Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Hypertension results in significant morbidity, mortality, and healthcare expenditures. Fortunately, it is largely preventable and treatable by implementing dietary interventions, though these remain underutilized. Here, we aim to explore the role of healthy dietary patterns in hypertension management and describe approaches for busy clinicians to address nutrition effectively and efficiently with patients. RECENT FINDINGS/RESULTS:DASH, Mediterranean, vegetarian, and vegan diets that include minimally processed, plant-based foods as core elements have consistently shown positive effects on hypertension. Recommendations that distill the most healthful components of these diets can significantly impact patient outcomes. Clinicians can harness evidence-based dietary assessment and counseling tools to implement and support behavioral changes, even during brief office visits. Healthful plant-based dietary patterns can often effectively prevent and treat hypertension. Clinicians may help improve patient outcomes by discussing evidence-based nutrition with their patients. Future work to promote infrastructural change that supports incorporating evidence-based nutrition into medical education, clinical care, and society at large can support these efforts.

This Letter to the Editor is a response to St-Jules and Fouque and their interpretation of postprandial hyperkalemia, especially regarding plant-based diets. Based on the reviewed literature review, potassium kinetic studies cited by the authors include only 1 study with a food-based intervention that actually showed reduced postprandial hyperkalemia with plant-based diets. The remainder of the studies used potassium salts or supplements that behave differently compared with whole plant foods. As such, we recommend avoiding restriction of whole plant foods in patients with chronic kidney disease when solely based on the theoretical risk of postprandial hyperkalemia.

The ketogenic diet is a very low carbohydrate diet that has received a lot of attention for its role in the treatment of type 2 diabetes and obesity. For patients with chronic kidney disease, there is limited evidence on the risks and/or benefits of this diet. However, from the limited evidence that does exist, there are several inferences that can be drawn regarding this diet for patients with kidney disease. The ketogenic diet may not be better than comparator higher carbohydrate diets over the long term. The diet also has low adherence levels in studies lasting ≥12 months. The diet"™s emphasis on fat, which often comes from animal fat, increases the consumption of saturated fat, which may increase the risk of heart disease. It has the potential to worsen metabolic acidosis by increasing dietary acid load and endogenous acid production through the oxidation of fatty acids. In addition, the diet has been associated with an increased risk of kidney stones in patients using it for the treatment of refractory epilepsy. For these reasons, and for the lack of safety data on it, it is reasonable for patients with kidney disease to avoid utilizing the ketogenic diet as a first-line option given alternative dietary patterns (like the plant-dominant diet) with less theoretical risk for harm. For those adopting the ketogenic diet in kidney disease, a plant-based version of the ketogenic diet may mitigate some of the concerns with animal-based versions of the ketogenic diet.

UNLABELLED:Climate change is worsening with tangible effects on our healthcare system. This review aims to examine the repercussions of the climate change on nephrology and explore potential strategies to mitigate its impact. This review examines dialysis's environmental impact, resource recycling methods, and plant-based diets for kidney health. Recent research highlights the advantages of plant-based diets in managing and preventing chronic kidney disease (CKD) and its complications. Integrating these practices can significantly lessen the environmental impact of nephrology. PURPOSE OF REVIEW/OBJECTIVE:The aim of this study is to discuss the bidirectional relationship of climate change and kidney disease and the impact of nephrology on climate change and to discuss potential solutions. RECENT FINDINGS/RESULTS:Each dialysis session consumes significant amounts of resource; reusing them will aid the environment. Plant-based diets slow renal disease and have a lower carbon footprint, making them ecologically friendly. SUMMARY/CONCLUSIONS:Climate change is a growing threat to population health and healthcare. Rising temperatures raise the risk of kidney problems. Dialysis treatments also impact the environment through its high resource requirements while generating high volumes of waste and greenhouse gases. Opportunities exist to reduce the environmental impact of dialysis treatments. Plant-based diets serve to benefit both kidney disease and the environment.

