Food Insecurity, CKD, and Subsequent ESRD in US Adults

Implementation of Ambulatory Kidney Supportive Care in a Safety Net Hospital

CONTEXT

Chronic kidney disease (CKD) disproportionately impacts lower socioeconomic groups and is associated with many symptoms and complex decisions. Integration of Kidney Supportive Care (KSC) with CKD care can address these needs. To our knowledge, this approach has not been described in an underserved population.

OBJECTIVES

We describe our adaptation of an ambulatory integrated KSC and CKD clinic for implementation in a safety net hospital. We report our utilization metrics; characteristics of the population served; and visit activities.

METHODS

We considered modifications from the perspectives of people with CKD, their providers, and the health system. Modifications were informed by meeting notes with key participants (hospital administrators [n = 5], funders [n = 1], and content experts [n = 2]), as well as literature on palliative care program building, safety net hospitals, and KSC. We extracted utilization data for the first 15 months of the clinic's operations, demographics, clinical characteristics, unmet health related social needs, and symptom burden, measured by the Integrated Palliative Outcome Scale-Renal (total Score, and sub-scores of physical, psychological, and practical impact of CKD) from the electronic health record. Results are reported using descriptive statistics.

RESULTS

Adaptions were proactive and done by clinical and administrative leaders. Meetings identified challenges of the safety net setting including people presenting with advanced disease and having several social needs. Modifications to our base model were made in staffing, data collection, and work flow. Show rate was approximately 68%, with a majority of people identifying as Black or Hispanic, and uninsured or on Medicaid. Symptom burden was lower than previous reports, driven by a better psychological sub-score.

CONCLUSIONS

We describe a feasible ambulatory care model of KSC in a safety net setting that can serve as a framework for the development of other noncancer palliative care ambulatory clinics. Future work will optimize our model.

The Effects of Food Security on Academic Performance of University Students at a Hispanic-Serving Institution

Several studies find that low food security has negative effects on academic performance in higher education in the U.S., but the samples for these studies often have low percentages of Hispanic students. Consequently, it remains unclear if food security affects academic performance in predominantly Hispanic settings. Our study aims to analyze whether food security affects academic performance at a Hispanic-Serving Institution (HSI). Using original survey data collected on 2020 students enrolled at a large research-intensive HSI and cumulative logit models, we assess whether food security influences concentration and graduation delays among students at an HSI in the U.S.-Mexico border region. Our findings strongly suggest that low food security reduces concentration and increases delays for graduation at the HSI. The results have important implications for HSI leaders who want to improve student success, and we offer recommendations for future programs and investments to build student food security at HSIs. Because food security is a strong social determinant of health, the study is closely related to the topic of addressing social determinants of health to improve Hispanic health outcomes. When universities take action to build food security among HSI students, they simultaneously make an investment to improve Hispanic health outcomes.

"I have to pick my battles": a mixed-methods study exploring food insecurity and dietary restrictions in pediatric kidney disease

BACKGROUND

Food insecurity (FI) is prevalent among children with chronic kidney disease (CKD), but its impact on health outcomes, and feasibility of prescribed diet restrictions is unknown. Accordingly, this study aims to explore associations of FI and CKD outcomes, and understand its role in following prescribed kidney diet recommendations.

METHODS

We performed a mixed-methods single-center cohort study of children with advanced CKD or kidney failure. Demographics, socioeconomic status, and health outcomes were compared across FI status; associations between FI and CKD outcomes were explored using multivariable regression. A qualitative sub-analysis of de-identified caregiver interview transcripts was analyzed for themes around diet restrictions.

RESULTS

There was a trend that FI patients were more likely to be of Black race (33% vs. 20%); have public insurance (67% vs. 48%); need more blood pressure medications (2 [0.75,3] vs. 1 [0,3]); and have a higher likelihood of emergency department (42% vs. 25%) or intensive care unit encounters (25% vs. 14%). There were no associations of FI and outcomes of interest. Major themes that emerged from caregiver interviews include (1) understanding of the kidney diet focuses on foods to avoid; (2) adapting to suggested dietary restrictions requires changes in meal preparation; and (3) challenges to adherence include social stigma, growth, budget, and time.

CONCLUSIONS

The impact of FI on children's medical needs with CKD remains inconclusive but trends suggest a higher risk. Regardless of FI status, adhering to prescribed diet restrictions in kidney disease involves significant dedication. Challenges involve food availability, a child's response to restrictions, and social stigma.

Rethinking Our Roots: The Ground-Up Approach to Heart Health & Planetary Sustainability

Cardiovascular disease is the leading cause of death in the United States. Poor dietary habits are not only a major modifiable risk factor for cardiovascular disease and other chronic illnesses, but they also harm planetary health. Our food system is complex, shaped by agricultural practices and human behaviors. To change it, we need to understand why current agricultural practices exist and address nutrition education, food insecurity, and nutritional security. There are effective ways to make our food system healthier, more equitable, and more sustainable. The best available evidence points to plant-forward diets as the keystone to this complex issue. This manuscript reviews how human and planetary health are connected through our food system and suggests solutions for diets that prevent and treat cardiovascular disease while promoting planetary health.

Embedding Equity and Inclusion Principles Into Nephrology Board Examinations: An Essential Part of Our Path Toward Kidney Health Justice

Recognition of widespread health inequalities across disease conditions and their startling impact on morbidity and health care costs have motivated multiple professional societies to ensure board examinations reflect and enhance inclusive, anti-biased, and equitable care. In this perspective, we offer five nephrology case examples and accompanying learning objectives to demonstrate how principles of inclusion, equity, and anti-bias can be embedded into nephrology examinations to enhance care for all populations.

The relationship between low levels of albuminuria and mortality among adults without major cardiovascular risk factors

AIMS

The aim of this study is to determine whether elevated levels of albuminuria within the low range [urinary albumin-to-creatinine ratio (UACR) <30 mg/g] are linked to cardiovascular death in adults lacking major cardiovascular risk factors.

METHODS AND RESULTS

The association between UACR and cardiovascular mortality was investigated among 12 835 participants in the 1999-2014 National Health and Nutrition Examination Survey using Cox proportional hazard models and confounder-adjusted survival curves. We excluded participants with baseline cardiovascular disease, hypertension, diabetes, pre-diabetes, an estimated glomerular filtration rate <60 mL/min/1.73 m2, currently pregnant, and those who received dialysis last year. Over a median follow-up of 12.3 years, 110 and 621 participants experienced cardiovascular and all-cause mortality. In multivariable-adjusted models, each doubling of UACR was associated with a 36% higher risk of cardiovascular death [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.02-1.82] and a 24% higher risk of all-cause mortality (HR 1.24, 95% CI 1.10-1.39). The 15-year adjusted cumulative incidences of cardiovascular mortality were 0.91, 0.99, and 2.1% for UACR levels of <4.18, 4.18 to <6.91, and ≥6.91 mg/g, respectively. The 15-year adjusted cumulative incidences of all-cause mortality were 5.1, 6.1, and 7.4% for UACR levels of <4.18, 4.18 to <6.91, and ≥6.91 mg/g, respectively.

CONCLUSION

Adults with elevated levels of albuminuria within the low range (UACR <30 mg/g) and no major cardiovascular risk factors had elevated risks of cardiovascular and all-cause mortality. The risk increased linearly with higher albuminuria levels. This emphasizes a risk gradient across all albuminuria levels, even within the supposedly normal range, adding to the existing evidence.

