Advancing Health Equity in Kidney Disease through Sustainable Policy and Community Partnership

This commentary accompanies “Qualitative Perspectives from African American Adults with CKD on Community-Based Fruit and Vegetable Promotion” by Dodgen et al.1 in this issue of CJASN. Their study exposes critical gaps in sustaining dietary interventions for African Americans with chronic kidney disease—gaps that reflect real-world barriers. I know this because I have lived it. A Personal Journey: When Eating Healthy Is Not Enough I was 21, fresh out of college with a mathematics degree earned in 3 years from the University of Houston and two prestigious job offers. I chose Shell Oil Company. All that remained was a routine physical. Then came the call: Shell could not hire me. I had too much protein in my urine. My mother took me to an urologist in Fort Worth—there were no nephrologists available. He could not replicate the test results and agreed to notify Shell I was fit to work. But as we wrapped up, he said, “Once they hire you, you should start dialysis.” I did not know what dialysis was. When I asked, he offered little explanation. When I asked for other options, he said I could try diet and exercise, but “most people aren't able to do it.” I asked what kind of diet. His reply: “A good one.” I asked what that meant. His response: “You’ll figure it out.” That was the extent of my nutritional counseling. My instincts told me the protein might be linked to my meat-heavy diet. Over the following decades, I learned through trial and error what my doctor could not explain: which foods to emphasize, how to balance nutrition with kidney function, and how to maintain the approach despite limited guidance. I transitioned from carnivore to vegetarian to vegan. I managed to avoid dialysis for four decades after that initial diagnosis, finally starting treatment 40 years later. Whether my dietary approach delayed progression, or I had slowly progressive disease is impossible to know. But I avoided dialysis for four decades after being told to start immediately—an outcome my urologist suggested was unlikely through dietary management alone. My story is not unique. It reflects a broader reality for African Americans living with CKD: vague dietary advice, limited access to culturally relevant guidance, and systemic barriers to healthy eating. While clinical care has evolved since my 1970 diagnosis, the fundamental gaps I experienced—cultural competency, sustainable support, systemic barriers—remain central to the findings of Dodgen et al. Study Overview Through in-depth interviews with African American adults with CKD who participated in a community-based fruit and vegetable intervention, Dodgen et al. show that removing barriers—like improving produce access, providing cooking lessons, and involving culturally aware health workers—enables dietary change for kidney patients. However, once interventions end, challenges such as cost and transport return, highlighting a need for lasting policy solutions. Policy Recommendations Expand Food Assistance for Patients With CKD: States have tried “food as medicine” programs with Medicaid waivers, reducing hospital admissions and costs.2 Making CKD eligible for enhanced supplemental nutrition assistance program and permanent produce prescriptions under Medicaid would expand these benefits nationwide. The Gus Schumacher program requires congressional reauthorization.3 Fund Community Health Workers (CHWs): CHWs improve outcomes in underserved groups, including reducing hospitalizations and improving chronic disease management,4 but lack sustainable funding. Federal legislation should make CHWs reimbursable under Medicare and Medicaid for care team integration. Integrate Nutrition Support: Medicare has expanded nutrition therapy coverage, but value-based payment models should fund comprehensive nutrition services as routine care, not just research interventions. Improve Transportation Access: Medicaid's transport typically covers medical visits, not food access. Federal guidance should recognize food access as health-related, supporting mobile markets and delivery services. Strengthen Community Partnerships: National Institutes of Health and Patient-Centered Outcomes Research Institute should fund multiyear community partnerships requiring sustained benefit and community-led design for lasting impact. From Documentation to Action We cannot continue conducting studies that temporarily remove structural barriers, document improvement, then watch inequities reassert themselves once funding ends. Kidney disease costs Medicare over $50 billion annually, with African Americans bearing disproportionate burden. These policies translate research into sustained practice—strategic prevention that lowers costs and improves lives. For nephrologists and researchers: the next study should be designed from inception with sustainability in mind—partnering with policy advocates, engaging community organizations beyond the study period, and using findings to support legislative changes. For patient advocates: Engage researchers and funders as partners in addressing the sustainability gap. For policymakers: the evidence exists. What is missing is the will to act. The participants in the Fruits and Vegetables for Kidney Health Study generously shared what works: accessible produce, practical instruction, culturally grounded support, and ongoing accountability improve kidney outcomes. They also revealed what does not work: expecting lasting change without addressing the conditions that make healthy choices difficult or impossible. Their voices and mine converge: we know what works. Let's build the policies and partnerships to make it permanent!