Background
African Americans are more than twice as likely to live in poverty as are whites [
1] and socioeconomic factors are believed to contribute in complex ways to racial disparities in chronic kidney disease (CKD) [
2]. Dietary factors may play a role in these disparities. Specific dietary patterns or components have been associated with greater risk of prevalent [
3,
4] or incident CKD [
5,
6]. Several dietary patterns have been associated with CKD progression in observational studies [
7‐
10], including diets which are non-adherent to the Dietary Approaches to Stop Hypertension (DASH) trial diet [
11]. Additionally, diets high in fruits and vegetables and low in dietary acid load (similar to the DASH diet [
12]) have demonstrated kidney-related benefits in controlled studies [
13,
14]. African Americans are more likely to experience food insecurity [
15] and/or live in “food deserts” [
16], which may contribute to documented racial disparities in diet quality [
17]. For example, African Americans with hypertension are less likely to follow a DASH trial accordant diet than are whites [
18], despite their being shown to potentially receive the greatest blood pressure benefit from the DASH diet [
19].
Although reasons for poorer diet quality among African Americans compared to whites are not fully understood, they are likely multifactorial, including African Americans’ perceptions of healthful dietary practices, access to healthful foods, cultural and familial norms, and preferences [
16,
20‐
22]. Prior studies have demonstrated African Americans’ perceived risk of CKD is low, presenting one potential barrier to CKD prevention [
23‐
25]. However, little is known about African Americans’ views on ways to prevent CKD through dietary interventions. Identification of factors likely to influence the success of dietary interventions among African Americans at high risk for CKD could greatly enhance preventive strategies.
We performed a qualitative study to elicit perspectives on CKD prevention via dietary modifications among African Americans of low socioeconomic status (SES), given empirical data suggesting their particularly high risk of adverse kidney outcomes [
26‐
28]. We focused our study on African Americans with a family history of ESRD as this risk factor is more common among African Americans than whites, and is associated with a 2-fold greater risk of developing ESRD [
29]. To inform future effectiveness studies aimed at preventing CKD among high-risk African Americans, we examined participants’ views on specific components of the DASH diet which has been associated with lower risk of kidney function decline [
11] and other favorable health outcomes [
30‐
33].
Discussion
In this qualitative study, African Americans of low SES and who are at high risk for developing CKD perceived several barriers to CKD prevention through dietary change, including the expense and unavailability of healthy foods, family member preferences, convenience of unhealthy foods, and inability to break lifelong habits. They identified vouchers for healthy foods, home and/or family-based interventions, nutritional counseling and group gatherings for persons interested in making dietary changes as potentially acceptable approaches to preventing CKD.
As in a previous study of low-income, hypertensive African Americans’ views of the DASH diet [
38], our participants identified both socioeconomic and cultural barriers to following a DASH-like diet--and the two may be interrelated. A key barrier identified by our participants was limited accessibility and high cost of healthful foods. Consistent with participants’ perceptions, the availability of affordable and nutritious food has been shown to be limited in many low income and/or minority communities, including those in Baltimore City [
39,
40]. Additionally, a recent meta-analysis of studies spanning 10 countries reported that healthier foods/diet patterns are more costly than less healthy foods [
41]. Notably, these barriers to dietary modifications have been overcome in some low income communities who have implemented programs to increase availability of healthful and affordable foods [
42,
43]. However, improving access alone may not increase consumption of healthful foods if they are perceived to be culturally inappropriate [
38] or less palatable [
44].
Family member food preferences posed a significant challenge to our participants, and likely relate, in part, to cultural norms among African Americans [
38]. There is a perception among some African Americans that healthful eating requires giving up part of their cultural heritage and conforming to the dominant culture [
45]. The idea of giving up cultural norms is particularly at odds with the altruistic concept of family-based collectivism, which places the interests and needs of the family before those of the individual and is a core value for many racial minority groups [
46]. While DASH diet recommendations have been presented in the context of soul food and other traditional diets in the African American community [
47,
48], effective adaptions of these recommendations have not fully penetrated high-risk populations. Thus, further efforts to make DASH diet recommendations which are culturally-tailored and acceptable to persons at risk for CKD and other consequences of hypertension, are warranted. Such approaches may aid in breaking the life-long habits our participants identified as significant barriers to dietary changes.