Association between urinary arsenic levels and kidney damage in US adults: NHANES 2007-2018

BACKGROUND

Chronic arsenic exposure is known to be associated with various diseases by inducing multiple organ dysfunctions. Despite the high prevalence of kidney diseases in the US and globally, population-level research on the link between inorganic arsenic and kidney damage remains limited. In our study, we assessed the association between urinary arsenic levels and kidney damage among US adults using a multi-marker approach.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (2007-2018). Multivariable logistic regression models were employed to estimate the odds ratios (ORs) for kidney damage based on total urinary arsenic levels and multiple kidney biomarkers, including albuminuria, low estimated glomerular filtration rate (eGFR), hyperuricemia, and elevated blood urea nitrogen (BUN), while adjusting for demographic, socioeconomic, and other risk factors. Total urinary arsenic levels were calculated by summing the levels of arsenous acid (As3), arsenic acid (As5), and their methylated metabolites, monomethylarsinic acid (MMA), and dimethylarsinic acid (DMA). Dimethylarsinic acid (DMA) was calibrated for arsenobetaine using a residual regression method to minimize the influence of seafood-related exposure.

RESULTS

After adjusting for covariates, we observed 1.29-fold higher odds (95 % CI 1.01, 1.64) of kidney damage in the highest quartile of urinary arsenic compared to the lowest quartile. Specifically, the odds of albuminuria and hyperuricemia were 1.49-fold (95 % CI 1.09, 2.03) and 1.38-fold (95 % CI 1.01, 1.88) higher, respectively, in the highest quartile. Additionally, for every one-unit increase in the natural log of arsenic levels, significant associations were observed for overall kidney damage (OR 1.10, 95 % CI 1.01, 1.20), albuminuria (OR 1.15, 95 % CI 1.03, 1.29), and hyperuricemia (OR 1.12, 95 % CI 1.02, 1.24) when considering arsenic levels in drinking water as a continuous variable.

CONCLUSION

Our study concludes that higher urinary arsenic levels are positively associated with kidney damage. Further prospective studies are needed to confirm these findings.

Embed systemic equity throughout industrial ecology applications: How to address machine learning unfairness and bias

Recent calls have been made for equity tools and frameworks to be integrated throughout the research and design life cycle -from conception to implementation-with an emphasis on reducing inequity in artificial intelligence (AI) and machine learning (ML) applications. Simply stating that equity should be integrated throughout, however, leaves much to be desired as industrial ecology (IE) researchers, practitioners, and decision-makers attempt to employ equitable practices. In this forum piece, we use a critical review approach to explain how socioecological inequities emerge in ML applications across their life cycle stages by leveraging the food system. We exemplify the use of a comprehensive questionnaire to delineate unfair ML bias across data bias, algorithmic bias, and selection and deployment bias categories. Finally, we provide consolidated guidance and tailored strategies to help address AI/ML unfair bias and inequity in IE applications. Specifically, the guidance and tools help to address sensitivity, reliability, and uncertainty challenges. There is also discussion on how bias and inequity in AI/ML affect other IE research and design domains, besides the food system-such as living labs and circularity. We conclude with an explanation of the future directions IE should take to address unfair bias and inequity in AI/ML. Last, we call for systemic equity to be embedded throughout IE applications to fundamentally understand domain-specific socioecological inequities, identify potential unfairness in ML, and select mitigation strategies in a manner that translates across different research domains.

Dietary Restriction, Socioeconomic Factors, Access to Kidney Transplantation, and Waitlist Mortality

INTRODUCTION

Dietary restrictions for patients with end-stage kidney disease (ESKD) are burdensome. Kidney transplantation (KT) candidates who lack neighborhood resources and are burdened by dietary restrictions may have decreased access to KT.

METHODS

In our two-center prospective cohort study (2014-2023), 2471 ESKD patients who were evaluated for KT (candidates) reported their perceived burden of dietary restrictions (not at all, somewhat/moderately, or extremely bothered). Neighborhood-level socioeconomic factors were derived from residential ZIP codes. We quantified the association of perceived burden of the dietary restrictions with a chance of listing using Cox models and risk of waitlist mortality using competing risks models. Then we tested whether these associations differed by neighborhood-level socioeconomic factors.

RESULTS

At evaluation, 18% of KT candidates felt extremely bothered by dietary restrictions. Those who felt extremely bothered were less likely to be listed for KT (adjusted hazard ratio [aHR] = 0.75, 95% confidence interval [CI]: 0.64-0.87); this association did not differ by neighborhood-level socioeconomic factors. Overall, the burden of dietary restrictions was not associated with waitlist mortality (p = 0.62). However, among candidates living in high food insecurity neighborhoods, those who felt extremely bothered had higher waitlist mortality (adjusted subhazard ratio [aSHR] = 2.07, 95% CI: 1.14-3.75, p[interaction] = 0.02). The association between dietary burden and waitlist mortality did not differ by neighborhood-level healthy food access.

CONCLUSION

The perceived burden of dietary restrictions is associated with a lower chance of listing for KT, and higher waitlist mortality only among candidates residing in neighborhoods with high food insecurity. Transplant centers should identify vulnerable patients and support them with nutrition education and access to food assistance programs.

Acute and chronic complication profiles among patients with chronic kidney disease in Alberta, Canada: a retrospective observational study

BACKGROUND

Chronic kidney disease (CKD) poses a substantial burden to individuals, caregivers, and healthcare systems. CKD is associated with higher risk for adverse events, including renal failure, cardiovascular disease, and death. This study aims to describe comorbidities and complications in patients with CKD.

METHODS

We conducted a retrospective observational study linking administrative health databases in Alberta, Canada. Adults with CKD were identified (April 1, 2010 and March 31, 2019) and indexed on the first diagnostic code or laboratory test date meeting the CKD algorithm criteria. Cardiovascular, renal, diabetic, and other comorbidities were described in the two years before index; complications were described for events after index date. Complications were stratified by CKD stage, atherosclerotic cardiovascular disease (ASCVD), and type 2 diabetes mellitus (T2DM) status at index.

RESULTS

The cohort included 588,170 patients. Common chronic comorbidities were hypertension (36.9%) and T2DM (24.1%), while 11.4% and 2.6% had ASCVD and chronic heart failure, respectively. Common acute complications were infection (58.2%) and cardiovascular hospitalization (24.4%), with rates (95% confidence interval [CI]) of 29.4 (29.3-29.5) and 8.37 (8.32-8.42) per 100 person-years, respectively. Common chronic complications were dyslipidemia (17.3%), anemia (14.7%), and hypertension (11.1%), with rates (95% CI) of 11.9 (11.7-12.1), 4.76 (4.69-4.83), and 13.0 (12.8-13.3) per 100 person-years, respectively. Patients with more advanced CKD, ASCVD, and T2DM at index exhibited higher complication rates.

CONCLUSIONS

Over two-thirds of patients with CKD experienced complications, with higher rates observed in those with cardio-renal-metabolic comorbidities. Strategies to mitigate risk factors and complications can reduce patient burden.

Metabolomic and Physiological Effects of a Cardiorenal Protective Diet Intervention in African American Adults with Chronic Kidney Disease

Chronic kidney disease (CKD) impacts 14% of adults in the United States, and African American (AA) individuals are disproportionately affected, with more than 3 times higher risk of kidney failure as compared to White individuals. This study evaluated the effects of base-producing fruit and vegetables (FVs) on cardiorenal outcomes in AA persons with CKD and hypertension (HTN) in a low socioeconomic area. The "Cardiorenal Protective Diet" prospective randomized trial evaluated the effects of a 6-week, community-based FV intervention compared to a waitlist control (WL) in 91 AA adults (age = 58.3 ± 10.1 years, 66% female, 48% income ≤ USD 25K). Biometric and metabolomic variables were collected at baseline and 6 weeks post-intervention. The change in health outcomes for both groups was statistically insignificant (p > 0.05), though small reductions in albumin to creatinine ratio, body mass index, total cholesterol, and systolic blood pressure were observed in the FV group. Metabolomic profiling identified key markers (p < 0.05), including C3, C5, 1-Met-His, kynurenine, PC ae 38:5, and choline, indicating kidney function decline in the WL group. Overall, delivering a directed cardiorenal protective diet intervention improved cardiorenal outcomes in AA adults with CKD and HTN. Additionally, metabolomic profiling may serve as a prognostic technique for the early identification of biomarkers as indicators for worsening CKD and increased CVD risk.

