Why Refer Patients With Cardiovascular-Kidney-Metabolic Syndrome to a Dietitian

25 March, 2024

Courtesy of Medscape, we share this highly informative release:

Subject: Why Refer Patients With CKM to a Dietitian



Why Refer Patients With CKM to a Dietitian?

Brandy L. Winfree, RDN March 20, 2024.

For 3 years, I walked into a dialysis clinic every day to care for patients who should not have been there.

These patients were mostly retired. Their kidney failure was secondary to diabetes or hypertension. They spent their lives working — often outdoors, in the South Georgia heat — looking forward to their golden years, to spending their days fishing with their grandchildren and gardening with their spouses.

After neglecting their health for years, they would find themselves spending their retirement with nurses and techs, connected to machines that would drain their energy so much that they would not have the strength to make a sandwich after treatment.

These patients didn't understand that skipping their blood pressure pills or ignoring their blood sugar would eventually destroy their kidneys. And, before meeting me, not one of them had ever seen a dietitian despite overwhelming evidence that nutrition intervention can postpone dialysis initiation.

Multidisciplinary Approach Needed to Manage CKM

A recent article addressed the newest acronym in primary care, CKM (cardiovascular-kidney-metabolic) syndrome, and the need for early screening and holistic care in its management. Recommendations made by the American Heart Association's Science Advisory and Coordinating Committee include using a multidisciplinary approach to treat excess adiposity, hypertriglyceridemia, hypertension, diabetes, and chronic kidney disease (CKD). This treatment includes pharmacology, dietetics, mental health care, and care management.

These new recommendations didn't surprise me or my colleagues, as we have seen the CKM cycle for years, though we didn't have a name for it. Our dialysis patients, who suffered with obesity, diabetes, hypertension, hypertriglyceridemia, and CKD for years, if not decades, before advancing to kidney failure had no idea that these systems were connected, nor that medical nutrition therapy (MNT) could address the cycle.

Have we not worked hard enough to educate our colleagues on the benefits of our care for their patients? Have we not networked with clinicians whose patients can most benefit from our care? How do we as a team move forward to allow these patients every opportunity to save themselves from spending what should be their golden years in a dialysis chair?

Nutritional Intervention to Manage CKM

Beyond the generic belief that most dietitians only work with obese patients to help them achieve a healthy weight — which we can and do — there is so much more that dietitians can bring to the table in the treatment and prevention of CKM. Dietitian-led nutrition intervention can improve patient outcomes, decrease burden on an already overwhelmed hospital system, and decrease physician workload.

A meta-analysis of more than 1200 participants across 11 studies found that patients with diabetes who received MNT from a dietitian showed significant improvements in cholesterol, fasting blood sugar, A1c, weight, body mass index (BMI), waist circumference, and systolic blood pressure. This means that every risk factor of CKM has the potential to be improved with dietitian-led nutrition therapy.

This analysis looked only at the clinical signs of improvement in patients who are provided with dietitian-led nutrition therapy. But analysis of more than 25,000 Medicare patients shows that MNT intervention in patients 55 or older with diabetes and cardiovascular disease (CVD) reduced utilization of hospital services by 9.5% and 8.6%, respectively. The analysis also indicated a decline in use of physician services by 23.5% and 16.9% for diabetes and CVD, respectively...

Every Patient Deserves the Chance to Succeed

One of my favorite nephrologists used to say, "Every patient deserves the chance to fail." His point was that it was the responsibility of the healthcare team to provide the patient with the support needed to improve their health, even if we didn't believe that they would put forth the effort to be successful.

We often found this frustrating because we would take the time to identify resources, even knowing that there was little chance the patient would use them. But the point was that the patient was given the opportunity to fail. They were given every option available to them.

While some patients would fail, others would flourish. And the positive reinforcement and increased independence that the team provided drove them to work harder and to adhere to treatments, medications, and diet.

Even those patients who we don't believe will actually make any changes deserve the opportunity to fail and the chance to succeed. The chance to save themselves from the dialysis chair. And with dietitian-led nutrition intervention, they can do just that.'

Joseph Ana

Center for Clinical Governance Research &

Patient Safety (ACCGR&PS) @ HRI GLOBAL


HIFA Profile: Joseph Ana is the Lead Senior Fellow/Medical Consultant at the Centre for Clinical Governance Research and Patient Safety (CCGR&PS) with Headquarters in Calabar, Nigeria, established by HRI Global (former HRIWA). He is the Country Coordinator for PACK Nigeria (Practical Approach to Care Kit) which is specifically designed to improve clinical competence (improving accuracy of diagnosis and treatment) in primary health care. He is also a Member of the World Health Organisation’s Technical Advisory Group on Integrated Care in primary, emergency, operative, and critical care (TAG-IC2). As the Cross River State Commissioner for Health (2004-2008), Joseph Ana led the introduction of the evidence based, homegrown quality tool, the 12-Pillar Clinical Governance Programme (12-PCGP) in Nigeria, which also suitable for lower-, low-, and middle income countries (LLMIC) with similar weak health sector and system. To ensure sustainability of 12-PCGP, the ‘Department of Clinical Governance, Servicom & e-health’ was established in Cross River State Ministry of Health in 2007. His main interest is in ‘Whole health sector and system strengthening in LLMICs’. He has written six books on the 12-Pillar Clinical Governance Programme, including the TOOLS manual for its Implementation, currently in its 2nd Edition. He served as Chairman of the Nigerian Medical Association’s Standing Committee on Clinical Governance (2012-2022), and he won the Association’s ‘Award of Excellence’ on three consecutive occasions for the innovation of 12-PCGP in Nigeria. He served as Chairman, Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act 2014. He was Member, National Tertiary Health Institutions Standards Committee (NTISC) of the Federal Ministry of Health, 2017-2022. He is the pioneer Secretary General/Trustee-Director of the Charity, NMF (Nigerian Medical Forum UK) which took the BMJ to West Africa in 1995. Joseph is a member of the HIFA Steering Group; the HIFA working group on Community Health Workers, and the Working Group on HIFA-WHO Collaboration (http://www.hifa.org/support/members/joseph-0 http://www.hifa.org/people/steering-group). Email: info AT hri-global.org and jneana AT yahoo.co.uk