Lifestyle medicine interventions that emphasize healthy behavior changes are growing in popularity in U.S. health systems. Safety-net healthcare settings that serve low-income and uninsured populations most at risk for lifestyle-related disease are ideal venues for lifestyle medicine interventions. Patient-reported outcomes are important indicators of the efficacy of lifestyle medicine interventions. Past research on patient-reported outcomes of lifestyle medicine interventions has occurred outside of traditional healthcare care settings. In this study, we aimed to assess patient-reported outcomes on nutrition knowledge, barriers to adopting a plant-based diet, food and beverage consumption, lifestyle behaviors, self-rated health, and quality-of-life of participants in a pilot plant-based lifestyle medicine program in an urban safety-net healthcare system. We surveyed participants at three time points (baseline, 3 months, 6 months) to measure change over time. After 6 months of participation in the program, nutrition knowledge increased by 7.2 percentage points, participants reported an average of 2.4 fewer barriers to adopting a plant-based diet, the score on a modified healthful plant-based diet index increased by 5.3 points, physical activity increased by 0.7 days per week while hours of media consumption declined by 0.7 h per day, and the percentage of participants who reported that their quality of sleep was "good" or "very good" increased by 12.2 percentage points. Our findings demonstrate that a lifestyle medicine intervention in a safety-net healthcare setting can achieve significant improvements in patient-reported outcomes. Key lessons for other lifestyle medicine interventions include using a multidisciplinary team; addressing all pillars of lifestyle medicine; and the ability for patients to improve knowledge, barriers, skills, and behaviors with adequate support.

Food has the potential to cause and exacerbate many lifestyle diseases. Or it can be used to prevent and treat illnesses like primary hypertension, the metabolic syndrome, and insulin resistance. In parallel, there is also a growing body of evidence of the role of diet in the treatment of kidney disease and its ensuing complications. Popular diets for this purpose have included low-carbohydrate diets, including the ketogenic diet, and higher carbohydrate diets like Mediterranean diets and other plant-based dietary patterns. Low-carbohydrate diets have not shown harm in patients with kidney disease and may benefit a select few. Mediterranean diets have an established record of cardioprotective benefits but also may be beneficial for the kidney. Intermittent fasting has benefits for metabolic health, but limited research exists on the risk or benefit for patients with kidney disease. Plant-based diets, especially those that are lower in protein, may slow kidney disease progression, mitigate uremia, and delay dialysis initiation. Although each dietary pattern has its unique pros and cons, most healthful dietary patterns favor the inclusion of whole, unprocessed foods, preferably from plant-based sources. In this perspective, we discuss the risks and benefits of major popular diets to help guide health care professionals in treating patients with kidney disease.

INTRODUCTION/UNASSIGNED:Interventions emphasizing healthful lifestyle behaviors are proliferating in traditional health care settings, yet there is a paucity of published clinical outcomes, outside of pay-out-of-pocket or employee health programs. METHODS/UNASSIGNED:We assessed weight, hemoglobin A1c (HbA1c), blood pressure, and cholesterol for 173 patients of the Plant-Based Lifestyle Medicine Program piloted in a New York City safety-net hospital. We used Wilcoxon signed-rank tests to assess changes in means, from baseline to six-months, for the full sample and within baseline diagnoses (i.e., overweight or obesity, type 2 diabetes, prediabetes, hypertension, hyperlipidemia). We calculated the percentage of patients with clinically meaningful changes in outcomes for the full sample and within diagnoses. FINDINGS/UNASSIGNED:The full sample had statistically significant improvements in weight, HbA1c, and diastolic blood pressure. Patients with prediabetes or overweight or obesity experienced significant improvements in weight and those with type 2 diabetes had significant improvements in weight and HbA1c. Patients with hypertension had significant reductions in diastolic blood pressure and weight. Data did not show differences in non-high-density lipoprotein cholesterol (non-HDL-C), but differences in low-density lipoprotein cholesterol (LDL-C) were approaching significance for the full sample and those with hyperlipidemia. The majority of patients achieved clinically meaningful improvements on all outcomes besides systolic blood pressure. CONCLUSION/UNASSIGNED:Our study demonstrates that a lifestyle medicine intervention within a traditional, safety-net clinical setting improved biomarkers of cardiometabolic disease. Our findings are limited by small sample sizes. Additional large-scale, rigorous studies are needed to further establish the effectiveness of lifestyle medicine interventions in similar settings.

Traditionally, diets for kidney disease were low in potassium. This recommendation was based on outdated research and often wrong assumptions that do not reflect current evidence. In fact, studies conducted over the past decades show patients with CKD, including kidney failure, do not benefit from the restriction of plant foods relative to control. Generally, dietary potassium does not correlate with serum potassium, and we posit that this is due to the effects of fiber on colonic potassium absorption, the alkalinizing effect of fruits and vegetables on metabolic acidosis, and the bioavailability of dietary potassium in plant foods. Also, consumption of plant foods may provide pleiotropic benefits to patients with CKD. Emerging dietary recommendations for kidney health should be devoid of dietary potassium restrictions from plant foods so that patient-centered kidney recipes can be encouraged and promoted.