Daily CSR

SPOT CKD: Advancing Early Detection and Health Equity

Debashish Mukherjee — Fri, 18 Sep 2026 04:26:00 +0200

In healthcare, some of the most consequential opportunities are also the easiest to overlook. They are the moments when an underlying condition could be identified early, but remains undetected.

Chronic kidney disease (CKD) is a clear example. Unlike conditions that produce obvious warning signs, CKD can develop silently, with little or no noticeable symptoms for many years. By the time it is identified, significant kidney damage may already have occurred. As a result, detecting CKD depends heavily on proactive identification and timely testing rather than waiting for symptoms to appear.

Several factors can contribute to missed opportunities, including gaps in clinical coding, limited awareness, and the competing demands placed on healthcare professionals. When these opportunities are overlooked, healthcare systems lose valuable time in which earlier intervention could potentially improve outcomes and help reduce inequalities in care.

For the National Health Service (NHS) in the United Kingdom, these missed opportunities have wider implications. They influence how effectively healthcare resources are deployed, how supported clinicians feel in identifying patients at risk, and how successfully health inequalities can be addressed. For patients, they can determine whether appropriate care begins at an early stage or only after the condition has progressed.

Why health equity matters

CKD does not occur at the same rate across all communities. The condition is particularly relevant in populations already experiencing health inequalities, including communities affected by socioeconomic disadvantage and areas with significant ethnic diversity.

Recognising this, the Hampshire and Isle of Wight (HIOW) and North East and North Cumbria (NENC) Integrated Care Boards (ICBs) sought to develop a different approach to identifying CKD—one designed to reduce the likelihood that early opportunities for detection would be missed.

HIOW encompasses a varied geography, including rural market towns, coastal communities such as the Isle of Wight, and diverse urban centres including Portsmouth and Southampton. Accessing healthcare is not equally straightforward for everyone. Language differences, transportation difficulties and limited digital connectivity can create practical barriers. Working patterns, including shift work, and caring responsibilities may make it difficult for some people to attend appointments or complete important tests. In other communities, cultural factors and limited access to online information can present additional challenges when seeking health advice or arranging healthcare.

The NENC Integrated Care System covers one of England’s largest geographical areas. It brings together urban centres with coastal, rural and post-industrial communities, each with distinct characteristics and needs. Strong community networks and local identities coexist with areas experiencing substantial deprivation and significant health challenges. By combining data and research with knowledge from local communities, the region is working to address disparities in health outcomes and expand opportunities for people across all communities.

SPOT CKD: Developing a collaborative approach

Against this background, NHS teams in HIOW and NENC, working with Boehringer Ingelheim, established SPOT CKD—Screening, Prevention, Outreach, and Treatment for Health Equity.

SPOT CKD is designed not simply as a conventional pilot programme, but as a collaborative model based on shared responsibility and local ownership. NHS teams identify priorities according to the needs of their populations, while the NHS and Boehringer Ingelheim contribute practical enablers such as data-driven insights, training and coordination. Local communities play an important role in shaping interventions, ensuring that proposed solutions reflect people's experiences of accessing and receiving care.

Healthcare innovators from the NHS, Boehringer Ingelheim and partner organisations then support implementation by introducing appropriate technologies and developing more connected care pathways. These pathways aim to strengthen the relationship between primary care and specialist renal services, helping patients move through the healthcare system in a more integrated way.

Key areas of focus

Priorities

NHS teams identify the most important areas for action by considering local health needs, population characteristics and the challenges faced by individual communities.

Enablers

Boehringer Ingelheim and NHS teams work together to support delivery through data insights, education and training, coordination, and other practical resources.

Outreach

Community experiences and perspectives help shape targeted outreach activities, making it possible to address barriers that may otherwise prevent people from accessing appropriate CKD detection and care.

Innovation

NHS teams, Boehringer Ingelheim and partner organisations work together to introduce new technologies and develop digitally enabled, integrated pathways that connect primary and specialist care more effectively.

Improving Chronic Illness Care with Medically Tailored Meals and Nutrition Support

Debashish Mukherjee — Tue, 29 Jul 2025 06:36:00 +0200

Meeting the Complex Health Needs of People with Chronic Illness Through Nutrition and Collaboration
Supporting the health of individuals with chronic diseases demands both creative solutions and strong partnerships. The Food is Medicine Coalition (FIMC) plays a vital role in underscoring how essential nutrition is in medical care by delivering medically tailored meals and nutrition support to people with diet-related health conditions.

Through funding from the DaVita Giving Foundation, FIMC and DaVita are striving to make a tangible difference by improving food access, quality of life, and reducing hospitalizations for individuals with kidney disease. This initiative is being implemented through three FIMC member organizations: Open Arms of Minnesota (Minneapolis), Project Angel Food (Los Angeles), and Second Harvest Food Bank of Central Florida (Orlando).

Alissa Wassung, Executive Director of FIMC, shares her insights in this Q&A about the connection between food and health, efforts to increase access to nutritious meals, and the impact on vulnerable populations.

