Abstract
Background:
Obesity is a chronic disease which directly contributes to the onset and progression of chronic kidney disease (CKD). For patients with advanced CKD (CKD G4-5D), kidney transplantation is the optimal treatment to improve morbidity and quality of life. However, obesity is a barrier to transplantation, due to an associated risk of postoperative complications and decreased graft survival.
Objective:
We sought to understand patient experiences with weight management and CKD to inform future studies in this area.
Design:
Descriptive qualitative study.
Setting:
London, Ontario, Canada.
Participants:
Individuals with CKD G4-5D and experiences with obesity and weight management.
Methods:
We interviewed 12 participants with CKD G4-5ND, using thematic analysis and a phenomenological framework. We explored their beliefs, experiences, and expectations of weight loss management. An inductive, open coding technique was used to generate themes that informed our understanding of their shared experiences.
Results:
We identified 6 themes from our data: strengths and gaps in healthcare support, influence of social circles and systems, past experiences with weight loss, limitations of current health status, knowledge and motivation around weight management, and personal autonomy in treatment choices.
Limitations:
Small homogenous population limits generalizability, self-report of weight loss attempts without numerical data.
Conclusions:
Our study emphasizes opportunities for healthcare providers to identify and address potential unmet needs in weight management, while also guiding patient-centered conversations on this topic.
Introduction
Obesity is a multifactorial disease contributing to increased morbidity and the onset and progression of chronic kidney disease (CKD).1-3 Obesity is increasing in prevalence among people with CKD 4 now seen in over 25% of patients waiting for a kidney transplant.5,6 In Canada, 46.2% of patients with very high-risk CKD have obesity. 5 Obesity is a barrier to kidney transplantation, a treatment which offers improved morbidity and mortality compared with being on dialysis. 7
Obesity is typically defined by body mass index (BMI), which only includes weight and height. 3 All Canadian transplantation centers limit transplantation in those with high BMI; BMI cut-offs vary between 35 and 45 kg/m2,3,8 due to the associated increased risk of post-transplant surgical complications.9,10 People who are overweight or obese and received a kidney transplant have longer hospital stays, higher rates of wound dehiscence and infections 10 and delayed graft function, measured as the need for dialysis within the first week post-transplant.
The European Renal Association Developing Education Science and Care for Renal Transplantation in European States (DESCaRTES) working group published guidelines on the management of obesity in kidney transplant candidates. 11 However, there is no Canadian equivalent, and few studies have explored the importance of patient perspectives on weight management in this setting. There are also few interventional studies focused upon weight management in those with advanced CKD. Lifestyle interventions focusing on diet and exercise as in the Look Action for Health in Diabetes (AHEAD) trial, excluded participants with an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73m2 or CKD G4-5T, but found that intensive lifestyle intervention (of reduced caloric consumption and moderate intensity physical exercise) in those who were overweight and obese resulted in a mean 9% weight loss compared with regular care.12,13 Patients with advanced CKD can also have functional limitations such as fatigue and reduced stamina, or mobility issues that limit exercise and access to weight management programs. 14
Medications including glucagon-like peptide-1 receptor agonists (GLP-1RA) (liraglutide, semaglutide, and dulaglutide) and specifically semaglutide in the STEP5 trial of participants with type 2 diabetes promoted a mean weight loss of 15.2% after 2 years, 15 but most trials of GLP-1RAs have excluded those with advanced CKD. Only very small cohort studies and small randomized control trials have been conducted in advanced CKD participants, with limited quality. 16
Bariatric surgery has been shown to promote significant weight loss (23% compared with 5% intensive medical therapy like insulin sensitizers/insulin alone) in carefully selected participants with a BMI above 40 kg/m2 or above 35 kg/m2 with comorbidities. 12 Bariatric surgery in participants with advanced CKD, have higher associated risks of post-op morbidity. 10 Newer GLP-1RAs, like tirzepatide, are now showing similar weight loss to bariatric surgery17-19 but have not been studied in patients with advanced CKD.
In Canada, only 30% of kidney transplant programs have adopted a weight management program. While most clinicians counsel patients on losing weight, engaging the health disciplines (dieticians, physiotherapists and psychologists) in weight loss discussions is low (34%, 4%, 2%, respectively). 20 Clinicians have identified barriers to obesity care including lack of obesity training in medical education. 21
This qualitative study aimed to explore the participants’ experience with weight management and identify potential barriers and facilitators experienced by participants with advanced CKD in weight management. This information will assist in informing the design, interventions and implementation of future weight management programs.