Academy of Nutrition and Dietetics Commentary on the Phosphorus Recommendation in the KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 Update

The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline's phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.

Food insecurity and kidney disease: a systematic review

BACKGROUND

The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain availability of nutritionally adequate and safe food; it is also associated with several chronic medical conditions. The aim of this systematic review is to investigate the current knowledge about the relationship between food insecurity and renal disease.

METHODS

We selected the pertinent publications by searching on the PubMed, Scopus, and the Web of Science databases, without any temporal limitations being imposed. The searching and selecting processes were carried out through pinpointed inclusion and exclusion criteria and in accordance with the Prisma statement.

RESULTS

Out of the 26,548 items that were first identified, only 9 studies were included in the systemic review. Eight out of the nine investigations were conducted in the US, and one was conducted in Iran. The studies evaluated the relationship between food insecurity and (i) kidney disease in children, (ii) kidney stones, (iii) CKD, (iv) cardiorenal syndrome, and (v) end stage renal disease (ESRD). In total, the different research groups enrolled 49,533 subjects, and food insecurity was reported to be a risk factor for hospitalization, kidney stones, CKD, ESRD, and mortality.

CONCLUSIONS

The relationship between food insecurity and renal disease has been underestimated. Food insecurity is a serious risk factor for health problems in both wealthy and poor populations; however, the true prevalence of the condition is unknown. Healthcare professionals need to take action to prevent the dramatic effect of food insecurity on CKD and on other chronic clinical conditions.

Advances in pediatric acute kidney injury pathobiology: a report from the 26th Acute Disease Quality Initiative (ADQI) conference

BACKGROUND

In the past decade, there have been substantial advances in our understanding of the pathobiology of pediatric acute kidney injury (AKI). In particular, animal models and studies focused on the relationship between kidney development, nephron number, and kidney health have identified a number of heterogeneous pathophysiologies underlying AKI. Despite this progress, gaps remain in our understanding of the pathobiology of pediatric AKI.

METHODS

During the 26th Acute Disease Quality Initiative (ADQI) Consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for opportunities to advance translational research in pediatric AKI. The current state of research understanding as well as gaps and opportunities for advancement in research was discussed, and recommendations were summarized.

RESULTS

Consensus was reached that to improve translational pediatric AKI advancements, diverse teams spanning pre-clinical to epidemiological scientists must work in concert together and that results must be shared with the community we serve with patient involvement. Public and private research support and meaningful partnerships with adult research efforts are required. Particular focus is warranted to investigate the pediatric nuances of AKI, including the effect of development as a biological variable on AKI incidence, severity, and outcomes.

CONCLUSIONS

Although AKI is common and associated with significant morbidity, the biologic basis of the disease spectrum throughout varying nephron developmental stages remains poorly understood. An incomplete understanding of factors contributing to kidney health, the diverse pathobiologies underlying AKI in children, and the historically siloed approach to research limit advances in the field. The recommendations outlined herein identify gaps and outline a strategic approach to advance the field of pediatric AKI via multidisciplinary translational research.

Paving a Path to Equity in Cardiorenal Care

Cardiorenal syndrome encompasses a dynamic interplay between cardiovascular and kidney disease, and its prevention requires careful examination of multiple predisposing underlying conditions. The unequal distribution of diabetes, heart failure, hypertension, and kidney disease requires special attention because of the influence of these conditions on cardiorenal disease. Despite growing evidence regarding the benefits of disease-modifying agents (e.g., sodium-glucose cotransporter 2 inhibitors) for cardiovascular, kidney, and metabolic (CKM) disease, significant disparities remain in access to and utilization of these essential therapeutics. Multilevel barriers impeding their use require multisector interventions that address patient, provider, and health system-tailored strategies. Burgeoning literature also describes the critical role of unequal social determinants of health, or the sociopolitical contexts in which people live and work, in cardiorenal risk factors, including heart failure, diabetes, and chronic kidney disease. This review outlines (i) inequality in the burden and treatment of hypertension, type 2 diabetes, and heart failure; (ii) disparities in the use of key disease-modifying therapies for CKM diseases; and (iii) multilevel barriers and solutions to achieve greater pharmacoequity in the use of disease-modifying therapies. In addition, this review provides summative evidence regarding the role of unequal social determinants of health in cardiorenal health disparities, further outlining potential considerations for future research and intervention. As proposed in the 2023 American Heart Association presidential advisory on CKM health, a paradigm shift will be needed to achieve cardiorenal health equity. Through a deeper understanding of CKM health and a commitment to equity in the prevention, detection, and treatment of CKM disease, we can achieve this critical goal.

Association between dietary total choline and abdominal aorta calcification among older US adults: A cross-sectional study of the National Health and Nutrition Examination Survey

BACKGROUND

Numerous studies indicate a potential bidirectional association between dietary choline intake and its derivative, betaine, and subclinical atherosclerosis. However, little research has been conducted on the relationship between dietary choline and severe abdominal aortic calcification (SAAC).

METHODS

This cross-sectional study analyzed population-based data from the National Health and Nutrition Examination Survey (2013-2014). Choline intake and food sources were measured using two 24-h dietary-recall interviews. The abdominal aortic calcification score was measured using a dual-emission x-ray absorptiometry scan. To assess the relationship between choline intake and SAAC, the study utilized restricted cubic spline and a multivariable logistic regression model.

RESULTS

Among the 2640 individuals included in the study, 10.9% had SAAC. After adjusting for all selected covariates, compared with the lowest quartile of dietary choline, the odds ratios of SAAC for the second-quartile, third-quartile, and fourth-quartile dietary choline intake were 0.63 (95% confidence interval [CI], 0.43-0.93), 0.63 (95% CI, 0.42-0.94), and 0.77 (95% CI, 0.5-1.16), respectively. The study found an L-shaped relationship between dietary choline and SAAC in the dose-response analysis. Subgroup analyses did not demonstrate any statistically significant interaction effects for any subgroup.

CONCLUSION

The study found that a higher intake of dietary choline is associated with a lower prevalence of SAAC. The dose-response analysis revealed an L-shaped relationship between dietary choline and SAAC. However, further studies are warranted to investigate the direct role of choline in the development of SAAC.

Home-Delivered Medically Tailored Meal Engagement Among Hemodialysis Patients and Providers

OBJECTIVE

Hemodialysis patients face one of the most difficult diets among clinical patient populations. Furthermore, dialysis dietary adherence is generally reported as low with providers generally lacking the time and resources to implement effective behavior change. The purpose of this study was to elucidate measures of patient and provider engagement with home-delivered medically tailored meals (MTMs).

METHODS

We surveyed patients and staff at dialysis centers within the Denver metropolitan area. Surveys focused on 1) patient dietary intake, 2) awareness, support, and utilization of meal programs, and 3) nutritional challenges and barriers (including food security).

