Can Renal Nutrition Education Improve Adherence to a Low-Protein Diet in Patients With Stages 3 to 5 Chronic Kidney Disease?

doi:10.1053/j.jrn.2012.10.004

Journal of Renal Nutrition

Volume 23, Issue 3, May 2013, Pages 164-171

https://doi.org/10.1053/j.jrn.2012.10.004 Get rights and content

Objective

Low adherence is frequently observed in patients with chronic kidney disease (CKD) who are following a low-protein diet. We have evaluated whether a specific nutrition education program motivates patients with CKD who do not yet receive dialysis to reduce their protein intake and whether such a program improves adherence to a low-protein diet over and above standard dietary counseling.

Design and Methods

This was a randomized controlled clinical trial conducted at the CKD outpatient clinic at Pedro Ernesto University Hospital, Rio de Janeiro, Brazil.

Subjects

This study included adult patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² who were receiving conservative treatment. Participants had received their first referrals to a renal dietitian.

Intervention

Patients were randomized to a normal counseling group (individualized dietary program: 0.6 to 0.75 g protein/kg/day or 0.6 to 0.8 g/kg/day for patients with diabetes and 25 to 35 kcal/kg/day with sodium restriction) or an intense counseling group (same dietary program plus nutrition education materials). The nutrition education material included 4 different actions to improve patient knowledge and understanding of the low-protein and low-sodium diet. Both groups were followed by means of individual monthly visits to the outpatient clinic for 4 months.

Main Outcome Measure

We looked for a change in protein intake from baseline values as well as the adherence rate, assessed as a 20% decrease of the initial protein intake (by 24-hour food recall).

Results

Eighty-nine patients completed the study (normal counseling n = 46; intense counseling n = 43). The number of patients who adhered to a low-protein diet was high but did not differ between groups (in the last visit 69% vs. 48%; P = .48; intense vs. normal counseling, respectively). The reduction in protein intake from baseline values was greater for the intense counseling group compared with the normal counseling group (at the last visit, −20.7 g/day [−30.9%] vs. −10.5 g/day [−15.1%], intense vs. normal counseling, respectively; P = .04).

Conclusion

An intense nutrition education program contributed to reducing protein intake in patients with stage 3 to 5 CKD over and above our standard dietary counseling. Nutritional education programs are effective in increasing patient adherence to protein intake recommendations.

Introduction

Protein restriction is traditionally recommended for patients with chronic kidney disease (CKD) who are not yet receiving dialysis. For adults with CKD who do not have diabetes and are not receiving dialysis (CKD stages 3-5), a protein-controlled diet providing 0.6 to 0.8 g dietary protein per kg body weight per day should be prescribed, as previously described.1, 2 The benefits of lowering the protein intake to ameliorate the metabolic disturbances that arise as a consequence of loss of renal function include better control of serum bicarbonate, phosphorus, urea nitrogen, and cholesterol levels,3, 4 as well as improved insulin sensitivity and a reduction in proteinuria.5, 6, 7, 8, 9 The low-protein diet is nutritionally safe¹⁰ and capable of improving nutritional status.8, 11

An important pitfall in restricting dietary protein is low adherence. Some studies report that only 20% to 46% of patients are able to successfully adhere to a diet with 0.6 to 0.8 g of protein/kg/day.6, 11, 12 The reasons for this finding are diverse and include social and economic factors (i.e., poverty, low educational level), treatment-related factors (i.e., lack of a renal dietitian and short consultations without follow up at predialysis care), and patient-related factors (i.e., limited knowledge of the reasons behind this dietary approach and of the food sources that are rich in protein; dietary dissatisfaction and lack of self-perception of success).12, 13 It is therefore relevant to work on comprehensive nutritional strategies that enable a level of adherence acceptable for the patient and capable of yielding the benefits of lowering protein intake.¹² These strategies include the prescription of dietary plans as well as the development of educational material and behavioral changes compatible with the patient's social and cultural environment.

Studies focusing on educational strategies in patients with CKD have to date been focused on the control of fluid status and phosphorus intake in patients undergoing dialysis.14, 15 Strategies used in these studies included the use of education materials (lectures, folders, posters, handouts, puzzles, and games), as well as more practical actions such as visits to restaurants, development of cooking recipes, and motivational interviewing.14, 15, 16, 17 These studies showed improved adherence to these complex dietary regimens.

To the best of our knowledge, no study to date has evaluated the impact of education programs in reducing protein intake and improving adherence to a low-protein diet in patients with CKD who are not yet receiving dialysis. Campbell et al.¹⁰ reported that individualized nutrition counseling had a positive effect on overall nutritional status in conservatively treated patients, but the adherence to this regimen was not assessed. Therefore, in this study we hypothesized that a specifically designed nutrition education program would contribute to decreased protein intake and would improve adherence in patients with CKD who are not yet receiving dialysis over and above our standard dietary counseling.

