Adrian Brown, PhD, NIHR Advanced Fellow and Associate Professor in Nutrition and Dietetics at University College London and programme co-lead of the MSc Dietetics (Pre-registration) course

Adrian Brown, PhD

Crisis Point: The Cause and Calamity, Neighborhood Disadvantage and Kidney Disease

Clinicians often think of healthcare as having a problem and a solution, but what if there was more going on underneath the surface?

When it comes to the rising threat of developing 

, there's more at stake than the values we can measure in a lab. This Crisis Point focuses on the detrimental problem of neighborhood disadvantage as the cause and the calamity of kidney disease.

Neighborhood disadvantage is a place-based measure, defined as 1/5th of a population living below the federal poverty line, and with indices such as the Area Deprivation Index (ADI). Measurable data from the US Census Bureau identified 24 million Americans living in disadvantaged neighborhoods, with a disproportionate amount of racial and ethnic families residing within these communities. For example, only 4.3% of white Americans live in a disadvantaged neighborhood compared to 20.9% of black Americans.

These inequities don’t just present through poverty, housing instability, educational opportunities, employment, and access to resources. Neighborhood disadvantage trickles down the line, impacting an individual’s health through daily exposure to unfavorable conditions, including processed food, air pollution, and dehydration. As a result, the pathways to exposure to kidney disease can be represented by acute kidney injury (AKI), with repeated episodes accelerating CKD progression, and they can also be chronic, causing slow debilitating decline over the years.

“I really think that it asks nephrologists and other care providers to treat an individual's social context as part of their care plan,” said Maya Clark Cutaia, PhD, RN, in an interview with 

“We all walk in every day with those things on our backs. You may not see it, but we walk in with our history, our culture, our trauma, you know, our joys, whatever. And if we can take those real-world contexts and apply them to what we want to do next. It'll inform how we treat a patient.”

Statistically, 18.8 to 40 million Americans live within food deserts, characterized by a reliance on gas stations and convenience stores, limited or no access to fresh fruits and vegetables, and poor transportation options and unsafe spaces for exercise.

Having limited access to nutrient-dense options can take a major toll on kidney health. Often, the most affordable and easy choices in disadvantaged neighborhoods are chips, fried food, and sodas, of which the additives and high-sugar levels can build in the kidneys and contribute to inflammation. This differentiates from nephrologists’ kidney-friendly diet recommendations, which are a plant-based protein diet focused on whole foods and vegetables, while taking into account the risk of muscle loss for patients on dialysis.

Previous research has linked food deserts and disadvantaged communities with an increased risk of obesity. In kidney disease, obesity has been seen as both a 

 of further injury and disease progression. Thus, individuals living in disadvantaged communities face environmental factors that minimize their health and exacerbate poor outcomes, adding further barriers to care, especially 

Structural barriers in disadvantaged neighborhoods, such as distance to transplant centers, transportation burdens, and lack of local primary care physicians reflect systemic flaws in the catering of the healthcare system towards advantaged communities.

A majority of patients in these communities either lack awareness or the time to receive routine wellness checks related to the often silent disease of CKD. By the time a patient presents with symptoms of kidney deterioration, they’re often passed the point of early stages and require more in-depth treatment, according to experts. The issue of access and resources will not ultimately resolve itself once a patient presents with symptoms that need treatment.

Patients experiencing CKD in the later stages, especially end stage kidney failure (ESKD) will require dialysis, or in severe cases, transplantation. However, the barriers to care that existed in the beginning stages of their illness become even more pronounced once they require help.

“Neighborhood disadvantage puts people out of the running,” said Clark-Cutaia about the entire continuum of kidney care.

According to a recent study, neighborhood disadvantage is linked to a significant lack of access to waitlisting and kidney transplantation, especially living donor kidney transplantation. This reality can be seen as a representation of the double-sided nature of neighborhood disadvantage and kidney health as the root of the problem and a barrier to a solution.

To combat neighborhood disadvantage and its downstream effects, it is important to meet patients where they are. As clinicians, that means creating a presence in communities through churches, mosques, workplaces, farms, or by connecting with community leaders to build trust in the healthcare system.

