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

New findings regarding the barriers to equitable access in transplant care in kidney failure and obesity 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 HCPLive. “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.

References

1. 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

2. 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