Section snippets

Methods

This was a randomized controlled clinical trial lasting 5 ± 1.5 months (4-7 months). The local research ethical committee approved this project, and all patients provided written informed consent before their inclusion in the study. The study was conducted at the CKD outpatient clinic at Pedro Ernesto University Hospital, Rio de Janeiro, Brazil. The following enrollment criteria were applied: adult (age ≥18 years), estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², absence of

Results

Table 1 shows no significant differences at baseline between the 2 nutrition intervention groups regarding demographics and clinical characteristics. Regarding marital status, most subjects in both groups were married. The majority of patients were considered to have CKD stages 3 to 4, and hypertension was the main comorbidity observed.

Table 2 describes changes in anthropometric parameters during the study according to the 2 intervention groups. Our population was composed by a majority of

Discussion

This randomized interventional study shows that a specifically designed nutrition education program aimed at reducing protein intake was effective in patients with CKD stages 3 to 5 compared with standard dietary counseling. This study emphasizes the usefulness of dedicated education strategies to achieve patient adherence to dietary restrictions in CKD.

Since monthly visits to the outpatient clinic are not feasible in the long run in routine clinical care, educational strategies such as the one

Practical Application

Because low adherence to the protein-restricted diet remains 1 of the biggest challenges when advising patients regarding the low-protein diet, the results and conclusion presented in this study will encourage and guide renal dietitians to plan the intervention of a low-protein diet.

Acknowledgments

To Eliete Coutinho Rodrigues, the technician of the laboratory of Pedro Ernesto University, for her important contribution in all laboratory analyses performed in this study. To Anete Mecenas for her participation in the study.

References (38)

V. Rigalleau et al.
A low-protein diet improves insulin sensitivity of endogenous glucose production in predialytic uremic patients
Am J Clin Nutr
(1997)
S. Eyre et al.
Positive effects of protein restriction in patients with chronic kidney disease
J Ren Nutr
(2008)
A.S. Levey et al.
Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study
Am J Kidney Dis
(1996)
K.L. Campbell et al.
Randomized controlled trial of nutritional counseling on body composition and dietary intake in severe CKD
Am J Kidney Dis
(2008)
N.C. Milas et al.
Factors associated with adherence to the dietary protein intervention in the Modification of Diet in Renal Disease Study
J Am Diet Assoc
(1995)
D. Caldeira et al.
Educational strategies to reduce serum phosphorus in hyperphosphatemic patients with chronic kidney disease: systematic review with meta-analysis
J Ren Nutr
(2011)
S. Stark et al.
Personal digital assistant-based self-monitoring adherence rates in 2 dialysis dietary intervention pilot studies: Balance Wise-HD and Balance Wise-HD
J Ren Nutr
(2011)
T.A. Dolecek et al.
Registered dietitian time requirements in the Modification of Diet in Renal Disease Study
J Am Diet Assoc
(1995)
J.M. Conway et al.
Accuracy of dietary recall using the USDA five-step multiple-pass method in men: an observational validation study
J Am Diet Assoc
(2004)
A. Keys et al.
Indices of relative weight and obesity
J Chronic Dis
(1972)

D.A. Lipschitz

Screening for nutritional status in the elderly

Prim Care

(1994)

A.R. Frisancho

New norms of upper limb fat and muscle areas for assessment of nutritional status

Am J Clin Nutr

(1981)

M. Postorino et al.

Abdominal obesity and all-cause and cardiovascular mortality in end-stage renal disease

J Am Coll Cardiol

(2009)

M. Flesher et al.

Self-management and biomedical outcomes of a cooking, and exercise program for patients with chronic kidney disease

J Ren Nutr

(2011)

J.D. Kopple et al.

Effect of dietary protein restriction on nutritional status in the Modification of Diet in Renal Disease Study

Kidney Int

(1997)

C.M. Avesani et al.

Is energy intake underestimated in nondialyzed chronic kidney disease patients?

J Ren Nutr

(2005)

A.P. Bazanelli et al.

