Hunger in Patients with Kidney Disease – Why it matters and what to do about it?

As a new pediatric nephrology fellow, my first weeks taking care of patients on hemodialysis were overwhelming. Each of my patients had complex problems and intricate physiology, and I initially learned to focus on the numbers – clearance, blood pressures and weight – in order to optimize therapies for each patient’s clinical disease and status. About three months into fellowship, however, I was stumped by a young girl with ESRD whose numbers just didn’t make sense. She was losing weight, admitted repeatedly for infections, and had worsening clinical and laboratory parameters which wouldn’t improve with interventions. Despite nutritional supplements, additional dialysis sessions, and medication adjustments, nothing changed. Finally, the root cause became clear – she was hungry, and her family couldn’t afford to buy food. 

Unfortunately, this isn’t a rare experience in the United States. Food insecurity is common, affecting 16.6% of American households and 7.8% of American children – and appears to be more common in those with chronic illness, such as kidney disease. Food insecurity is defined as limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire such foods in socially acceptable ways. I have seen families frequently make trade-offs between buying medication versus food, or choosing inappropriate food for their children’s medical problems due to cost. Parents have told me they often go hungry in order to feed their children – providing a human face to the statistics published by the U.S. Department of Agriculture (USDA) Economic Research Service showing that half of all parents or caregivers experiencing food insecurity shield their children from having to skip meals by skipping meals themselves. 

Why should food insecurity matter to nephrologists? Food insecurity is an essential social determinant of health with significant implications, including poorer overall levels of health, chronic medical conditions, and lower levels of psychosocial and physical functioning. A recent report showed that two-thirds of families with food insecurity have to choose between paying for medical care or food within the past year.These findings in children mirror studies in adult ESRD patients where food insecurity was associated with worse nutritional status and poorer quality of life. Among adults with chronic kidney disease, food insecurity accelerates disease progression, and may increase the risk of ESRD. Patients with food insecurity often use coping strategies which are deleterious for their health, including medication under-use or non-adherence, postponing or forgoing preventive care, or relying on a low-cost diet of energy rich but nutrient-poor foods. 

While awareness of food insecurity has increased in pediatrics and screening for food insecurity is frequently part of general pediatrics care, there no similar recommendations in either pediatric or adult subspecialties. Given the implications for our patients and their diseases, I would argue that all patients with kidney disease, especially those with ESRD, should be screened for food insecurity as part of their routine nephrology and dialysis care. Physicians, dietitians, and other health providers often counsel patients with kidney disease on dietary interventions, and awareness of food security status is paramount in providing optimal care. Many interventions and recommendations (such as a low-salt diet or phosphorus restriction) may be challenging or impossible to implement for patients who are food insecure. Screening should be performed with a standardized screening instrument, with several available and validated by the AAP, AAFP and USDA. Screening should be coupled with timely and appropriate referrals to food resources – an area of intervention that requires innovation, collaboration and community-based solutions. While eliminating food insecurity may be the eventual goal, the first step is to screen patients at risk; as only once we recognize, name, and quantify a problem can we start to identify solutions. 

 Post by Michelle Starr, NSMC Intern Class 2018