Methods
Recruitment
We conducted a qualitative study of people with lived experiences of weight loss who were diagnosed with both obesity and advanced stage kidney disease (CKD G4-5D). Data were collected through qualitative semi-structured interviews with 12 participants from Southwestern Ontario, in the London Health Sciences Centre catchment area. Inclusion criteria consisted of participants who have CKD G4-5D with current/previous experiences with obesity and/or being asked to lose weight by a care provider, and age >18 years old. Exclusion criteria included those unable to consent or if they were unable to verbally communicate in English. An introductory email with study details and study approved flyers were shared with kidney and metabolic care providers and posted in patient care centers at London Health Sciences Centre (LHSC) and St. Joseph’s Healthcare in London, Canada. Health care providers, within the patient’s circle of care, introduced the study to the patient and confirmed experience with weight management. They were provided the study information flyer and interested patients were referred to the research assistant who provided further information and obtained informed consent. This study was approved by the Western University Research Ethics Board (approval no. 120680).
Interview and Data Collection
A multidisciplinary team of investigators including qualitative scientists, patients partners, medical students, and clinicians developed an interview guide with questions to prompt open ended conversations in 5 domains: personal life, experience with weight, facilitators and barriers, thoughts on weight loss tools, ideas for a new program (Supplemental Appendix A). This guide was revised to ensure that participant experiences would be adequately and fairly discussed. The interviewer (M.N.) practiced interview techniques with the team to ensure follow up questions were not leading or introducing bias to participants during data collection. Basic demographic data were collected prior to the interview.
M.N. conducted a 1:1 semi-structured interview with all participants, offered in person in a private location at LHSC, by telephone, or videoconferencing via Microsoft Teams. The interview was recorded and transcribed by Microsoft Teams and Trint. The duration of interviews were approximately 50 minutes, on average.
Data Analysis
Interview recordings were reviewed and transcription errors corrected manually by M.N. Rooted in phenomenological theory and thematic analysis using Braun and Clarke’s 6-phase framework, meaning was extracted from 12 transcripts and similar participant experiences were identified. Microsoft Excel was used to organize the data analysis. Briefly, thematic analysis involved an inductive coding method, with an open coding approach on a line by line and paragraph by paragraph basis. Additionally, the significant excerpts highlighted (codes) kept the original language used by participants, to reduce interpretive bias. Similar codes were grouped into sub themes and similar subthemes into overarching themes. Alongside thematic analysis which shaped our understanding of the data, we used aspects of descriptive phenomenology through seeking the essence of the lived experiences of participants by preserving the language in meaning units to avoid adding our own interpretation when capturing the study participants’ experiences. Patients were recruited and interviewed until data saturation was complete. Data saturation was determined prospectively during routine debriefing meetings with interviewers M.N. and R.B. after every 3 interviews and consensus/discrepancies were resolved with meetings with L.M. After the last 3 interviews, there were no new sub themes or insights emerging, resulting in 12 interviews, which is an expected number in homogenous populations. 22
Data Reliability and Verification
Two independent reviewers (M.N., R.B.) performed the initial coding of the data. M.N. (male) and R.B. (female) were both medical students at the time of data collection and analysis with some clinical experience, however, they had no experience in managing patients with CKD and obesity or personal lived experience with obesity. L.M. (female) is a nephrologist and has clinical experience providing medical care for patients with advanced CKD and experiences with obesity. The interviewer and coders approached the data with genuine curiosity, and bracketed assumptions to avoid introducing bias when asking questions to participants and during coding. Interviewer and data analyzers had no relationships with participants. M.N. and R.B. discussed and agreed upon initial coding of the data as well as an emerging theoretical framework. Intercoder reliability was determined to be concordant through regular meetings between interviewers M.N. and R.B. every 3 interviews. We defined concordance where most codes (>90%) were similar between interviewers. If codes differed, we reconciled them with consensus in meetings with L.M. Subsequently, a collaborative approach was used to refine similar codes into subthemes and larger overarching themes. All authors reviewed the themes and reached a consensus with the insights of a patient partner.
