Food Insecurity and Kidney Disease

Introduction

Race is a social construct on the basis of nationality, ethnicity, and phenotypic and/or social characteristics (1). Structural racism is “the processes of racism that are embedded in laws (local, state, and federal), policies, and practices of society and its institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaging, or otherwise neglecting racial groups viewed as inferior.” (1) Black people and other people of color are disproportionately affected by kidney disease, its progression, poor dialysis, and transplant outcomes, and adverse social determinants of health, including poor access to nutritious food, health care, appropriate housing, quality education, and neighborhood environment (2–4). Structural racism is becoming widely recognized as the cause for these racial health inequities and poor outcomes, but its role in the development and perpetuation of adverse social determinants of health is rarely recognized in the mainstream medical literature.

The purpose of this study is to consider how structural racism drives health inequities and adverse social determinants of health using the literature on food insecurity in kidney disease as an example. This study reviews literature on food insecurity in pediatric and adult kidney disease, discusses the pivotal role of racism in this relationship, and emphasizes our shared responsibility to address these inequities.

Food Insecurity Is a Problem for Patients with Kidney Disease

Food insecurity, defined as the limited or uncertain availability of nutritionally adequate and safe foods, disproportionately affects racial minorities and patients with kidney disease (4–6). The prevalence of food insecurity in an outpatient pediatric nephrology clinic was 35% (5). In samples of patients on dialysis, 16% of adults (6) and 64% of children (4) reported food insecurity.

Food insecurity is associated with diets high in energy-dense, high-sodium foods that are often more easily available and affordable, and low in fruits and vegetables (7,8). Inadequate nutrition can negatively affect a patient with advanced kidney disease by affecting fluid status, blood pressure, electrolytes, acid/base balance, and appropriate growth (8). Food insecurity is a potentially modifiable risk factor for kidney disease. Cross-sectional analyses in low-income adults from two large cohorts found that food insecurity was associated with a 46% and 35% higher odds of CKD (9). In the National Health and Nutrition Examination Survey, this association was no longer significant after adjusting for education, marital status, insurance, poverty income ratio, and smoking status, suggesting an important role for other social determinants of health in this relationship (9). In a prospective cohort study of adults with CKD, food insecurity was associated with 38% higher likelihood of CKD progression to ESKD after adjustment for demographics, income, diabetes, hypertension, eGFR, and albuminuria (7). In pediatric patients on dialysis, food insecurity was associated with more unplanned hospitalizations, intensive care unit admissions, infections, and significantly lower child and parent-proxied health-related quality of life scores (4).

There are clear racial and ethnic disparities within food insecurity in kidney disease. A National Health and Nutrition Examination Survey analysis among adults with CKD showed that, although Mexican American adults were 23% of the study population, a striking 54% of those with food insecurity were Mexican American. Non-Hispanic Black adults were 33% of the study population and 29% of those with food insecurity, whereas Non-Hispanic White adults were 41% of the study population and only 13% of those with food insecurity. Similar trends were seen for the non-CKD group (7). Pediatric data consistently demonstrate that food insecurity disproportionately affects Black and other minority groups. In the pediatric study described above, food insecurity was more prevalent among Black, Native Hawaiian, and American Indian/Alaskan Native participants compared with White participants (71% versus 50%) (4). Among children with CKD, Black children have a significantly higher prevalence of food insecurity (41% versus 14%) and lower socioeconomic status compared with White children (3). Additionally, Black children with CKD had more hypertension, which persisted after adjustment for socioeconomic status, suggesting contributing roles of structural racism and/or genetic factors such as APOL1 risk variants, which are associated with hypertension and more common in Black people (10). Racism also causes increased and repeated stress, which contributes to cardiovascular disease in Black American people (3). Both racism and food insecurity exacerbate and potentially accelerate the poor kidney outcomes.