Underreporting of energy intake in peritoneal dialysis patients

J Ren Nutr

(2010)

American Dietetic Association

Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline

(June, 2010)

Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation

Am J Kidney Dis

(2000)

Cited by (67)

Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis
2023, Kidney Medicine
Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life.
Systematic review and meta-analysis
Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy.
Randomized controlled trials of interventions.
Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life.
A random-effects meta-analysis with evidence certainty assessed using GRADE.
Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD], −0.43 mg/dL; 95% CI, −0.74 to −0.11; P = 0.008); 24-hour albuminuria (WMD, −53 mg/24 h; 95% CI, −56 to −50; P < 0.001); systolic blood pressure (WMD, −4.5 mm Hg; 95% CI, −6.7 to −2.4; P < 0.001); diastolic blood pressure (WMD, −2.2 mm Hg; 95% CI, −3.7 to −0.8; P = 0.003); and body weight (WMD, −1.1 kg; 95% CI, −2.0 to −0.1; P = 0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9 mL/min/1.73 m²; 95% CI, −0.6 to 2.3; P = 0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life.
Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools.
Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.
Nutritional status and the risk of malnutrition in older adults with chronic kidney disease – implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN
2023, Clinical Nutrition
Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient’s preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.
New approaches in the nutritional treatment of advanced chronic kidney disease
2022, Nefrologia
El paciente con enfermedad renal crónica avanzada (ERCA) presenta una elevada prevalencia de malnutrición. Las restricciones dietéticas que aplicamos habitualmente en cuanto a macro y micronutrientes obligan a nuestros pacientes a seguir pautas dietéticas alejadas de los patrones saludables.
Determinar si un programa de intervención nutricional personalizado, minimizando las restricciones habituales estaría justificado si mejorase la evolución de la enfermedad renal comparado con el tratamiento estándar.
Determinar los cambios en las ingestas de nutrientes y en los parámetros antropométricos y bioquímicos, así como los episodios de hiperpotasemia.
Se realizó un ensayo clínico de intervención educativa, unicéntrico, randomizado y controlado en los pacientes de la consulta ERCA del Complejo Hospitalario Universitario de Albacete. Se incluyeron 75 pacientes, asignando 35 en un grupo control y 40 en el grupo de intervención con seguimiento a un año. La situación nutricional se determinó mediante datos antropométricos, composición corporal por bioimpedancia, parámetros bioquímicos en sangre y orina y cuestionario de recuerdo de 24 h. La intervención nutricional se realizó de tres formas: individual, colectiva y recuerdo telefónico.
Al inicio del estudio, el IMC mostró una situación de exceso de peso con una media en hombres de 28,83 kg/m² (5,4) y de 26,96 kg/m² (4,09) en mujeres. El 70% de nuestros pacientes mostraron exceso de peso. La circunferencia abdominal fue de 105,3 cm (10,2) y 92,3 cm (13,7) para hombres y mujeres, respectivamente, sin cambios significativos a lo largo del estudio. El porcentaje de masa grasa (MG) fue elevado tanto hombres como en mujeres durante todo el estudio. Los parámetros bioquímicos no mostraron una situación de malnutrición y solo se observaron diferencias significativas en el filtrado glomerular (FG), que aumentó en el grupo intervención. Ningún paciente presentó episodios de hiperpotasemia durante el estudio. La ingesta energética mostró una inadecuada distribución de macronutrientes en ambos grupos con una pobre ingesta de hidratos de carbono (HC), que se suple con un exceso de grasa. Para los micronutrientes sí observamos en el grupo intervención un aumento en las ingestas de potasio y fibra con una disminución de las de sodio y fósforo.
Malnutrición no es sinónimo exclusivamente de desnutrición y engloba tanto los problemas derivados del déficit como del exceso de ingesta de nutrientes. El 70% de nuestros pacientes mostraron exceso de peso y un porcentaje de masa grasa mayor del deseable. La aplicación de un programa de educación nutricional individualizado realizando una dieta rica en vegetales y fibra, menos aterogénica, no provocó alteraciones electrolíticas y supuso un enlentecimiento en la progresión de la enfermedad renal.
Patients with advanced chronic kidney disease (ACKD) have a high prevalence of malnutrition. The dietary restrictions that we usually apply in terms of macro and micronutrients force our patients to follow dietary guidelines that deviate from healthy patterns.
To determine if a personalized nutritional intervention program, minimizing the usual restrictions would be justified in case it improved the evolution of kidney disease compared to standard treatment.
To determine changes in nutrient intakes and in anthropometric and biochemical parameters, as well as quantify episodes of hyperkalemia.
A single-center, randomized and controlled educational intervention clinical trial was conduct in patients from the ERCA outpatients clinic at the Complejo Hospitalario Universitario de Albacete. 75 patients were included, assigning 35 to a Control group and 40 to the Intervention group with 1-year follow-up. The nutritional status was determined using anthropometric data, body composition by Bioimpedance, blood and urine biochemical parameters and a 24-h recall questionnaire. The nutritional intervention was carried out in three different ways: individual, collective and telephone recall.