RESULTS

We surveyed 118 patients (mean age 61.0 ± 14.2 year, 58.5% male, and dialysis vintage of 4.6 ± 4.9 years) and 26 staff across the included dialysis facilities. Patients were 20.3% White/Non-Hispanic, 35.6% Hispanic/Latin, and 31.4% Black/African American. Most patients reported eating 2 meals per day (N = 53, 44.9%) and 52.2% reported difficulty with following a kidney diet. The most cited reasons for not following the diet were behavioral or knowledge (38.5%), taste (26.3%), time/convenience (26.9%) and food autonomy (16.9%). Sixty participants (52.2%) reported living in a food desert and 26.3% reported food insecurity. Seventy-one patients (61.2%) were aware of MTMs but only 40.5% had been referred. Most (76.9%) dialysis providers were aware of MTMs but only 15 (57.7%) had actually referred patients to such a service. Black individuals were less likely to be referred for MTMs than White or Hispanics/Latin (29.7% vs 48.1% White and 45.0% Hispanic/Latin) individuals.

CONCLUSION

Medically tailored meals (MTMs) represent a potential method to alleviate or bypass some of the many barriers expressed by patients. Our findings reveal a critical need for education around MTMs for both patients and providers. Medically tailored meals (MTMs) could potentially demonstrate health kidney dietary patterns that might translate to altered dietary preferences or toward future behavior change.

The relationship between low levels of albuminuria and cardiovascular mortality among apparently healthy adults

Background

Albuminuria is associated with cardiovascular events among adults with underlying cardiovascular disease and diabetes, even at low levels of urinary albumin excretion. We hypothesized that low levels of albuminuria in the 'normal' range (urinary albumin-to-creatine ratio (UACR) <30 mg/g) are associated with cardiovascular death among apparently healthy adults.

Methods

We studied adults who participated in the 1999-2014 National Health and Nutrition Examination Survey. We excluded participants with baseline cardiovascular disease, hypertension, diabetes, estimated glomerular filtration rate (eGFR) <60ml/min/1.73m2, those who were currently pregnant, and those who had received dialysis in the last year. After excluding these conditions, only 5.0% of the remaining population had UACR ≥30 mg/g (N=873) and were excluded. The final sample size was 16,247. We assessed the relationship between UACR and cardiovascular and all-cause mortality using multivariable-adjusted Cox proportional hazards models. Models were adjusted for age, sex, race or ethnicity, smoking status, systolic blood pressure, hemoglobin A1c, total cholesterol, health insurance, food insecurity, serum albumin, body mass index, use of statins, and eGFR.

Results

Mean age was 38.9 years (SD 13.6) and 53.7% were women. The median length of follow-up was 12.2 years. In multivariable-adjusted models, each doubling of UACR (within the <30 mg/g range) was associated with a 36% higher risk of cardiovascular death [HR 1.36 (95% confidence interval (CI) 1.11-1.65)] and a 28% higher risk of all-cause mortality [HR 1.28 (95%CI 1.17-1.41)]. The highest tertile of UACR (7.1-29.9 mg/g) was associated with an 87% higher risk of cardiovascular death [HR 1.87 (95%CI 1.20-2.92)] and 59% higher risk of all-cause mortality [HR 1.59 (95%CI 1.28-1.96)], compared with the lowest tertile (< 4.3 mg/g).

Conclusions

In a nationally representative sample of relatively healthy community-dwelling adults, higher levels of albuminuria in the conventionally "normal" range <30 mg/g in healthy individuals are associated with greater mortality. Overall, our findings contribute to the growing body of evidence on the existence of a risk gradient across all levels of albuminuria, even in the so-called normal range.

Diabetic Kidney Disease Prevention Care Model Development

More than one-third of people with diabetes develop diabetic kidney disease (DKD), which substantially increases risks of kidney failure, cardiovascular disease (CVD), hypoglycemia, death, and other adverse health outcomes. A multifaceted approach incorporating self-management education, lifestyle optimization, pharmacological intervention, CVD prevention, and psychosocial support is crucial to mitigate the onset and progression of DKD. The American Diabetes Association convened an expert panel to develop the DKD Prevention Model presented herein. This model addresses prevention and treatment, including screening guidelines, diagnostic tools, and management approaches; comprehensive, holistic interventions; well-defined roles for interdisciplinary health care professionals; community engagement; and future directions for research and policy.

Adults are just big kids: pediatric considerations for adult critical care nephrology

PURPOSE OF REVIEW

In recent years, there has been growing attention to pediatric kidney health, especially pediatric acute kidney injury (AKI). However, there has been limited focus on the role of pediatric AKI on adult kidney health, specifically considerations for the critical care physician.

RECENT FINDINGS

We summarize what is known in the field of pediatric AKI to inform adult medical care including factors throughout the early life course, including perinatal, neonatal, and pediatric exposures that impact survivor care later in adulthood.

SUMMARY

The number of pediatric AKI survivors continues to increase, leading to a higher burden of chronic kidney disease and other long-term co-morbidities later in life. Adult medical providers should consider pediatric history and illnesses to inform the care they provide. Such knowledge may help internists, nephrologists, and intensivists alike to improve risk stratification, including a lower threshold for monitoring for AKI and kidney dysfunction in their patients.

Inequities in kidney health and kidney care

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health.

Proceedings of a Workshop to Promote Community Health Worker Interventions in Nephrology

ABSTRACT

Latinx populations face a higher burden of kidney failure and associated negative outcomes compared with non-Latinx White populations, despite sharing a similar prevalence of CKD. Community health worker (CHW) interventions have been shown to improve outcomes for Latinx individuals, but they are largely underutilized in kidney disease. We convened a workshop of four ongoing kidney disease CHW programs to identify successes, challenges, potential solutions, and needed research to promote CHW programs for Latinx individuals with kidney disease. Key points from the workshop and recommendations for intervention and research are highlighted. Facilitators of program success included prioritizing trust-building with participants, enabling participants to determine what aspects of the intervention were needed, providing participants with tools to help themselves and others after the intervention, and taking a trauma-informed approach to relationships. Challenges included persistent systemic barriers despite successful care navigation and low recruitment and retention. Research is needed to capture the effect of CHW interventions on outcomes and to determine how to implement CHW interventions for people with kidney disease nationwide.

Association of Higher Intake of Plant-Based Foods and Protein With Slower Kidney Function Decline in Women With HIV

BACKGROUND

We investigated whether there exists an association between dietary acid load and kidney function decline in women living with HIV (WLWH) receiving antiretroviral therapy (ART).

SETTING

One thousand six hundred eight WLWH receiving ART in the WIHS cohort with available diet data and a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/minute/1.73 m2.

METHODS

A brief dietary instrument conducted from 2013 to 2016 under the Food Insecurity Sub-Study was used for assessing fruits and vegetables (FV) and protein intake. A mixed-effects model with random intercept and slope was used to estimate subjects' annual decline rate in eGFR and the association between FV intake and eGFR decline, adjusting for sociodemographics, serum albumin, comorbidities, time on ART, ART drugs, HIV markers, and baseline eGFR. We evaluated whether markers of inflammation mediated the effect of FV intake on decline in eGFR, using causal mediation analysis.

RESULTS

We found a dose-response relationship for the association of FV intake and eGFR decline, with lesser annual decline in eGFR in the middle and highest tertiles of FV intake. An increase of 5 servings of FV intake per day was associated with a lower annual eGFR decline (-1.18 [-1.43, -0.94]). On average, 39% of the association between higher FV intake and slower eGFR decline was explained by decreased levels of inflammation.

CONCLUSIONS

Plant-rich diet was associated with slower decline in kidney function. Inflammation is a potential path through which diet may affect kidney function. The findings support an emerging body of literature on the potential benefits of plant-rich diets for prevention of chronic kidney disease.

Association of Plant-Based Protein Intake with Cognitive Function in Adults with CKD

Key Points

Higher plant protein intake was associated with higher cognitive scores in people with kidney disease. Future trials are needed to determine whether increasing plant protein intake improves measures of cognition in patients with kidney disease.