Results
Twelve participants were consented and interviewed. Two participant interviews were conducted via video and 10 by telephone. Seven participants (58%) were women and 5 (42%) were men (confirmed via self-report of gender-identity), and they varied in level of kidney disease from CKD G4-5ND (participants on dialysis did not complete the study). Eleven participants (92%) were of Caucasian ethnicity, and 1 (8%) Asian. One participant (8%) had a history of bariatric surgery, and 2 (17%) were on the transplant list. None of the participants had a history of kidney transplantation. Codes were condensed into 63 recurring subthemes (Supplemental Appendix B) which were further subdivided into 6 themes (Table 1).
Six Themes Identified From Interviews With Description and Example Supporting Statement.
Strengths and Gaps in Health Care Support
Participants noted both strengths and gaps in their healthcare support surrounding weight management. One participant said, “after many conversations with the pharmacists and the dietitian, I began to understand. I have a better idea of how everything worked together. And so, by talking to them, I was able to understand why I was taking my medications, why I had to eat the foods that I was eating” (P1). Some explicitly mentioned they were comfortable talking about weight, “the doctors could be more direct about it say, look it, you’re too big, we can’t do it, drop 20” (P4).
When reflecting on the healthcare advice they received for weight loss, many participants could not recount any meaningful weight loss discussions with providers during their weight journey. One participant summarized, “Well, there’s basically nothing to do with the weight management with my family doctor” (P7). Confusion and contradictory information on what to eat and what to avoid was consistently identified, “I was told by the dietitian that came I couldn’t look at brown bread anymore, and I like brown bread. You’re only going to eat, white and then I read on the Internet that that is old way, and the new way is you can eat whole wheat bread” (P6).
While only a few of our participants had experience with the transplant process, some noted emotionally charged encounters around weight, “So with all the kidney stuff that I’m going through, I was told that if I didn’t lose the weight to get to the proper BMI, they wouldn’t consider me for a transplant. And that, that hit me like a ton of bricks” (P5).
Influence of Social Circles and Systems
For most (8/12 participants), weight did not impact their social interactions. When asked if it affected their work, one participant said, “No, I wouldn’t think so, no” (P12). In addition, contemplating one’s weight and health in general, seemed to be very individualized: “Like I have, family and friends. I mean, you know, I enjoy their company, but we don’t talk about our illnesses, per se. I mean, we mention them, but we don’t dwell on them” (P10). Participants found speaking about their weight with others was helpful, “There was a time when I was 30 and there was a group of us from work and we all decided that we were going to go together like a group and lose some weight. And I did. I lost quite a bit of weight” (P5).
Participants also explained that access to health options and finances did not have an impact on their weight loss attempts but could appreciate how rising food costs could affect more disadvantaged persons, “. . . I’m fortunate to be a nurse and I do make good wages so we can afford to buy even though the food is more expensive . . . And some people don’t have that luxury . . . So, they buy chips or cookies or whatever fills them up” (P5).
Most participants lived with their family and reported them to be supportive in dietary changes and significant others followed shared dietary habits, “You know. Well, it all depends on what my wife cooks. Depending on the food that she cooks, like, we tend to cook healthy, but I like eating my breads. I like eating my pastas . . . it hard for the weight as well” (P7).
Past Experiences Mediate Current Thoughts on Weight Loss
All participants reported past experiences with weight loss using diet, and about half with exercise. Diets resulted in short term weight loss that were not sustainable in the long term. One participant recounting their regret with past diets, “I’ve tried to follow all kinds. I’ve even, my wife and I joined Weight Watchers one time. And it cost us of fortune. And we hardly lost any weight at all. And nothing’s ever worked for me” (P2). Another participant remarked about the discouraging experience of short-lived diets, “Well I didn’t have to worry about money . . ., so it wasn’t a big deal like I could afford Jenny Craig. But it’s you know, I just felt, gee, I should have left that money in the bank account. And, you know, like because it didn’t do me any good. I didn’t, lose any weight from it, and it was discouraging . . . It’s crazy, spend all that money and not lose weight” (P11). Among challenges with sustaining a diet, “I find I’ll go through phases where I’ll cut back on the amount I eat. But then I’m always. I’m always hungry, too” (P7), a recurring topic was how emotions influence eating habits. Typically, during periods of sadness, participants found they would consume more food, “I know a lot of it’s got to do with I think with your emotions, like I’m an emotional eater I know that. I went through depression and stuff like that. So, for me, it’s very emotional” (P6).