How do you define food insecurity, and why is it significant in the context of public health?
Food insecurity is the inability to consistently access sufficient nutritious food for maintaining a healthy and active lifestyle. It encompasses more than just hunger—it also includes uncertainty about future meals, the financial inability to afford wholesome food, and dependence on inexpensive but unhealthy options.

This issue is particularly urgent in the U.S. because it disproportionately impacts marginalized groups such as low-income households, older adults, veterans, people of color, and those with chronic conditions. Inadequate nutrition is linked to increased risks of diseases like diabetes and heart disease, creating a cycle where food insecurity worsens health, increases medical expenses, and reduces economic mobility. Addressing this challenge is essential to improving population health and ensuring everyone has the opportunity to live well.

What is FIMC’s perspective on the intersection of chronic illness and food insecurity, and what needs are most urgent for affected individuals?
FIMC recognizes that chronic illness and food insecurity are tightly linked, often compounding one another, especially in vulnerable populations. While medically tailored meals (MTMs) are developed to meet specific medical needs rather than solely to combat hunger, they can play a pivotal role in breaking this cycle.

Without access to disease-appropriate nutrition, people with serious health conditions face difficulty managing their illnesses, resulting in more hospital visits, increased healthcare costs, and declining health.

Key needs on the ground include:

Access to Medically Tailored Meals (MTMs): Having meals that meet specific health requirements and are delivered to the home can significantly support recovery and disease management.
Nutrition Counseling and Education: Registered dietitians provide tailored guidance, ensuring cultural preferences and individual choices are respected in care plans.
Healthcare System Integration: Providers must treat food as part of medical care by screening for food insecurity and prescribing MTMs as part of the treatment plan.
Reliable Funding: Many nonprofits in this space rely heavily on donations and grants, underscoring the need for policy reforms to incorporate MTMs into healthcare benefits.

To tackle these issues, a holistic approach is needed—one that includes direct service delivery, evidence-based research, policy advocacy, and stronger connections between health and community services.

How does food access relate to managing or preventing conditions like kidney disease?
The connection between chronic diseases and food insecurity is well-established, and kidney disease serves as a clear example. Nutrition is a crucial part of managing chronic kidney disease (CKD). A proper diet helps control blood pressure, blood sugar, and fluid levels—all essential in slowing disease progression and avoiding complications.

However, individuals facing food insecurity often cannot afford or find foods low in sodium, potassium, and phosphorus—nutrients that must be carefully managed in CKD. Inexpensive processed foods, often high in these elements, can worsen health outcomes. Many CKD cases are linked to unmanaged diabetes and high blood pressure, both of which are heavily influenced by diet. Early access to nutritious foods can help delay or prevent the development of such illnesses.

Research shows that MTMs not only help patients better manage their conditions but also reduce hospital admissions and lower healthcare spending. Including nutrition as a part of comprehensive medical care leads to improved outcomes and prevents chronic diseases from escalating.

How do partnerships like the one between FIMC and DaVita enhance access to medically tailored nutrition, and what makes them successful?
Partnerships between FIMC and organizations such as DaVita are vital in expanding access to tailored meals and nutritional support for people with chronic illnesses. These collaborations reinforce the message that nutrition is a core element of health management.

FIMC member agencies pioneered MTM services during the HIV/AIDS epidemic four decades ago. Since then, studies—often based on these agencies’ work—have confirmed that MTMs result in better health and reduced costs. Some states have adapted their healthcare systems to include these services due to their effectiveness.

Philanthropic support, like the grant from DaVita, helps bridge service gaps. In Minneapolis, Los Angeles, and Central Florida, many patients would lack access to the necessary nutrition without these programs. These partnerships allow FIMC agencies to innovate and build responsive, community-focused programs that meet emerging health needs.

What additional components of FIMC’s programs support long-term health beyond meal delivery, and how do partners like DaVita contribute?
Beyond meal delivery, FIMC’s programs offer education, policy work, and community involvement to empower clients to make informed food choices and manage their health long-term. Partners such as DaVita play a role in identifying patients, making referrals, and contributing medical expertise.

Last year, FIMC introduced the first formal standards for medically tailored meals, reflecting its ongoing commitment to quality. Registered dietitians are crucial in this process, offering medical nutrition therapy and culturally sensitive education to support lasting health improvements.

These programs are rooted in community engagement, whether through volunteerism, local donations, or collaborative program design. Working with healthcare providers like DaVita enhances these services, creating a stronger, more integrated care system for people living with complex conditions.

What’s the future of healthcare and food as medicine partnerships like this one?
Looking ahead, continued collaboration will be essential for building a more equitable, effective healthcare system. The goal is to embed food as a standard part of medical treatment, expand access to MTMs, and drive broader policy changes.

By working together, FIMC and DaVita can promote a patient-first healthcare model that values nutrition as much as traditional medical treatments. These joint efforts not only improve health outcomes but also reduce costs, elevate community health, and give people the tools they need to live healthier lives.