Background

Patients with CKD have accelerated cardiovascular and cognitive aging when compared with the non-CKD population. This cognitive decline contributes to excessive rates of physical and functional decline, reduced quality of life, and mortality in the CKD population. Mediterranean diets, a plant-forward diet, have been associated with positive cognitive performance in the general non-CKD population and with some beneficial outcomes in CKD. However, it is still unclear whether plant-based diets are associated with cognitive decline in patients with CKD.

Methods

Using the National Health and Nutrition Examination Survey 2011–2012 and 2013–14 data, we conducted a secondary analysis evaluating the relationship of plant-based and unprocessed plant protein with cognitive outcome measures in eligible participants aged 60 years and older. All data were extracted from the available National Health and Nutrition Examination Survey demographic, questionnaire, examination, and laboratory data. CKD was calculated and defined in participants as urine albumin to creatinine ratio ≥30 mg/g and/or eGFR <60 ml/min. In incremental models, we adjusted for total energy intake, age, sex, race/ethnicity, body mass index, total energy intake, diabetes, hypertension, education, smoking, and alcohol.

Results

Higher plant-based protein above median dietary intakes was significantly associated with higher executive function scores in participants with CKD (P < 0.05). For all patients and in those with CKD, plant-based protein was significantly associated (P < 0.05) with higher composite cognitive scores in nearly all statistical models. Higher unprocessed plant protein was significantly associated (P < 0.05) with higher composite cognitive scores in all categorical models.

Conclusions

Higher plant protein intake was a significant predictor of certain individual and composite cognitive score measures within the general and in the CKD population. Future interventional trials are needed to determine whether increasing plant-based protein intake improves measures of cognition in patients with CKD.

Material Need Insecurities among People on Hemodialysis: Burden, Sociodemographic Risk Factors, and Associations with Substance Use

Key Points

Food insecurity and housing instability may affect dialysis outcomes through health behaviors like treatment adherence and their effect on access to transplantation or home dialysis therapies. People on hemodialysis who were younger, with less educational attainment, with lower incomes, or experiencing financial strain were more likely to experience material need insecurities. Participant race was not associated with material need insecurities, although residential segregation moderated associations between age, sex, and food insecurity.

Background

Despite their relevance to health outcomes, reports of food insecurity and housing instability rates among adults on hemodialysis are limited. Their relation to sociodemographic and behavioral factors are unknown for this population.

Methods

We enrolled a convenience sample of people receiving hemodialysis at Baltimore and Washington, DC metropolitan area facilities. Participants completed measures of socioeconomic position, food insecurity, housing instability, and substance use disorder. We cross-referenced participant and facility zip codes with measures of area poverty and residential segregation. We examined associations between individual-level and area-level sociodemographic characteristics, food insecurity, and housing instability using multivariable logistic regression models.

Results

Of the 305 participants who completed study surveys, 57% were men and 70% were Black, and the mean age was 60 years. Thirty-six percent of the sample reported food insecurity, 18% reported housing instability, and 31% reported moderate or high-risk substance use. People on hemodialysis who were younger, with lower educational attainment, with lower incomes, or experiencing financial strain were more likely to have material need insecurities (P < 0.05 for all). Among participants living in segregated jurisdictions, men had increased odds of food insecurity compared with women (odds ratio 3.7; 95% confidence interval, 1.61 to 8.53); younger participants (age <55 years) had increased odds of food insecurity compared with older participants (odds ratio 3.3; 95% confidence interval, 1.49 to 7.32). Associations between sex or younger age category and food insecurity were not statistically significant in less segregated counties (P interaction for residential segregation×sex: P = 0.006; residential segregation×younger age category: P = 0.12).

Conclusions

Food insecurity, housing instability, and substance use were common among this sample of adults on hemodialysis. Younger adults on hemodialysis, particularly those living in residentially segregated jurisdictions, were at increased risk for food insecurity. Future research should examine whether material need insecurities perpetuate disparities in dialysis outcomes.

Podcast

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/K360/2023_12_01_KID0000000000000279.mp3

Prime time for chronic kidney disease

Chronic kidney disease (CKD) represents a public health burden worldwide and is associated with significant morbidity and mortality. Most patients with CKD are managed by primary care practitioners and this educational series hope to improve knowledge and delivery of care to this high-risk patient population with CKD.

Food Insecurity and Chronic Kidney Disease: Considerations for Practitioners

The coronavirus disease 2019 pandemic has exacerbated existing health disparities related to food security status. Emerging literature suggests individuals with Chronic Kidney Disease (CKD) who are also food insecure have a greater likelihood of disease progression compared to food secure individuals. However, the complex relationship between CKD and food insecurity (FI) is understudied relative to other chronic conditions. The purpose of this practical application article is to summarize the recent literature on the social-economic, nutritional, to care through which FI may negatively impact health outcomes in individuals with CKD. While several studies have reported on the cross-sectional prevalence of FI among persons with CKD, literature is lacking about the severity and duration of exposure to FI on CKD outcomes. Future research is needed to better understand how FI impairs CKD care, nutritional and structural barriers that impact disease prevention and disease progression, and effective strategies to support patients.

Barriers to and Strategies for Dietary Adherence: A Qualitative Study Among Hemodialysis/Peritoneal Dialysis Patients and Health Care Providers

OBJECTIVES

The objectives of this study were: (1) investigate hemodialysis (HD)/peritoneal dialysis (PD) patients' barriers to dietary adherence, (2) identify strategies to overcome these barriers, and (3) examine dialysis providers' perceptions toward patients' barriers to dietary adherence and strategies to overcome these barriers.

METHODS

A qualitative descriptive approach was conducted from February-May 2022. A total of 21 HD/PD participants and 11 health care providers participated in individual interviews. HD/PD participants also responded to a 57-item food frequency questionnaire. Six months of serum laboratory values were obtained from the medical charts. Content analysis methodology was used to identify themes. Mann-Whitney U tests were conducted to examine diet quality and laboratory values of the HD and PD participants using SPSS v.27 with statistical significance of P < .05.

RESULTS

The median (interquartile range) diet quality score for HD/PD patients was 36 (26-43) with no differences observed between the patient populations. Mann-Whitney U tests showed no differences between serum laboratory values between the patient populations. Barriers identified by the HD/PD patients were communication/patient education and dietary habits. Barriers identified by the health care providers were communication/patient education and socioeconomic status. Strategies to overcome these barriers were enhancing communication between all parties involved in the care and tailoring educational information to the patient's background.

CONCLUSIONS

Communication and patient education were themes identified among both health care providers and patients. Therefore, open communication among the patients and providers and enhancement of the nutrition education handouts may improve dietary adherence.

Structural Racism, Historical Redlining, and Incidence of Kidney Failure in US Cities, 2012-2019

SIGNIFICANCE STATEMENT

Residing in neighborhoods designated as grade D (hazardous) by the Home Owners' Loan Corporation (HOLC) under historical redlining-a discriminatory housing policy beginning in the 1930s-has been associated with present-day adverse health outcomes such as diabetes mortality. Historical redlining might underlie conditions in present-day neighborhoods that contribute to inequitable rates of kidney failure incidence, particularly for Black individuals, but its association with kidney disease is unknown. The authors found that among adults with incident kidney failure living in 141 metropolitan areas, residence in a historically redlined neighborhood rated grade D was associated with significantly higher kidney failure incidence rates compared with residence in a redlined grade A (best) neighborhood. These findings suggest that historical racist policies continue to affect current-day racial inequities in kidney health.

BACKGROUND

Historical redlining was a 1930s federally sponsored housing policy that permitted the Home Owners' Loan Corporation (HOLC) to develop color-coded maps and grade neighborhoods' mortgage lending risk on the basis of characteristics that included racial makeup. This practice has been associated with present-day health disparities. Racial inequities in kidney disease-particularly for Black individuals-have been linked to residential segregation and other structural inequities.