When participants described their experiences with exercise it typically involved aerobic forms of exercise such as biking, or walking. Simple exercises that easily incorporated into their living situation were common, “I live on the third floor of an apartment, so I walk the stairs, every day in and out. Like I say, I haven’t really got too serious about that once. I gotta get a kidney transplant. So, once I get all that, then I’m going to start really trying to pick up a daily routine of exercise” (P12).
Limitations of Current Health Status
For many, even simple exercises such as walking outdoors were met with restrictions due to health conditions such as musculoskeletal pain or low energy, secondary to their kidney disease. One participant said, “Just having the energy to do it. There’s some days where I just, I don’t have the energy to do that, especially right now with my kidneys, the way they are” (P12). Participants commented on common sequelae of CKD like peripheral edema, further limiting activities like walking, “Oh, sometimes my feet and legs swell, you know? Or get real bad pains and then. And then I’m laid up for a day or two” (P8). There was also a reduction in the ability to participate safely in certain activities out of fear of injury, “I used to ride my bike to and from work . . . a long time ago. But then it started with the arthritis in my neck, so turning my neck to check, make sure there was no car coming, was not safe because it was painful. So, I had to give up the bike. And so, I just do the walking” (P5). Chronic pain was also a barrier “And then you start to exercise . . . When I do that, run into that, it hurts. And I have to back off a little bit on the exercise. And then, kind of like, recover and, you start again” (P9).
Knowledge and Awareness of Obesity, and Motivation for Weight Loss
All participants agreed that diet and exercise were factors affecting their weight. When asked about family history and metabolism, about half agreed that they were contributing factors, “I want to say maybe hereditary, but I don’t. I don’t really know” (P8). Few participants reflected on the possibility of mental health leading to weight gain “I don’t know what influenced my weight. I don’t know, when I hit about 38 or 39, I noticed I started to gain weight . . . And I don’t know if it was stress, marriage break up, my kids and everything that went along with it, I, I don’t know, maybe it was the stress of my lifestyle, you know, like, I had a lot of stress in my life” (P11).
When participants were asked how an ideal weight was defined, many answered with a weight that makes them feel like they can participate in more activities “I would say that it [healthy weight] means, that you don’t struggle with, doing things. That you go for a walk, its nice and easy, which is fine and all that. If you handle something, you don’t have to struggle to manipulate to do things” (P9). Many reported understanding what is healthy by assessing food nutrition labels, “And I read the label, and see what’s in it, not too much salt, not too much potassium, not too much this and that and so on. And I kind of been following the golden rule about, not too much of this and not too much of that and so on” (P9).
Self-awareness of obesity and its impacts on health were quite variable among participants. Some expressed fear of not losing weight and its impact on access to transplantation. Some believed they did not have obesity and that obesity did not play a major role in their life, whereas others believed they are obese, but content they are not morbidly obese, “Well to me it’s like, I don’t think, . . . it’s [my weight] not a huge part of my life, of course, I wish I was thinner but I don’t think I’m 500 pounds either” (P6).
The source of motivation for weight loss between participants varied as well. Fear of not getting a transplant was a strong motivator “I know I have to do those [diet and exercise] so I can have a transplant. That’s enticing” (P4) and “I need the transplant. I plan on being around. And so, I lost the weight and got the BMI that they told me I needed to be at” (P5). One participant described that the journey of weight loss itself was motivating as they started to feel better internally, “I’ve seen good results. And I feel better. Now that I got my sugars down and under control and stuff. I feel a lot better” (P12).
On the other hand, some participants cited a lack of motivation in staying consistent with exercise regimens or diets, “I mean, I know that I feel better when I’m doing stuff like physically active that makes me feel better, but like a vicious cycle. I can’t make myself do it sometimes. Um, actually, there’s more stuff in me that makes me not do it that I need to overcome. I need to have better willpower, better forcing myself to do things” (P6).
When asked about ideas that might help support weight loss, many answered with interventions that they have already tried in the past such as diet and exercise, with no specific modality mentioned. Some also cited that motivation would be the largest barrier to even joining a support program and this would need to be addressed, “You know, you really have to be motivated, and I think if you would be motivated. And I don’t know how you can do that for a general population, it’s got to be very much personalized” (P10). More than half noted that they would be open to participating in a program of behavior change.
