits in increasing accessibility and convenience, though challenges like internet availability and patient familiarity with technology persist. They emphasize a balanced approach, integrating technology with traditional clinical skills to meet diverse patient needs. (See their responses )

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Q6. Looking ahead, which emerging trends or potential innovations in kidney nutrition excite you most?

TLDR: Experts are excited about future innovations in kidney nutrition, including the potential of value-based care models, expanded Medicare coverage, and new dietary interventions like plant-dominant diets. They also see telehealth as a key tool in providing specialized, accessible care, and envision technological advancements enhancing patient education and early intervention in kidney disease management. (See their responses )

Q7. Story time! I’d love to hear about any experiences or situations where nutrition played a critical role in improving a patient’s life.

TLDR: These personal stories from our experts illustrate the transformative power of nutrition in kidney care. From stabilizing kidney function in advanced stages to managing critical symptoms and improving lab values, nutrition therapy has been pivotal in enhancing patient outcomes and quality of life, and underscores its integral role in managing kidney disease. (See their responses )

Q8. What else should readers know? What questions would you want your dietitian peers to answer?

• Rory wants you to know: Registered Dietitians are the nutrition experts and are therefore the appropriate specialists for providing nutrition interventions/MNT. In addition, RDs have a broad background and training that make them key team members in the management of chronic diseases, including CKD.
• Karla asks: How can we show insurance companies the importance of food choices/using the science of nutrition? How can we add eGFR or other micronutrient tests to annual well checks to help delay or reduce the severity of diseases will save insurance companies money rather than treat the disease at late diagnosis? For example, compare the costs of dialysis and MNT. Is it that we would need a 40+ year study? Too many variables?

Discussion

Here are a few insights and perspective from around the dietitian community shared on a LinkedIn thread last week. Join the discussion here.

Sara Eve Schaeffer, MBA, MA, RD : “And don’t forget that MNT is covered post-transplant! ”

Jessica Panetta, MA, RD : “Promotion of MNT is great. Conversion is better. 1) Physicians need to know about MNT + actively refer to RDs. 2) Individuals referred to RDs then need make the appointment, show up, and act on the recommended interventions. This is a multifaceted issue that could warrant an entire article! To connect it back to the original message- awareness and education are crucial catalysts for change here, in my opinion.”

Rebecca Baranoff, MSW, CCA, CRC, CPC : “When I worked in dialysis it seemed MNT was used only in short studies and the margins in which a patient qualified for the study were really narrow. It’s possible though that the new guidelines have set different margins for this treatment. The other thing that happened was the patients that were given MNT PO were older patients with cognitive deficits. So how do we educate patients so they really understand why they are getting this therapy?”

Bethany Keith, MS, RDN, LD, CNSC : “I believe that connecting CKD patients with RDs goes hand in hand with early identification of CKD. Many people don’t know that they have kidney disease until stage 3 or later, when they could have been make dietary changes earlier on to help slow the progression of CKD. Access to renal dietitians is slowly increasing due to the rise of telehealth in the post pandemic world. Now many people can talk to a renal dietitian from the comfort of their own home, however people in rural areas may not have access to internet or be aware of telehealth options. I think the potential interventions that Jimenez and colleagues outlined are spot on!”

Rory Caswell Pace, MPH, RD, CSR, FAND, FNKF : “Dietitians ABSOLUTELY have the ability to impact patient activation. Because MNT includes engaged counseling to facilitate health-related behavior change, there is significant opportunity to increase patients'/clients' health literacy and self-care skills, which are captured in the PAM.”

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