METHODS

Using a registry of people with incident kidney failure and digitized HOLC maps, we examined the association between residence in a historically redlined US census tract (CT) with a historical HOLC grade of D or hazardous) and present-day annual CT-level incidence of kidney failure incidence among adults in 141 US metropolitan areas, in 2012 through 2019.

RESULTS

Age-adjusted and sex-adjusted kidney failure incidence rates were significantly higher in CTs with a historical HOLC grade D compared with CTs with a historical HOLC grade of A or best (mean, 740.7 per million versus 326.5 per million, respectively, a difference of 414.1 per million). Compared with national averages of all adults in our sample, rates of kidney failure incidence were higher for Black adults in our study sample, irrespective of CT HOLC grade. Age-adjusted and sex-adjusted incidence rates for Black persons in CTs with a HOLC grade D were significantly higher than for Black persons residing in HOLC grade A CTs (mean, 1227.1 per million versus 1030.5 per million, respectively [a difference of 196.6 per million]).

CONCLUSIONS

Historical redlining is associated with present-day disparities in kidney failure incidence, demonstrating the legacy of historical racist policies on contemporary racial inequities in kidney health.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_08_24_JASN0000000000000165.mp3.

Diagnosis of Chronic Kidney Disease and Assessing Glomerular Filtration Rate

Chronic kidney disease (CKD) is a silent progressive disease. It is diagnosed by assessing filtration and markers of kidney damage such as albuminuria. The diagnosis of CKD should include not only assessing the glomerular filtration rate (GFR) and albuminuria but also the cause. The CKD care plan should include documentation of the trajectory and prognosis. The use of a combination of serum cystatin C and creatinine concentration offers a more accurate estimation of GFR. Social determinants of health are important to address as part of the diagnosis because they contribute to CKD disparities.

Diet and Food and Nutrition Insecurity and Cardiometabolic Disease

Poor nutrition is the leading cause of poor health, health care spending, and lost productivity in the United States and globally, which acts through cardiometabolic diseases as precursors to cardiovascular disease, cancer, and other conditions. There is great interest in how the social determinants of health (the conditions in which people are born, live, work, develop, and age) impact cardiometabolic disease. Food insecurity is an example of a powerful social determinant of health that impacts health outcomes. Nutrition insecurity, a distinct but related concept to food insecurity, is a direct determinant of health. In this article, we provide an overview of how diet in early life relates to cardiometabolic disease and then continue to focus on the concepts of food insecurity and nutrition insecurity. In the discussions herein we make important distinctions between the concepts of food insecurity and nutrition insecurity and provide a review of their concepts, histories, measurement and assessment devices, trends and prevalence, and links to health and health disparities. The discussions here set the stage for future research and practice to directly address the negative consequences of food and nutrition insecurity.

Socioeconomic status, mental health, and nutrition are the principal traits for low back pain phenotyping: Data from the osteoarthritis initiative

Background

Low back pain (LBP) is a heterogeneous disease with biological, physical, and psychosocial etiologies. Models for predicting LBP severity and chronicity have not made a clinical impact, perhaps due to difficulty deciphering multidimensional phenotypes. In this study, our objective was to develop a computational framework to comprehensively screen metrics related to LBP severity and chronicity and identify the most influential.

Methods

We identified individuals from the observational, longitudinal Osteoarthritis Initiative cohort (N = 4796) who reported LBP at enrollment (N = 215). OAI descriptor variables (N = 1190) were used to cluster individuals via unsupervised learning and uncover latent LBP phenotypes. We also developed a dimensionality reduction algorithm to visualize clusters/phenotypes using Uniform Manifold Approximation and Projection (UMAP). Next, to predict chronicity, we identified those with acute LBP (N = 40) and persistent LBP over 8 years of follow-up (N = 66) and built logistic regression and supervised machine learning models.

Results

We identified three LBP phenotypes: a "high socioeconomic status, low pain severity group", a "low socioeconomic status, high pain severity group", and an intermediate group. Mental health and nutrition were also key clustering variables, while traditional biomedical factors (e.g., age, sex, BMI) were not. Those who developed chronic LBP were differentiated by higher pain interference and lower alcohol consumption (a correlate to poor physical fitness and lower soceioeconomic status). All models for predicting chronicity had satisfactory performance (accuracy 76%-78%).

Conclusions

We developed a computational pipeline capable of screening hundreds of variables and visualizing LBP cohorts. We found that socioeconomic status, mental health, nutrition, and pain interference were more influential in LBP than traditional biomedical descriptors like age, sex, and BMI.

Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

EXPOSURE

Zip code-level average distance between households and nearest supermarket.

OUTCOME

Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

ANALYTICAL APPROACH

Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

RESULTS

Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

LIMITATIONS

Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

CONCLUSIONS

There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Food Insecurity Is Common in the Orthopedic Trauma Population at a Rural Academic Trauma Center

Background

Food insecurity is an increasingly recognized public health issue. Identifying risk factors for food insecurity would support public health initiatives to provide targeted nutrition interventions to high-risk individuals. Food insecurity has not been investigated in the orthopedic trauma population.

Methods

From April 27, 2021 to June 23, 2021, we surveyed patients within six months of operative pelvic and/or extremity fracture fixation at a single institution. Food insecurity was assessed using the validated United States Department of Agriculture Household Food Insecurity questionnaire generating a food security score of 0 to 10. Patients with a food security score ≥ 3 were classified as Food Insecure (FI) and patients with a food security score < 3 were classified as Food Secure (FS). Patients also completed surveys for demographic information and food consumption. Differences between FI and FS for continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe the relationship between food security score and participant characteristics. Logistic regression was used to determine the relationship between patient demographics and odds of FI.

Results

We enrolled 158 patients (48% female) with a mean age of 45.5 ± 20.3 years. Twenty-one patients (13.3%) screened positive for food insecurity (High security: n=124, 78.5%; Marginal security: n=13, 8.2%; Low security: n=12, 7.6%; Very Low security: n=9, 5.7%). Those with a household income level of ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Widowed/single/divorced patients were 10.2 times more likely to be FI (95% CI 2.3-45.6). Median time to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) than for FS patients (t=7 minutes, p=0.0202). Age (r= -0.08, p=0.327) and hours working (r= -0.10, p=0.429) demonstrated weak to no correlation with food security score.

Conclusion

Food insecurity is common in the orthopedic trauma population at our rural academic trauma center. Those with lower household income and those living alone are more likely to be FI. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a more diverse trauma population and to better understand its impact on patient outcomes. Level of Evidence: III.

Impact of SARS-CoV-2 Pandemic on food Security in Patients With chronic Kidney Disease

OBJECTIVE

The present study aims to determine the degree of Food Insecurity (FI) in adult patients with CKD during the COVID-19 pandemic, as well as the association between FI and food consumption.

METHODS

A cross-sectional study was conducted on patients with chronic kidney disease (CKD), with and without substitutive treatment, and older than 18 years of age. Food security was measured using the Mexican Food Security Scale (MFSS). Sociodemographic data and a food frequency questionnaire were obtained. Multinomial logistic regression was performed using the 4 categories of food security (food security as reference); principal component analysis was also performed to assess the relationship between food consumption patterns and sociodemographic characteristics.

RESULTS

The prevalence of FI in patients with CKD was 71.6%, the most prevalent degree of FI was moderate. As FI increased, a greater amount of beans, eggs, sweets/desserts, soft drinks, and artificial juices (P < .001) was consumed. The risk factors of FI were diabetes, hypertension, unpaid occupation, living in the country's capital, having children at home, or a decrease in income due to the pandemic. Four main components were identified that were associated with the different degrees of FI.