Personal Autonomy in Treatment Choices
Most participants were anxious about the transplant workup process but willing to engage. Most found the BMI cutoff reasonable, “I’m not against somebody like the doctor saying, ‘I’m sorry we can’t give you the kidney transplant because you’re too heavy.’ Like, I know I’m heavy. And yes, if it would affect a negative effect then I would want to be told you know” (P8). A few participants explained that the quantity of life afforded by conforming to a new lifestyle was not something they were interested in “And [the] doctor is the one that is advising me what I should try to steer clear of. And I do the best I can. If I go out in the restaurant and have a nice meal I want to enjoy, like the simple thing, go get a hamburger and French fries, well I’ll just, I’ll go ahead and do that” (P9).
When participants were presented with interventions such as weight loss medications (ie, Ozempic or Wegovy) for obesity management, some were hesitant due to concerns with becoming reliant on them. One participant commented on their beliefs around pharmacological weight management, “I feel like it’s almost like it’s like cheating because I’m taking Ozempic. Which is doing the work. Like, you know, I, just follow my feelings with Ozempic and I’m losing weight, so I don’t begrudge it. I’m happy for it. But it’s almost as if I’m cheating because I’m really not doing anything that much” (P2). About half denied any interest for an exercise program on dialysis and a quarter for behavior modification counseling.
Discussion
Through rich qualitative interviews we gained a fulsome understanding of the lived experiences of obesity and weight management in those with advanced CKD. Participants cited common barriers and facilitators to losing weight, some of which have also been cited by health care professionals in our study by Hamadi et al 23 (such as lack of motivation, inconsistent healthcare system support, family support and positive past experiences). Six themes emerged from the codified transcripts that provide insight and add to similar findings from other research studies.24-27
Health literacy was initially explored as it is known that patients with low literacy may have difficulty engaging in CKD self-care and adherence with weight loss programming23,28-30 while those with higher levels of nutritional knowledge are more likely to engage in these behaviors. 31 In our study we found participants did not lack basic knowledge of factors influencing weight loss. This may be because these patients are frequently interacting with healthcare providers given their chronic disease history. However, on further exploration, there was a disconnect between participants’ ideas of a target goal weight versus common clinical targets. Many believed a healthy goal weight would be a return to physical abilities previously lost, like increased endurance. Thus, there is likely benefit from further health education for this population. Supporting this we found many participants were willing to engage in a program to learn new healthy behaviors, and participants who received a nutritionist consult in the past, found it helpful and implemented the suggestions.
A mindset of hope or hopelessness can promote healthy weight loss behaviors or lack thereof, respectively.24,32 One of the strongest sources of motivation cited by participants was from the personal experience or vicarious experiences of those with advanced CKD. Otherwise, participants noted a lack of motivation was a barrier to adherence with diet and exercise programs. Motivational interviewing directly address root motives, 33 and one review seems to show a moderate impact on mean weight loss. 34 In addition, support of adherence in diet and exercise strategies through activities like maintaining a food log, or a dietician review, leads to more durable weight loss results.26,33,35
Social environments are often discussed as an important factor in weight management.24-26,36,37 A quantitative study on the impact of social facilitation showed a 0.032 kg decrease in weight for each unit of increased support in healthy eating and physical exercise by family, and to a lesser degree by friends and coworkers. 36 Interestingly in our study, most participants noted that social environments like work and friend circles did not heavily influence their weight loss journey. Family eating was however influential, as participants would typically share the same dietary practices as their partners. Social facilitation may then be an underutilized method of supporting weight loss in this population, with a primary focus on family eating habits, and secondarily on other nonhousehold social circles. 25
A common shared experience of weight loss was that of calorie restriction and dieting. Unfortunately, there is no single ideal diet for weight loss, but a spectrum of healthy diets that follow low protein, low salt and low phosphate regimens. 38 These may conflict with dietary advice for other conditions like diabetes 39 which some of our participants experienced, as well as many diets that do not incorporate CKD nutritional conditions. Participants relied primarily on education booklets provided by their nephrologist’s office in making a diet. Most of our participants relied on food labels in making diet choices and only a few had additional training beyond that in the form of dietician counseling. Using food labels alone has conflicting evidence whether it results in durable weight loss.40,41 The reliance on food labels and self-made diets underscores the need for more guided nutritional education and support in the context of past dietary failures. 42 Only 7.5% of North American weight management programs are tailored for CKD patients. 23 Another important barrier to adherence to diets was emotional eating, a habit commonly reported amongst a third of the participants. Integrating consistent stress management techniques into a population where over half of patients on maintenance dialysis report anxiety and depression 43 is an overlooked aspect of diet adherence.