Structural Racism at the Root of Food Insecurity and Other Social Determinants of Health

The literature on food insecurity in pediatric and adult kidney disease acknowledges the important role of financial constraints due to low income and/or the high cost of medical expenditures, poverty, and environmental constraints in this relationship (4,7,9) but lacks discussion on the role of structural racism in establishing these disparities. In the early 1900s, governments and private institutions deliberately and systematically created racially segregated neighborhoods throughout the United States through zoning, mortgage discrimination, and redlining. These systemically racist policies separated Black people and other people of color from White people and forced them to live in less desirable areas. These practices became unlawful after the Fair Housing Act of 1968, yet the structures of segregation persist (1). These policies continue to affect the physical and social environments of these communities due to disinterest, disengagement, and decreased investment and resources from the government and private sectors (1). Therefore, segregated communities have inferior educational resources, fewer high-quality teachers, limited employment opportunities, lower-quality housing, chemical and physical hazards, and concentrated poverty (1). The lack of investment and resources created food deserts (areas with limited access to nutritious foods) and food swamps (areas with excessive high-energy food sources), making a nutritious diet difficult to obtain and contributing to food insecurity (7,9). Racial segregation of neighborhoods and persistent structural racism make it extremely difficult for residents to practice healthy behaviors and access quality health care, which contribute to poor health outcomes of Black people and other people of color who disproportionately suffer from CKD, ESKD, and their complications (1–3).

The Role of the Nephrologist to Address Food Insecurity and Racism

It is our responsibility as physicians, nurses, medical assistants, social workers, and nutritionists to take care of all aspects of our patients. We must start by screening patients and families using the two-question Hunger Vital Sign to assess food security status (4,5). For those who are food insecure, they should be connected with community health care navigators who can facilitate access to food, social services, resources, and programs. As nephrologists, we need to meet the patients in their own communities and facilitate partnerships between dialysis centers and clinics with food pantry sites to ensure availability of nutritious and ESKD-appropriate foods. At our institution, we started a food security program in 2018 to provide on-site nutritious, diet-appropriate foods and recipes to food-insecure pediatric patients on dialysis and their families. Food-insecure families are provided enough food for six meals per person, per week for the entire family. This endeavor was possible due to community partnerships with charitable food donation organizations and contributions from private companies, farms, and individuals. We also partner with community-based organizations to provide food-insecure families with local resources to address other adverse social determinants of health. We have demonstrated that these interventions decreased health care utilization, dialysis catheter–related infections, and improved quality of life (unpublished data).

Programs that increase accessibility to nutritious foods are a good start, but acknowledging the foundational role that racism plays in perpetuating food insecurity is necessary to advocate for more permanent solutions. To address food insecurity requires comprehensive programs that include not only easy access to nutritious, culturally appropriate food and community engagement, but advocacy on a larger scale to change governmental policy. Programs need educational components, and financial, housing, and environmental support that are developed in partnership with the community. A shining example of a comprehensive, multidimensional food security program was Fannie Lou Hamer’s Freedom Farms in Sunflower County, Mississippi, established in 1969 that provided Black families with land, agriculture, food, housing, education, and financial support for Black-owned businesses to overcome the hunger, poverty, and inadequate housing imposed on Black people by White supremacist society (11). Nephrologists and institutions such as the American Society of Nephrology and American Society of Pediatric Nephrology must continue advocating for policies and reforms aimed to provide resources to impoverished, segregated neighborhoods that will improve schools and housing, expand access to nutritious food, and increase investment into these communities to reduce racial health inequities and to mitigate structural racism. Dialysis centers can start this work by engaging patients and community leaders to address their immediate needs and determine how their centers can improve the communities in which they are located.

Racism built the systems and beliefs that are designed to oppress Black people and other people of color. Although some progress has been made, many of these practices remain today. Structural racism gave rise to the adverse social determinants of health, including food insecurity, in minority communities, and is responsible for racial health inequities and disparate outcomes in kidney disease. It continues to negatively affect the health, well-being, opportunities, and lives of our patients and their families. It is time we acknowledge this and prioritize working together to dismantle structural racism, adverse social determinants of health, and racial disparities via research, resources, community engagement, and advocacy. As James Arthur Baldwin, Black novelist and activist, once said, “We have made the world we are living in and we have to make it over again.”

Disclosures

S. Hingorani reports having consultancy agreements with Omeros. The remaining author has nothing to disclose.

Funding

This work was supported by the US Department of Health and Human Services National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases Institutional National Research Service Award T32 DK007662, Pediatric Nephrology Training Program.