Awareness and access can play a major role in improving patient outcomes. For example, on-site education and screening to reduce transportation/time burdens, along with mobile units for blood and urine testing can bypass systemic barriers and help patients get the preemptive help they need.

To address social determinants of health, clincians should aim to implement earlier screening and referrals and to connect patients to social workers for food transporation and social support needs.

Ethically and clinically, health care practitioners have a responsibility to their patients to treat neighborhood disadvantage as a clinical value and to find solutions for these barriers to care the same way they would treat an erroneous lab measure.

 is the inaugural Evelyn Lauder Associate Dean for Nurse Practitioner Programs and Professor at the Hunter-Bellevue School of Nursing at Hunter College.

 is a NIHR Advanced Fellow and Associate Professor (Principal Research Fellow) in Nutrition and Dietetics in the Centre of Obesity Research at University College London (UCL) and programme co-lead of the MSc Dietetics (Pre-registration) course at UCL.

 is the Chief Medical Officer at Evergreen Nephrology.

 is the Chief Executive Officer and Founder of Carna Health.

 is a nephrologist and Professor of Public Health Sciences and Medicine, Division of Nephrology and Hypertension at Loyola University Chicago, and the Editor in Chief of 

 is a postdoctoral researcher at the Leverhulme Centre for Demographic Science at the University of Oxford.

 is the Dr. Robert H and Eva M Moyad Research Professor of Urology, Co-Chief of Dow Division of Health Services Research, Professor of Internal Medicine, and Professor of Urology at the Medical School at the University of Michigan.

Editor’s Note: Cutaia declares no relevant disclosures. Brown reports no relevant disclosures. Pflederer reports relevant disclosures with Evergreen Nephrology. Viscomi reports relevant disclosures with Carna Health, Dama Health, QuantaBrain, and others. Shahinian reports no relevant disclosures.

Christie-Mizell CA. Neighborhood Disadvantage and Poor Health: The Consequences of Race, Gender, and Age among Young Adults. 

International Journal of Environmental Research and Public Health

Neighborhood Atlas - Home. Wisc.edu. Published 2018. 

https://www.neighborhoodatlas.medicine.wisc.edu/

Niculae A, Gherghina ME, Peride I, Tiglis M, Nechita AM, Checherita IA. Pathway from Acute Kidney Injury to Chronic Kidney Disease: Molecules Involved in Renal Fibrosis. 

International Journal of Molecular Sciences

Rhone A. USDA ERS - Documentation. Usda.gov. Published January 5, 2025. 

https://www.ers.usda.gov/data-products/food-access-research-atlas/documentation

American Kidney Fund. Kidney-friendly eating plan | American kidney fund. www.kidneyfund.org. Published December 1, 2021. 

https://www.kidneyfund.org/living-kidney-disease/healthy-eating-activity/kidney-friendly-eating-plan

Bellasi A, Di Lullo L, Di Iorio B. Chronic Kidney Disease: The Silent Epidemy. 

Li Y, Menon G, Kim B, et al. Residential Neighborhood Disadvantage and Access to Kidney Transplantation. 

https://doi.org/10.1001/jamanetworkopen.2025.49679

Videos

7 experts come together to address neighborhood disadvantage and its impact on kidney health in the latest Crisis Point. 

Destigmatizing Obesity in Kidney Failure Patients Seeking Transplants, With Adrian Brown, PhD

barriers to equitable access in transplant care

 may open the door to a new future of clinical obesity management in this patient population.

This was the first systematic review to synthesize the perspectives of both clinicians and patients on obesity management in kidney failure before transplantation, and the findings underscored a disconnect between clinicians’ communication and patients' psychological well-being, especially when stigma was present.

“Enhancing communication is actually essential,” said Adrian Brown, PhD, NIHR Advanced Fellow and Associate Professor in Nutrition and Dietetics at University College London and programme co-lead of the MSc Dietetics (Pre-registration) course, in an interview with 

Clinicians should receive training to help them discuss weight sensitively, to guide weight bias and stigma, and to support patients in a way that makes them feel respected, and that the communication and the engagement are collaborative.”