Unsurprisingly, our participants expressed well-known barriers to participating in physical exercise like low energy, fear of falling and reduced mobility. Occupational therapists can help overcome environmental barriers and studies show that patients with CKD G5ND report higher perceptions of energy after engaging in physical activity.27,44 Given the beneficial functional impact of exercise on advanced CKD and obesity, 45 it is important to address these barriers to encourage exercise interventions for patients with advanced CKD and obesity.
Participants spoke about opportunities they see to improve health care delivery for people with end-stage kidney disease and obesity. Fewer than half of participants recalled any meaningful conversations about weight loss with healthcare providers from any discipline. Most recall generic advice about physical activity, which can be problematic in advanced CKD because of specific nutritional and physical activity requirements. Patients on maintenance dialysis are at higher risk of hypotension with high intensity exercises and may not know of the optimal exercises.46,47 Moreover, most of our participants did not recall significant relationships or moments with care providers in general. It is known that those who receive appropriate, personalized counseling on weight loss are more likely to gain motivation to lose weight48. In the present study, it is unclear whether participants had not actually received counseling, or that they had received counseling, yet had nore recalled that they had. We further explored the patient-provider relationship by examining the participants’ views on the method of discussing serious health issues like weight loss and kidney transplantation. This is important as weight implicit bias is prevalent in some populations of providers and can impact the quality of care received which would require additional training to address.49,50 In our study population, we did not find consistent deficiencies in the method of communication with participants and providers on weight-related topics.
The interviews also touched upon the topic of self-perception of obesity and how personal autonomy influences treatment adherence. One aspect of this is internalized stigma, one participant viewed taking Ozempic as “cheating” or inconsistent with their values of hard work for weight loss. It may be beneficial to help reduce internalized stigma surrounding obesity, such as anchoring discussions on weight protective behaviors rather than on the weight itself. 51 Similarly, some participants valued quality of life over restricting their food choices for better kidney health. Some data suggest a correlation between health-related quality of life and medication adherence in CKD populations. 52 Patient autonomy is as important as clinical endpoints, as it can dictate their willingness to follow a management plan. Therefore, it is increasingly important to ensure patient perceptions of treatment are consistent with their values and desired quality of life throughout treatment period. 53 This may address factors leading to patient hesitations with trying new weight loss methods other than diet and exercise.
This study has important implications for clinical practice and research. Our findings were similar to a Danish study 24 that found “restrictions and exhaustion” and “support and self-discipline” as barriers to weight loss and a US study 54 finding “conflicting tenets of “kidney-friendly” versus popular diets” as similar barriers. Some regional differences exist, such as higher cost barriers 25 to weight loss management in the United States, compared with Canada’s public healthcare system. Within Canada, provincial differences in systems support, such as access to bariatric surgery centers, 55 formulary coverage of GLP-1 RAs 56 and access to specialized care centers greatly shape the weight management experience.
Rather than focusing upon weight loss numbers, we learned that quality of life, functional measures, and better mental health might be more important to patients. Many programs evaluate eligibility criteria using a number like BMI, 81% of Canadian transplant centers compared with about 99% of US centers, 20 but there is emerging data that show other factors may be more informative, like Mark et al 57 who show that higher measures of pre transplant functionality (ability to perform daily tasks) are associated with better survival post-transplant. Our work also suggests the importance of multidisciplinary teams in weight management programs, 58 supported by previous findings from our research group. 59
Limitations and Future Research Directions
One of the primary limitations of our study is generalizability. Our study population was limited in number, consisting of 12 participants and had a homogenous makeup of mostly Caucasian individuals with self reported gender-identity, which limits the applicability of results to other populations. Future studies should include diverse populations to examine the differences in gender-identity, biological sex, ethnicity and other important demographic factors as it pertains to weight management experiences. A minor limitation is given the time constraints of the interview (approx. 50-minute interviews), not all statements could be thoroughly explored in their respective context, this could potentially lead to unintended bias in how the research team understood participant statements. Lastly, there was a lack of biometric data of past weight loss attempts which could have provided a more thorough understanding of the relationship between objective health changes and how participants perceive and report this change.