CONCLUSION

The present study allowed us to conclude that more than 70% of CKD patients in the study cohort had some type of FI, which makes it difficult to adhere to treatment and may increase the risk of advanced CKD. A less healthy food pattern is associated with greater FI.

Designing Interventions Addressing Structural Racism to Reduce Kidney Health Disparities: A Report from a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

Structural racism embodies the many ways in which society fosters racial discrimination through "mutually reinforcing inequitable systems" that limit access to resources and opportunities that can promote health and well being among marginalized communities. To achieve health equity, and kidney health equity more specifically, structural racism must be eliminated. In February 2022, the National Institute of Diabetes and Digestive and Kidney Diseases convened the "Designing Interventions that Address Structural Racism to Reduce Kidney Health Disparities" workshop, which was aimed at describing the mechanisms through which structural racism contributes to health and health care disparities for people along the continuum of kidney disease and identifying actionable opportunities for interventional research focused on dismantling or addressing the effects of structural racism. Participants identified six domains as key targets for interventions and future research: (1) apply an antiracism lens, (2) promote structural interventions, (3) target multiple levels, (4) promote effective community and stakeholder engagement, (5) improve data collection, and (6) advance health equity through new health care models. There is an urgent need for research to develop, implement, and evaluate interventions that address the unjust systems, policies, and laws that generate and perpetuate inequities in kidney health.

Association between food insecurity and kidney stones in the United States: Analysis of the National Health and Nutrition Examination Survey 2007-2014

Purpose

Although food insecurity is a major public health concern associated with various diseases, the relationship between food insecurity and kidney stones remains unclear. We aimed to investigate the association between food insecurity and kidney stones in the US population.

Materials and methods

Four continuous cycles of data from the year 2007 to 2014 were obtained from National Health and Nutrition Examination Survey (NHANES) in the current study. We utilized the Household Food Security Module to assess the food security status of individuals. The primary outcome was whether participants ever had kidney stones, and the secondary outcome was a stone recurrence. A multivariate logistic regression model adjusting for potential confounders was constructed to evaluate the independent association between food insecurity and kidney stones.

Results

A total of 21,914 participants were included in our analysis, with 8.8% having a history of kidney stones and 33.2% of these reporting stones recurrence. Food insecurity was associated with increased risks of kidney stones (odds ratio: 1.21; 95% confidence interval: 1.05-1.39; P = 0.010) and kidney stones recurrence (odds ratio: 1.33; 95% confidence interval: 1.00-1.77; P = 0.052) after adjusting for all potential confounders. In addition, participants with very low food security had 38% and 47% higher risks of kidney stones (odds ratio: 1.38; 95% confidence interval: 1.13-1.69; P = 0.002; P for trend = 0.009) and kidney stones recurrence (odds ratio: 1.47; 95% confidence interval: 1.03-2.10; P = 0.032; P for trend = 0.029), respectively.

Conclusion

There exists a significant association between food insecurity and kidney stones, which reveals the significance of the improvement of food insecurity in the alleviation of kidney stone formation and recurrence.

Addressing Food Insecurity: Lessons Learned from Co-Locating a Food Pantry with a Federally Qualified Health Center

Introduction:

Social determinants of health, such as food insecurity, contribute to chronic health conditions, decreased quality of life, and health disparities. Increasingly, healthcare systems seek to address social determinants of health by integrating medical and social care.

Description:

Eskenazi Health Center Pecar is a Federally Qualified Health Center providing comprehensive primary care to vulnerable patients in Indianapolis, IN, USA. This health center, in coalition with community partners, established and continually developed an integrated food pantry model to address food insecurity, improve nutrition education, and support patient access to healthy food.

Discussion:

Food insecurity and poor nutrition are common in primary care and contribute to the incidence and outcomes of chronic conditions such as obesity, hypertension, and diabetes. Long-term management of food assistance and nutrition programs requires substantial resources, partnerships, and leadership. We describe lessons learned in food pantry partnership, funding, logistics, and sustainability in a collaborative food access model integrated into healthcare. These lessons learned can be utilized by other health systems to scale up and accelerate strategies to better address food security and nutrition education. This paper articulates best practices for integrating a food pantry model within primary care with the goal of long-term sustainability and direct impact on patient health outcomes.

Implementing a Process for Screening Hospitalized Adults for Food Insecurity at a Tertiary Care Center

ABSTRACT

Food insecurity has been linked to numerous chronic conditions and higher healthcare costs; however, screening for food insecurity lags behind screening for other social determinants of health, particularly in the hospital setting. Although our hospital serves a population with a high prevalence of food insecurity, no process previously existed to universally screen patients. Our multidisciplinary team developed and implemented a process to screen hospitalized adults for food insecurity and connect them with food resources, which we piloted on a 26-bed hospital medicine unit. We integrated a validated 2-item screen into the electronic health record (EHR) nursing admission workflow, and provided 2 weeks of nursing education before process implementation. Adherence to screening was monitored weekly and adjustments were made using plan-do-study-act cycles. After 28 weeks, 361/587 (61.5%; weekly average 61.1%) encounters were screened (compared with a baseline of 2.2%), with 21/361 (5.8%) identified as food insecure. The implementation of an EHR-based food insecurity screening process in the hospital setting increased screening and identification of food insecure patients. Through improved integration of screening questions into the existing nursing workflow and continued education, success was sustained despite challenges with nursing staff turnover and staff shortages during the COVID-19 pandemic.

Assessing the Relationship Between Emergency Food Assistance and Social Vulnerability During the COVID-19 Pandemic

Food insecurity is a major public health challenge that is associated with negative health outcomes in wealthy countries. In US urban areas, food banks and pantries played an expanded role in providing emergency food assistance and addressing food insecurity during the COVID-19 pandemic. This study seeks to determine if socially vulnerable neighborhoods are more likely to receive emergency food assistance during this pandemic, after controlling for distance to emergency food distribution sites and spatial clustering. The study area is El Paso County, Texas-an urban area on the US-Mexico border. Dependent variables represent both coverage and intensity of emergency food transfers (EFTs) from local food banks and pantries during November 2020, at the census tract level. Independent variables are derived from the widely used Social Vulnerability Index (SVI) developed by the Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry. Our statistical analyses are based on multivariable generalized estimating equations that account for spatial clustering and proximity to emergency food distribution sites. Results indicate that both coverage and intensity of EFTs are significantly greater in neighborhoods with higher social vulnerability and proximity to emergency food distribution sites, but lower in neighborhoods that are more vulnerable in terms of housing and transportation. Our findings highlight the significance of neighborhood-level social factors in influencing access to the emergency food network during a public health crisis and have important implications for government agencies and nonprofit organizations associated with public health and emergency preparedness in US urban areas.

Food Insecurity May be an Independent Risk Factor Associated With Erectile Dysfunction in the United States: Analysis of the National Health and Nutrition Examination Survey Data

INTRODUCTION

While food insecurity is a global public health problem associated with obesity, diabetes, hypertension and coronary heart disease, literature regarding the relationship between food insecurity and erectile dysfunction (ED) is scarce.

AIM

We aimed to determine the associations between food insecurity and ED in the National Health and Nutrition Examination Survey.

METHODS

Data was extracted from 3,891 participants (aged ≥ 20 years) with ED in the 2001-2004 National Health and Nutrition Examination Survey. Multivariable logistic regression analysis with sampling weights was conducted to evaluate the associations.

MAIN OUTCOME MEASURE

Food security was assessed utilizing the Household Food Security Module. A single-question self-report from the Massachusetts Male Aging Study was utilized to evaluate ED status.

RESULTS

Approximately 10.2% of individuals had food insecurity. Food insecurity was significantly associated with ED after full adjustment (odds ratio [OR] 1.56; 95% confidence interval [95% CI] 1.16-2.09; P = .003). Men with very low food insecurity had 59% higher risks of ED compared with those having high food security (OR 1.59; 95% CI 1.13-2.27; P = .006). Moreover, the associations were stronger in the old people (age ≥ 60) (OR 2.15; 95% CI 1.26-3.66; P = .004).