Potential facilitators of CKD prevention through dietary modifications detailed by our participants included individual, as well as home and community-based programs and interventions. Receipt of education from an individual who had personal experience with making dietary changes was viewed favorably by our participants. Similarly, focus group participants in an obesity prevention study among African American women preferred to learn about diet and physical activity from someone like them, as opposed to, for example, celebrities who were not viewed as credible given their access to resources unavailable to most [
49].
The notable finding that none of our participants had prior knowledge of the DASH diet (despite over half reporting a diagnosis of hypertension) suggests substantial gaps in dissemination of evidence-based dietary approaches exist in this population, which is an opportunity for clinicians caring for African Americans at high risk for CKD. Home-based educational programs, as suggested by our participants, may be particularly effective in reaching disadvantaged populations who may face transportation, childcare and other barriers to clinic-based services [
50]. For example, a home-based diabetes education trial among Hispanics led to significant reduction in hemoglobin A1c levels [
51].
At age 40 years (the mean age of our study participants), African American men and women in the general U.S. population have a 16.8% and 18.9%, respectively, lifetime risk of developing advanced CKD (estimated glomerular filtration rate <30 ml/min/1.73 m
2) [
52]. While participants in our study reported some knowledge of established causes and risk factors for CKD, and all had at least one biological risk factor for kidney disease (i.e. diabetes or hypertension), many did not consider themselves to be at high risk of developing CKD. For example, participants were generally aware that family history is an important determinant of CKD [
53,
54] and all participants had at least one first degree family member with ESRD. Yet, consistent with a prior study from our group which was largely composed of African Americans at high-risk for CKD [
23], few participants perceived their personal risk of CKD to be high. While this finding argues for increased education among African Americans at high risk for CKD, risk awareness alone may not suffice. Perceived susceptibility to CKD has been associated with poorer blood pressure management [
23], suggesting that fatalistic attitudes about CKD might impede its prevention, perhaps particularly when patients face significant barriers to managing risk factors.
Our study had limitations which should be considered. First, our focus groups included a relatively small number of participants and were conducted in an urban U.S. city. Additional concepts or themes might be generated by interviewing additional participants in the study area or participants in other settings. Furthermore, participants of research studies may be more activated around their health than non-participants, which could have influenced group discussions. Second, we used self-reported data to determine participants’ clinical status, and did not recruit participants across strata of socio-demographic or clinical factors, therefore, certain groups may have been underrepresented. Third, we included participants with at least one indicator of low SES, however, individual differences across indicators (e.g. high educational attainment but low annual income) may have influenced participant responses. Fourth, we did not return the transcripts to participants to review, which may have impaired the accuracy of the inferences made from participant statements. Fifth, we did not assess the health literacy of our participants, and we did not specifically delineate between objective and perceived knowledge. By asking open-ended questions and asking participants to elaborate, we facilitated discussion of what was most likely perceived knowledge. To better differentiate, future work might include a validated survey of a similar population. Lastly, while the DASH diet has been associated with many favorable health outcomes, it has not been evaluated for its potential effect on CKD prevention in controlled studies. Thus, our study may serve to generate hypotheses for such future interventions.
To our knowledge, our study is among the first to report detailed views about the role of dietary interventions in CKD prevention among African Americans at high risk for CKD. We extended prior studies of barriers to healthful eating among African Americans by also elucidating potential facilitators of change in a population in need of targeted interventions As the body of literature on effective dietary strategies for reducing kidney injury continues to grow [
13,
14] our findings may inform translation of these strategies to vulnerable populations.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AJ analyzed the focus group data and drafted the manuscript. LEB and CA contributed substantially to the design of the study, the interpretation of the data, and revised the manuscript. TC analyzed the focus group data contributed to the drafting of the manuscript. K.K. recruited participants for the study, organized the focus groups and contributed to the drafting of the manuscript. LLB contributed to the design of the study, moderated the focus group sessions and contributed to the drafting of the manuscript. YL contributed to the analysis of the quantitative data and to the drafting of the manuscript. DCC conceived of the study design, acquired funding for the study, analyzed and interpreted the data and critically revised the manuscript. All authors read and approved the final manuscript.