While this study explored the common facilitators and barriers to weight management, further research is needed to understand the relative impact of each factor on achieving weight loss and how to prioritize these efforts in accordance with a patient’s unique circumstances. This would be highly useful in the development of weight management programs for kidney transplant centers.
Cultural and socioeconomic factors influence many important aspects of the weight management experience from food practices, healthcare relationships, concepts of healthy weight and social dynamics. For example, nutrition counseling may be ineffective if not done in a culturally appropriate manner, fundamentally changing the theme of healthcare supports and gaps. The theme of influence of social circles and systems may contain very different findings in the context of cultures where community and family drive health decisions. Future studies should examine the cross-cultural differences of these communities living in Canada. Our research group is currently studying Indigenous experiences with weight management and CKD.
Suggestions for Care Providers
This study highlights the importance of individualized care for patients with advanced CKD and obesity, which can be implemented by addressing the key factors influencing weight management, identified in the 6 themes that emerged from participant interviews.
We learned that a strength of the provider-patient relationship was the rapport and trust patients had built with them through honest communication. In addition, our participants had a basic level of health literacy as it pertained to factors influencing weight, however, there was a disconnect between the patient versus provider-expected weight loss goals. This is further delineated by a perceived gap in healthcare where participants noted lack of meaningful weight-based conversations. Thus, personalized advice and supportive goal-oriented discussions are important. Fear of negative health outcomes secondary to CKD was a strong motivator for weight but overtime weight loss behaviors were difficult to maintain. We learned consistent touch points with providers may reinforce those behaviors. In addition, there may be more meaningful opportunities to include the health disciplines in weight management discussions including dieticians and addressing depression and anxiety and its weight increasing coping strategies like emotional eating. Similarly, recognizing a patient’s functional abilities was needed for appropriate physical activity prescriptions. We understood dietary practices were heavily influenced by the significant other, representing a potentially underutilized method to leverage family diet dynamics for weight loss. Also, an often overlooked component is patient buy-in, which is mediated through their values of health and quality of life; ensuring treatment plans are consistent with that is important for treatment adherence.
An intentional effort by nephrologists and other care providers to recognize these mediators of the weight loss journey can help patients, irrespective of access to weight loss transplantation programs, achieve transplant candidacy.
Conclusion
Patients who have CKD G4-5D and obesity face additional barriers to weight management than those with no kidney disease or early CKD. The current study provides useful insights and adds to the limited data of lived experiences in this population. With current BMI restrictions for kidney transplant, it is important to engage with patients in a nonstigmatizing manner, and to factor in a patient’s autonomy and quality of life. Despite the known benefits of weight loss on overall health and kidney outcomes, there is a lack of personalized tailored support for individuals. Similarly, while the motivation to lose weight is partly to get a kidney transplant, there is variability in the extent of interventions patients are willing to participate in, driven by various internal motivators and external influences, some of which may be addressed by care providers.
Supplemental Material
sj-docx-1-cjk-10.1177_20543581251380499 – Supplemental material for Weight Management Experiences Among People With CKD: A Qualitative Study
Supplemental material, sj-docx-1-cjk-10.1177_20543581251380499 for Weight Management Experiences Among People With CKD: A Qualitative Study by Mateen Noori, Rutvi Brahmbhatt, Kristin K. Clemens and Louise Moist in Canadian Journal of Kidney Health and Disease
Supplemental Material
sj-docx-2-cjk-10.1177_20543581251380499 – Supplemental material for Weight Management Experiences Among People With CKD: A Qualitative Study
Supplemental material, sj-docx-2-cjk-10.1177_20543581251380499 for Weight Management Experiences Among People With CKD: A Qualitative Study by Mateen Noori, Rutvi Brahmbhatt, Kristin K. Clemens and Louise Moist in Canadian Journal of Kidney Health and Disease
Supplemental Material
sj-pdf-3-cjk-10.1177_20543581251380499 – Supplemental material for Weight Management Experiences Among People With CKD: A Qualitative Study
Supplemental material, sj-pdf-3-cjk-10.1177_20543581251380499 for Weight Management Experiences Among People With CKD: A Qualitative Study by Mateen Noori, Rutvi Brahmbhatt, Kristin K. Clemens and Louise Moist in Canadian Journal of Kidney Health and Disease
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
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