CONCLUSIONS

Food insecurity might be associated with higher risks of developing ED. Wang W, Chen J, Peng L, et al. Food Insecurity May be an Independent Risk Factor Associated With Erectile Dysfunction in the United States: Analysis of the National Health and Nutrition Examination Survey Data. Sex Med 2022;XX:XXXXXX.

Food Access, Dietary Intake, and Nutrition Knowledge of Adults on Probation

OBJECTIVE

To examine food access, dietary intake, and perceptions about diet and associations with health among adults on probation.

DESIGN

Using a mixed-methods approach, interviews were used to understand food access, dietary intake, and diet and associations with health. A survey measured self-assessed diet quality and diet and associations with health.

SETTING

One probation office in Rhode Island.

PARTICIPANTS

English-speaking adults on probation in 2016 (n = 22 interviews, n = 304 surveys).

MAIN OUTCOME MEASURE(S)

Food access, dietary intake, knowledge about diet and health, and perceptions about healthy food.

ANALYSIS

We used a thematic analytic approach to analyze the interviews. Descriptive statistics were performed for the survey.

RESULTS

Many interviewees had inadequate food access, although most participated in the Supplemental Nutrition Assistance Program, and some received food from food banks. Interviewees primarily shopped at grocery stores and prepared food at home, and dietary intakes did not meet the 2020-2025 Dietary Guidelines for Americans. Almost two-thirds (64.2%) of survey participants reported good or fair diet quality. Based on the survey results, the majority of participants strongly agreed and agreed with the statements, "The types of foods I eat affect my health" and "The types of food I eat affect my weight."

CONCLUSIONS AND IMPLICATIONS

This study identified low-quality dietary intake and food acquisition strategies, such as shopping sales, buying bulk, and going to multiple stores, by US adults on probation to access food with limited resources. Participants reported interest in eating healthier foods and knew there was a connection between dietary intake and health. These data support addressing ways to improve food access and dietary quality, focusing on future programs and policies for this population.

Burden of chronic kidney disease and its risk-attributable burden in 137 low-and middle-income countries, 1990-2019: results from the global burden of disease study 2019

BACKGROUND

Chronic kidney disease (CKD) is a global public health concern, but its disease burden and risk-attributable burden in CKD has been poorly studied in low - and middle-income countries (LMICs). This study aimed to estimate CKD burden and risk-attributable burden in LMICs from 1990 to 2019.

METHODS

Data were collected from the Global Burden of Disease (GBD) Study 2019, which measure CKD burden using the years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs) and calculate percentage contributions of risk factors to age-standardized CKD DALY using population attributable fraction (PAF) from 1990 to 2019. Trends of disease burden between 1990 and 2019 were evaluated using average annual percent change (AAPC). The 95% uncertainty interval (UI) were calculated and reported for YLDs, YLLs, DALYs and PAF.

RESULTS

In 2019, LICs had the highest age-standardized DALY rate at 692.25 per 100,000 people (95%UI: 605.14 to 785.67), followed by Lower MICs (684.72% (95%UI: 623.56 to 746.12)), Upper MICs (447.55% (95%UI: 405.38 to 493.01)). The age-standardized YLL rate was much higher than the YLD rate in various income regions. From 1990 to 2019, the age-standardized DALY rate showed a 13.70% reduction in LICs (AAPC = -0.5, 95%UI: - 0.6 to - 0.5, P < 0.001), 3.72% increment in Lower MICs (AAPC = 0.2, 95%UI: 0.0 to 0.3, P < 0.05). Age-standardized YLD rate was higher in females than in males, whereas age-standardized rates of YLL and DALY of CKD were all higher in males than in females in globally and LMICs. Additionally, the YLD, YLL and DALY rates of CKD increased with age, which were higher in aged≥70 years in various income regions. In 2019, high systolic blood pressure, high fasting plasma glucose, and high body-mass index remained the major causes attributable age-standardized CKD DALY. From 1990 to 2019, there were upward trends in the PAF of age-standardized DALY contributions of high fasting plasma glucose, high systolic blood pressure, and high body-mass index in Global, LICs, Lower MICs and Upper MICs. The greatest increase in the PAF was high body-mass index, especially in Lower MICs (AAPC = 2.7, 95%UI: 2.7 to 2.8, P < 0.001). The PAF of age-standardized DALY for high systolic blood pressure increased the most in Upper MICs (AAPC = 0.6, 95%UI: 0.6 to 0.7, P < 0.001).

CONCLUSIONS

CKD burden remains high in various income regions, especially in LICs and Lower MICs. More effective and targeted preventive policies and interventions aimed at mitigating preventable CKD burden and addressing risk factors are urgently needed, particularly in geographies with high or increasing burden.

Disparities in Mental Health and Well-Being Among Black and Latinx Patients With Kidney Disease

Black and Latinx individuals in the United States are afflicted disproportionately with kidney disease. Because of structural racism, social risk factors drive disparities in disease prevalence and result in worse outcomes among these patient groups. The impact of social and economic oppression is pervasive in physical and emotional aspects of health. In this review, we describe the history of race and ethnicity among black and Latinx individuals in the United States and discuss how these politicosocial constructs impact disparities in well-being and mental health. Lastly, we outline future research, clinical considerations, and policy considerations to eliminate racial and ethnic disparities in well-being among black and Latinx individuals with kidney disease.

Race, Income, and Medical Care Spending Patterns in High-Risk Primary Care Patients: Results From the STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) Study

Rationale & Objective

Little is known about how socioeconomic status (SES) relates to the prioritization of medical care spending over personal expenditures in individuals with multiple comorbid conditions, and whether this relationship differs between Blacks and non-Blacks. We aimed to explore the relationship between SES, race, and medical spending among individuals with multiple comorbid conditions.

Study Design

Cross-sectional evaluation of baseline data from a randomized controlled trial.

Setting & Participants

The STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) study is a completed randomized controlled trial of Duke University primary care patients with diabetes, hypertension, and chronic kidney disease. Participants underwent survey assessments inclusive of measures of socio-demographics and medication adherence.

Predictors

Race (Black or non-Black) and socioeconomic status (income, education, and employment).

Outcomes

The primary outcomes were based on 4 questions related to spending, asking about reduced spending on basic/leisure needs or using savings to pay for medical care. Participants were also asked if they skipped medications to make them last longer.

Analytical Approach

Multivariable logistic regression stratified by race and adjusted for age, sex, and household chaos was used to determine the independent effects of SES components on spending.

Results

Of 263 STOP-DKD participants, 144 (55%) were Black. Compared with non-Blacks, Black participants had lower incomes with similar levels of education and employment but were more likely to reduce spending on basic needs (29.2% vs 13.5%), leisure activities (35.4% vs 20.2%), and to skip medications (31.3% vs 15.1%), all P < 0.05. After multivariable adjustment, Black race was associated with increased odds of reduced basic spending (OR, 2.29; 95% CI, 1.14-4.60), reduced leisure spending (OR, 1.94; 95% CI, 1.05-3.58), and skipping medications (OR, 2.12; 95% CI, 1.12-4.04).

Limitations

This study was conducted at a single site in Durham, North Carolina, and nearly exclusively included insured patients. Further, the impact of the number of comorbid conditions, medication costs, or copayments was not assessed.

Conclusions

In primary care patients with multiple chronic diseases, Black patients are more likely to reduce spending on basic needs and leisure activities to afford their medical care than non-Black patients of equivalent SES.

ClinicalTrials.gov Identifier

NCT01829256