Brown and colleagues conducted a mixed-methods systematic review, constructing 4 main themes from 738 participants from 7 studies investigating patients' and clinicians' perspectives on obesity management in kidney failure. These included:

Hungry and exhausted: The impact of dialysis on eating behaviour and activity (n = 339)

Weight stigma–lack of support, trust and open communication (n = 212)

Lack of resources as a barrier for weight loss (n = 339)

Who gets a transplant? Moving beyond BMI to improve equity in transplantation (n = 631).

In total, 4 studies included clinicians’ perspectives (n = 495), such as dieticians (n = 41), nephrologists (n = 438) and transplant surgeons (n = 12).

Hungry and exhausted: The impact of dialysis on eating behaviour and activity

Appearing in 6 papers, investigators identified diet and exercise as the most common weight loss interventions in patients with kidney failure.

From this study, investigators observed communication linguistics surrounding dietary advice included portion control, mindful eating and self-monitoring as the most common interventions for obesity management.

From a patient’s perspective, this guidance was hard to adhere to, given the “incompatibility” between this advice and the dietary/liquid restrictions, hunger, and exhaustion while going through dialysis. In fact, dialysis itself was often reported as a hindrance to weight loss based on its impact on eating behaviour, energy, and hunger, deterring intentional meal preparation and the stress and boredom patients expressed during treatment.

Building off of dialysis’s impact on energy related to diet, exhaustion was an obstacle for patients attempting to exercise, even though this was the second most common obesity management approach.

Weight stigma–lack of support, trust and open communication

This theme stood out as a measure of the communication barriers between patients and clinicians, specifically how instances of bias led to what patients described as inadequate support and advice, often leading them to feel responsibility and self-blame.

As study investigators observed, clinicians tended to tiptoe around conversations surrounding weight and obesity, not wishing to “embarrass” patients by initiating the topic. Dialysis facilities themselves were seen as a separate barrier, given the lack of privacy and public nature of treatment. Overall, clinicians either expressed an expectation for patients to bring obesity up for themselves, or a desire to focus on other clinical workload.

Investigators noted a few instances of clinicians' apparent bias and negative attitudes towards patients with obesity, and identified this stigma as a roadblock toward transplantation and a detriment to patients' psychological well-being.

Lack of resources as a barrier for weight loss

Brown and colleagues described this theme as resource-related barriers, including lack of time, limited obesity knowledge, and funding. Overall, these reduced the ability and motivation of the patient and clinician to address obesity.

Some patients viewed weight loss as time-consuming; others did not have an urgency to lose weight until reaching a more severe level of CKD. Notably, both patients and clinicians reported a lack of time and motivation to actively pursue or support weight loss.

According to Brown, many clinicians felt obesity management was outside the scope of their role, which led to gaps in care. Clinicians were unsure about their roles in addressing obesity in dialysis and identified the absence of obesity management guidelines as a key challenge.

Of note, barriers to food access, including cost and inaccessibility, were also identified as a major barrier to weight loss for patients with kidney failure.

Who gets a transplant? Moving beyond BMI to improve equity in transplantation

Lastly, from the findings, Brown and colleagues discovered 4 papers where clinicians considered obesity during transplant eligibility assessments. Overall, there was a lack of consensus on how to measure body composition or operationalize eligibility for kidney transplantation.

A majority of clinicians believed having a body mass index (BMI) ≥ 40 kg/m2 was a contraindication for kidney transplantation, with 50% suggesting a BMI of 40 kg/m2 was an appropriate limit, while others said 30–35 kg/m2. Otherwise, clinicians believed BMI limits excluded patients.

“There needs to be a shift to create a system that recognizes obesity as a medical condition in its own life, requiring coordinated care,” said Brown. “And this needs to be prioritized for transplant access, both for the patients and the clinicians, working towards getting better clinical outcomes and ultimately getting patients access to transplantation.”

Editor’s Note: Brown reports relevant disclosures with Novo Nordisk and Reset Health.

