Abstract: TH-PO525

Primary Care Providers’ Dietary Counseling of Their Low Income African American (AA) Patients with CKD

Session Information

Category: Chronic Kidney Disease (Non-Dialysis)

  • 307 CKD: Health Services, Disparities, Prevention


  • Crews, Deidra C., Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
  • Boulware, L. Ebony, Duke University School of Medicine, Durham, North Carolina, United States
  • Roter, Debra L., Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
  • Greer, Raquel C., Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
  • Park, Stella, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
  • Ephraim, Patti, Johns Hopkins University, Baltimore, Alabama, United States
  • Ameling, Jessica, University of Michigan, Ann Arbor, Michigan, United States
  • Boyer, Lapricia Lewis, Johns Hopkins University, Baltimore, Alabama, United States
  • Albert, Michael C, Johns Hopkins Health System, Baltimore, Maryland, United States
  • Cooper, Lisa A., Johns Hopkins University School of Medicine, Baltimore, Maryland, United States

Diet influences outcomes in CKD, but little is known about how patients with CKD are counseled about their diet. We examined primary care providers' (PCPs) use of the 5A's (Assess, Advise, Agree, Assist, and Arrange) counseling strategy in diet discussions with AA patients with CKD, and explored their use of a 6th 'A' “Awareness”, reflecting recognition and discussion of the home and community food environment within which the patient resides--especially relevant for patients living with food insecurity.


In a trial of urban AAs with uncontrolled hypertension, we audio-recorded patients' routine visits with their PCPs at the first visit after enrollment. Among 44 patients with CKD [eGFR<60 (33%) and/or ACR ≥30mg/g (88%)], we assessed presence of diet discussions and use of the 6A's in the discussions. Using linear regression, we examined predictors of number of A's used.


Mean age was 59.5 years, 37% were male and 31% had annual income <$10K; 63% were obese, 70% had diabetes and mean systolic BP was 147 mmHg. A majority (67%) were either at risk for or with food insecurity (inability to afford nutritionally adequate foods). Most (88%) visits included dietary counseling, most commonly in the context of Assess (68%) and Advise (61%); Agree (14%), Assist (14%) and Arrange (9%) were infrequent. Only one visit included reference to Awareness. Median number of A's was 2 (IQR 1-2.5). No visit included all A's. Representative quotes are in the Table. Visits attended by patients earning <$10K included fewer A's than those of patients with higher incomes, though not statistically significant (-0.5, 95% CI -1.4, 0.4).


Among urban AAs with CKD, dietary counseling by their PCP primarily included assessing or advising on diet. PCPs may struggle to cover all A's in the context of visits with high risk patients. Multidisciplinary approaches to dietary counseling of high risk CKD patients warrants investigation.

6A's Framework and Representative Quotes
Assesses diet or weight“How are you doing with the salt in your diet?"
Advises on topics of diet or weight"Try to stay away from bananas. If you eat a banana, eat a half. Because of the diabetes.”
Agrees on a specific planPhysician: "Our plan for now is for you to continue all this dietary stuff you"
Assists in identifying barriers/supports for behavior changePhysician asks about eating out and the patient says they can seldom afford to, so doctor responds “But of course, that also makes it tough to afford the fresh stuff.”
Arranges a specific plan for follow up"I would like to see you back in a month. By then you should have seen the nutritionist."
Awareness, recognition and discussion of food environmentPhysician suggests adding apricots to patient’s diet, but patient does not know what they are. Physician recognizes that “Those aren’t common. I wouldn’t find them in a store around here.”


  • NIDDK Support