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Addressing disparities in renal diet adherence: leveraging social support to improve dietary behaviors among end-stage kidney disease patients with obesity
Dissertation

Addressing disparities in renal diet adherence: leveraging social support to improve dietary behaviors among end-stage kidney disease patients with obesity

Bengucan Gunen
Doctor of Philosophy (Ph.D.), Drexel University
Sep 2026
DOI:
https://doi.org/10.17918/00011579
pdf
Gunen_Bengucan_20262.05 MB
PDF Embargoed Access, Embargo ends: 30 Sep 2027

Abstract

Chronic kidney disease Diet Diet adherence Kidney disease Renal diet Obesity
Chronic kidney disease affects approximately 15% of the United States population, and patients are asked to follow dietary recommendations to preserve kidney function. Furthermore, individuals with concurrent end-stage kidney disease and obesity are advised to follow complex dietary recommendations for kidney disease and weight management. Although renal diet adherence is approached as an individual health behavior in clinical guidelines, patients' ability to follow dietary recommendations may depend on the social relationships, household roles, and resources available to them. This dissertation examined how social support and other social factors shape renal diet adherence among adults with chronic kidney disease and obesity. Three complementary studies used qualitative, quantitative, and participatory mixed-methods approaches. Aim 1 used semi-structured interviews with 40 adults with ESKD and obesity recruited from 22 U.S. states to examine perceived social support, renal diet adherence, and the interpersonal contexts in which dietary self-management occurs. Interpretive phenomenological analysis identified differences in participants' ability to access and leverage support for grocery shopping, meal preparation, and other dietary behaviors. Household members were the primary source of instrumental support, while gender and caregiving roles influenced whether support could be used effectively. Loss of support, fatigue, social isolation, and competing household food preferences could undermine adherence even among participants with knowledge of renal dietary recommendations. Aim 2 used data from the Chronic Renal Insufficiency Cohort to examine sociodemographic disparities in adherence to dietary recommendations and the contribution of social connectedness to dietary behaviors among adults with chronic kidney disease. A proxy measure of social connectedness was developed and evaluated against the Lubben Social Network Scale. High social connectedness scores were associated with higher odds of adhering to protein guidelines. Analyses also identified sociodemographic differences in adherence, as female participants had greater odds of following sodium and fiber recommendations. Aim 3 used Photovoice within a prospective longitudinal cohort of adults with ESKD and obesity receiving hemodialysis in Philadelphia. Ten participants generated photographs documenting their food environments and participated in interviews and focus groups that were integrated with dietary, social support, and longitudinal health data. Participants described how family relationships, caregiving responsibilities, household food practices, fatigue, changing social roles, and disruptions associated with ESKD shaped their food choices. Supportive relationships could facilitate meal planning, food acquisition, and home preparation, whereas limited or mismatched support could constrain available dietary strategies. Across the three studies, findings demonstrate that renal diet adherence is not solely an individual behavior but a process shaped by household dynamics, gender and social roles, changing support networks, and opportunities to receive and provide assistance. Dialysis care and behavioral interventions may better support dietary self-management by assessing patients' social environments and offering strategies that account for the availability, type, and function of social support.

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