Oganesova Z, MacLaughlin HL, McCafferty K, et al. Patient and clinician perspectives on the management of obesity in kidney failure prior to kidney transplantation: a mixed-methods systematic review. eClinicalMedicine. 2026;91:103649. doi:

https://doi.org/10.1016/j.eclinm.2025.103649

Brown A. Barriers to Obesity Management in Kidney Failure Before Transplantation. HCPLive. Published February 24, 2026. Accessed February 26, 2026. 

https://www.hcplive.com/view/barriers-to-obesity-management-in-kidney-failure-before-transplantation

Brown discusses a destigmatised future of obesity management in patients with kidney failure. 


Barriers to Obesity Management in Kidney Failure Before Transplantation

The first systematic review to synthesize both patients’ and clinicians’ perspectives on obesity management in kidney failure prior to transplantation has revealed significant challenges, highlighting the need for more equitable access to transplant care.

The review, which analyzed 7 studies with 738 participants, identified multiple barriers affecting patients’ ability to lose weight and clinicians’ capacity to provide support, including dialysis-related fatigue and hunger that limit lifestyle modification, weight stigma and poor communication in clinical settings, limited access to structured weight-management resources, and strict BMI-based eligibility criteria that may restrict equitable access to transplantation.

“These biases influence how clinicians communicate and whether they offer meaningful support, as we can see from previous data, and they can make patients feel fearful, ashamed, and less willing to engage,” said Adrian Brown, PhD, NIHR Advanced Fellow and Associate Professor in Nutrition and Dietetics at University College London and programme co-lead of the MSc Dietetics (Pre-registration) course. “What we have seen is that patients who feel stigmatized are less likely to actually come back to that clinician for support.”

Obesity is increasingly recognized as a risk factor for developing and progressing 

, linking weight management directly to transplant eligibility. Many transplant centers require patients to reach a body mass index (BMI) of 35–40 kg/m² to be listed for kidney transplantation, excluding a substantial proportion of otherwise eligible candidates. Understanding the lived experiences of both patients and clinicians is therefore essential to developing practical, fair, and effective approaches to weight management.

Across the 7 included studies, patients’ mean age ranged from 54 to 58 years, with mean BMI 27.3 and 39.5 kg/m². In studies reporting ethnicity, patients were predominantly Black or White, with up to 78.8% identifying as Black in some U.S. cohorts.

Patients described significant barriers to weight management, including fatigue and hunger associated with dialysis, which made it difficult to adhere to dietary and activity recommendations. They reported experiencing weight stigma, feeling blamed or infantilized, which in turn undermined motivation to lose weight. Limited access to structured support and resources, including healthy foods, compounded these challenges. Many patients also expressed frustration with rigid BMI thresholds, viewing them as arbitrary measures that unfairly restricted access to transplantation.

“Clinicians, meanwhile, expressed their own challenges,” the investigators explained. “Many felt that they lacked training and knowledge about obesity, were uncertain how to safely support weight loss, and described competing clinical priorities, limited time, and difficulty initiating weight discussions—particularly in the busy and cognitively taxing dialysis environment.”

The review emphasizes the urgent need for targeted strategies to address these barriers. Recommendations include specialized training for clinicians on obesity management and weight bias, structured multidisciplinary support programs for patients, and more nuanced transplant eligibility criteria that move beyond BMI alone.

By integrating patient and clinician perspectives, the findings underscore the importance of compassionate, individualized approaches that account for the physical, emotional, and systemic challenges faced by people with kidney failure.

Oganesova Z, MacLaughlin HL, McCafferty K, et al. Patient and clinician perspectives on the management of obesity in kidney failure prior to kidney transplantation: a mixed-methods systematic review. 

‌Johansen KL. Obesity and Body Composition for Transplant Wait-List Candidacy—Challenging or Maintaining the BMI Limits? 

https://doi.org/10.1053/j.jrn.2013.02.005

Systematic review identifies patient and clinician barriers to obesity management before kidney transplantation, with Adrian Brown, PhD.

Adrian Brown, PhD

Articles