Models of value-based care (VBC) are being implemented across nephrology and causing seismic shifts in how nephrology professionals approach the care of patients with kidney disease. For the first time in history, nephrologists have strong financial incentives to delay progression to dialysis. This has given the nephrology space an opportunity to reassess approaches to preventative management, which could challenge old paradigms of care.1
Nutrition services that follow current and more precise nutrition approaches are at the heart of successful VBC. Although the effectiveness of lifestyle and nutrition in the care of patients with kidney disease is well established in the medical literature, implementation of services to address these aspects of care might seem burdensome.
Nephrology practices that want to provide better nutrition care may want to consider these 5 important points:
- Get a dietitian on board: This may seem obvious, but hiring and training a dietitian can be a large asset to an organization in bringing lifestyle and nutrition interventions into the practice. This key person can help provide patient care and identify opportunities to engage patients in their health.2,3
- Reimbursement for nutrition works: Nutrition care is reimbursed by many insurance providers. Medicare and many large insurance providers reimburse for dietitian care at rates anywhere from $90-$250 or more per patient-care hour depending on geographic area. This means nephrology practices can add a dietitian, with their services being cost neutral or mildly profitable.4
- Don’t miss patients who ‘want to change’: The current VBC environment has a great deal of novel artificial intelligence technology and computer-driven algorithms to help identify patients at greatest risk for hospitalization and progression. It will be important to see how various software programs improve outcomes and create equitable treatment. Practices should attempt to identify patients who want to change their lifestyles but who may fall through algorithm gaps. Physicians in particular can start a supportive conversation toward lifestyle change simply by asking patients what they have heard about nutrition, lifestyle, and kidney disease and then offer to refer them to a dietitian to implement a personalized plan.
- Practice up-to-date renal nutrition: Watch out for “watered down nutrition” that focuses solely on potassium, phosphorus, and sodium. Simply having dietitians on a VBC-focused team doesn’t mean that there is an effective nutrition strategy for patients that will give results.
Older renal nutrition guidelines were designed for people on dialysis and then inadvertently adopted across all kidney disease states inappropriately. Patients receiving dietary education on low potassium, low phosphorus, low sodium diets (oddly still the accepted “nutrition intervention” for nephrology) will not see results of slowing of kidney disease progression. Even obvious opportunities for nutrition therapy such as weight loss or diabetes management are based on antiquated models of “calories in-calories out” or “carb counting,” neither of which has strong evidence to support efficacy.
Instead, practices need to look at all opportunities for preserving kidney function. The type and quantity of protein, gut health, alkalinity of the diet, metabolic acidosis, and proactive treatment of anemia all have connections with preserving kidney function.2,5
5. Give careful consideration and research to nutrition and lifestyle models that are working in and out of nephrology: For example, David Unwin, MD, at the UK’s National Health System, has the highest number of patients in type 2 diabetes remission in the world. His real-world data over the last 6 years offers a compelling model for helping patients achieve nutritional changes despite limited time and resources.6 His model of leveraging psychological approaches in helping patients understand their “why” for change, giving them feedback on changes, and supporting them with group sessions gives a practical patient-empowering model for change.
In summary, VBC incentives are helping shape a new nephrology environment that will need to embrace and promote lifestyle and nutrition changes. Organizations that center their interventions on facilitating lifestyle change and engaging nutrition professionals on a high level will have an edge in achieving the best outcomes possible for their patients.
Jessianna Saville, MS, RDN, is the founder and director of the Kidney Nutrition Institute, an organization based in Titusville, Florida, focused on the advancement of renal nutrition to prevent and treat kidney disease
- Godwin M, Lin E. Health policy trends in kidney disease. Adv Chronic Kidney Dis. 2022;29(1):3-4. doi:10.1053/j.ackd.2022.03.002
- Kalantar-Zadeh K, Saville J, Moore LW. Unleashing the power of renal nutrition in value-based models of kidney care choices: Leveraging dietitians’ expertise and medical nutrition therapy to delay dialysis initiation. J Ren Nutr. 2022;32(4):367-370. doi:10.1053/j.jrn.2022.05.001
- Naber T, Purohit S. Chronic kidney disease: Role of diet for a reduction in the severity of the disease. Nutrients. 2021;13(9):3277. doi:10.3390/nu13093277
- Academy of Nutrition and Diabetics. Services, fees and management resources. www.eatrightpro.org/payment/business-practice-management/services-fees-and-management-resources. Accessed November 20, 2022.
- Kalantar-Zadeh K, Moore LW. Precision nutrition and personalized diet plan for kidney health and kidney disease management. J Ren Nutr. 2022;30(5):365-367. doi:10.1053/j.jrn.2020.07.005
- Unwin D, Khalid AA, Unwin J, et al. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutr Prev Health. 2020; 2;3(2):285-294. doi:10.1136/bmjnph-2020-000072
This article originally appeared on Renal and Urology News