Social Determinants of Chronic Kidney Disease
In this podcast, James Matera, DO, speaks about the impact of poverty and food insecurity on chronic kidney disease (CKD), including an update to a study funded by the National Institutes of Health on food purchasing patterns among participants of a dietary intervention trial who are African American with hypertension and CKD.
- Aggarwal RA, Iragavarapu MS, Grover R, et al. Food purchasing patterns among participants of a dietary intervention trial for African Americans with hypertension and CKD. American Society in Nephrology. Accessed November 11, 2022. https://www.asn-online.org/education/kidneyweek/2021/program-abstract.aspx?controlId=3609072
- Community-Based Dietary Approach for Hypertensive African Americans with Chronic Kidney Disease. ClinicalTrials.gov. Accessed November 11, 2022. ClinicalTrials.gov identifier NCT03299816. https://clinicaltrials.gov/ct2/show/NCT03299816
For more chronic kidney disease content, visit the Resource Center.
James Matera, DO, is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center (Freehold, New Jersey).
Jessica Bard: Hello, everyone, and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant 360, a multidisciplinary medical information network.
In the United States, people who are Black make up about 13% of the population, but account for 35% of people with kidney failure, according to the National Kidney Foundation.
Dr James Matera is here to speak with us today about social determinants of chronic kidney disease. Dr Matera is a practicing nephrologist, Senior Vice-President of Medical Affairs and Chief Medical Officer at CentraState Medical Center in Freehold, New Jersey. Thank you for joining us today, Dr. Matera.
There is a recent update to a study on a community-based dietary approach for African Americans with hypertension and chronic kidney disease. What did that update reveal?
Dr James Matera: I've become very in tuned to social determinants of health, and primarily in chronic kidney disease where we know it's a very costly therapy, and we do know that there's a predilection in some of our patients who have struggles with some of the determinants of health.
I want to focus first on food insecurities and how important that is. We know from way back that dietary modification in renal disease does help. There's no doubt about that. When we look at some of the reasons that patients don't do as well and we think about their dietary resources, we see that come into line as these patients often don't have a very good diet.
First, I want you to think about what the two most common areas that we see for dialysis in the United States in chronic kidney disease. It's diabetes and hypertension. Dietary modifications in both of those, including things like the DASH diet are so important.
If we take out the NHANES data that we all know about and dissect that out, there was a question in there that looked at... What they wanted was the patients to answer simply yes or no. The question said, in the last year, did you or your household members ever cut the size of your meals or skip meals because you didn't have enough money for food? 2,300 patients actually answered yes to that question.
They took that cohort, followed them over 12 years, and what they found was that there was a greater progression in that group to end-stage renal disease. That's a powerful message that can help.
And why is that? That's what I always answer, and then I'll talk a little bit about the study, but diet quality always equates to financial resources. Dietary and cultural patterns are very common among our ethnic groups, such as in Freehold here alone where I practice, we have a large Hispanic group that's located in downtown Freehold. When you do a geo spot of that, that's the highest incidence of diabetes and hypertension. We know that that's a hotpot for CKD.
Some things that we did is we put a federally qualified health center right in the middle so that they have access to healthcare. Number two is we coupled with the Mayor of Freehold and we bring fresh fruit and vegetables out to that FQHC at least once a week for free, coupled with some of our local New Jersey farms to provide that so they get better access to food.
The interesting study, there's Dr Crews, she's a wonderful nephrologist, she works out at Johns Hopkins. She started this study looking at these factors that they broke down into two basic groups.
One group was a group of patients that simply got a $30 gift card per week to go out and buy their own food. They were given tips on what was healthy food, but they were allowed on their own. The second group was broken down into education where they had a dietician do that, and then they got a delivery every week of $30 worth of healthy food. They weren't making their own choices, they were given a diet.
They were going to follow them for 12 months. But just today in the American Society of Nephrology, I just happened to be on that right before this webcast, they came out with some four-month data. Their primary endpoint was these are all low-income African American patients with both CKD and hypertension. They wanted to look at the effect of their urinary albumin excretion.
In looking at their first four-month data, there was a marked decrease in the group that had the education and the food delivered to them, compared to the group that just had a $30 gift card given to them to go out and purchase their own food.
I think it's very important because the results are so outstanding in the first four months, I really want to see how this follows out. There was also a decrease of diastolic blood pressure, which is of prime importance in these. I think that that really points in the way of food insecurities and being able to do this.
Again, with our session here in Freehold, we made cards, basic recipe cards that we put out in coordination with the Mayor, and we hand those out to people. People are going to eat what their culture is. People are going to eat what their food allowances are. People are going to eat within that. In our particular area, we found very high Hispanic population with a high-carbohydrate diet, rice, beans, things like that. Just giving them the access to fresh vegetables, I think is going to be a major impact.
Put the access where the people are. That's very helpful.
Jessica Bard: Would you say that those findings surprised you at all?
Dr James Matera: I'm not sure they surprised me, but I think it really reinforced how important it is because we oftentimes, as doctors, we don't focus on the social determinants of health. I was talking to high school students the other day, I said, a lot of times we'll send a patient home with a prescription for a medication and they may not afford that and they're too embarrassed to tell you that they can't afford it.
So they don't take it and you may not know, and you're wondering why is this patient's blood pressure not getting any better or why is their albumin still high? I put them on the correct medications and they may not be taking it. I think the same is with food. It's embarrassing to some people, and unless you ask specific pointed questions like that, you may not uncover these very important determinants.
Jessica Bard: An important take-home message would be to take a good history there too.
Dr James Matera: Sometimes you got to ask that pointed question, do you have money to have your meals? What's a typical meal for you? Especially a diabetic who's eating rice with every meal. That's something we want to take into account.
Jessica Bard: Is there anything else you'd like to add?
Dr James Matera: I think when we look at this, also poverty's a big determinant that we have to look at. There's no doubt that people who live in impoverished areas, not just in the United States, but globally, have a higher instance of CKD and then end-stage renal disease.
If we look back through some of the studies, back in 2011, it was known that almost 28% of African Americans live below the US poverty levels compared to only 10% of non-Hispanic whites. As a result, we see a higher incidence of chronic kidney disease and end-stage renal disease in that population.
It just makes sense to me that we need to try to lessen some of those, or at least bridge some of those gaps so that we can reduce their incidence. Socioeconomic status is clearly associated with increased CKD risk. We know that they have lower eGFRs in general. We know that they have higher albuminuria, and you take those two together, add on diabetes or hypertension, CKD is a natural follower.
If we really want to impact those, we not just only have to worry about giving them the correct goal-directed therapy, medical therapy, but making sure that they have the wherewithal to be able to sustain the needs, buy the therapy, get the medications, or if not, figure out ways to do that because again, prescribing and taking are going to be very different in their total outcomes. We have to get better at looking at social determinants of health when we want impact and bend the curve, the cost curve of these types of diseases.
Jessica Bard: That's well said. Thank you, Dr Matera. We appreciate you being on the podcast today.
Dr James Matera: Thank you.
Jessica Bard: For more chronic kidney disease content, visit the resource center at consultant360.com