At the beginning of the study, the BMI showed a situation of weight excess with a mean of 28.83 kg/m² (5.4) in men and 26.96 kg/m² (4.09) in women. 70% of our patients had overweight. The abdominal circumference was 105.3 cm (10.2) and 92.3 cm (13.7) for men and women respectively without significant changes throughout the study. The percentage of fat mass (FM) was high in both groups for men and women throughout the study. We did not find biochemical parameters of malnutrition and only significant differences were observed in glomerular filtration rate (GFR), which increased in the intervention group. No patient presented any episodes of hyperkalemia during the study. The energy intake in both groups showed an inadequate distribution of macronutrients with a poor intake of carbohydrates (CH) that was supplemented with an excess of fat. In the case of micronutrients, we did observe an increase in potassium and fiber intakes with a decrease in sodium and phosphorus in the intervention group.
Malnutrition is not exclusively an intake deficit and encompasses both the problems derived from a deficit and an excess of nutrients intake. Un to 70% of our patients showed weight excess and a fat mass higher than desirable. The implementation of an individualized nutritional education program, including a vegetables and fiber rich diet, less atherogenic, not only did not cause electrolyte alterations but also slowed the progression of kidney disease.
No additional benefit of prescribing a very low-protein diet in patients with advanced chronic kidney disease under regular nephrology care: a pragmatic, randomized, controlled trial
2022, American Journal of Clinical Nutrition
Whether a very low-protein diet supplemented with ketoanalogues (sVLPD), compared with a standard low-protein diet (LPD), improves outcomes in patients with chronic kidney disease (CKD) under stable nephrology care is undefined.
To compare the effectiveness of sVLPD compared with LPD in patients regularly seen in tertiary nephrology care.
Participants were patients with CKD stages 4–5, followed for at least 6 mo, randomly allocated to receive sVLPD or LPD [0.35 or 0.60 g/kg ideal body weight (IBW)/d, respectively], stratified by center and CKD stage. The primary outcome was time to renal death, defined as the first event between end-stage renal disease (ESRD) and all-cause mortality; secondary outcomes were the single components of the primary outcome, cardiovascular outcome, and nutritional status.
We analyzed 223 patients (sVLPD, n = 107; LPD, n = 116). Mean age was 64 y, 61% were male, and 35% had diabetes. Median protein intake (PI), which was 0.8 g/kg IBW/d at baseline in both groups, was 0.83 and 0.60 g/kg IBW/d in LPD and sVLPD, respectively, during the trial with a large decrease only in sVLPD (P = 0.011). During a median of 74.2 mo, we recorded 180 renal deaths (141 dialysis and 39 deaths before dialysis). Risk of renal death did not differ in sVLPD compared with LPD (HR: 1.17; 95% CI: 0.88, 1.57; P = 0.28). No difference was observed for ESRD (HR: 1.12; 95% CI: 0.81, 1.56; P = 0.51), mortality (HR: 0.95; 95% CI: 0.62, 1.45; P = 0.82), or time to fatal/nonfatal cardiovascular events (P = 0.2, log-rank test). After 36 mo, still active patients were 45 in sVLPD and 56 in LPD. No change of nutritional status emerged during the study in any arm.
This long-term pragmatic trial found that in patients with CKD under stable nephrology care, adherence to protein restriction is low. Prescribing sVLPD compared with standard LPD is safe but does not provide additional advantage to the kidney or patient survival.
Food as medicine? Exploring the impact of providing healthy foods on adherence and clinical and economic outcomes
2022, Exploratory Research in Clinical and Social Pharmacy
Chronic disease prevalence is increasing. Adherence to dietary guidelines is low (<50%) despite positive impacts in disease progression, clinical outcomes, and medical costs. It is important to summarize the impact of providing medically-tailored meals to patients on adherence rates, clinical outcomes, and potential economic outcomes.
A systematic review was conducted to identify, extract, and appraise food-provision studies from January 1, 2013-May 1, 2018 for heart disease, diabetes (DM), and chronic kidney disease (CKD). The key findings related to adherence and clinical outcomes were compiled. Published literature was utilized to determine the economic impact of key clinical outcomes.
Across diseases, 100 articles (N = 43,175 patients) were included. Dietary adherence was considered “compliant” or ≥ 90% consistently. Significant (p < 0.05) clinical outcomes included 5–10% LDL reduction, 4-11 mmHg SBP reduction, 30% reduction in metabolic syndrome prevalence, 3–5% weight reduction, 56% lower CKD mortality rates, and increased dialysis-free time (2 years:50%, 5 years:25%, calculated cost savings of 80.6–94.3%). Literature review showed these outcomes would result in decreased: cardiovascular (CV) event risk (20–30% reduction: $5–11 billion annually), hospitalization costs ($1–8 billion), and dialysis rates (25–50% reduction: $14–29 billion annually). For heart failure patients, results include: 16% fewer readmissions (saving $234,096 per 100 patients) and a 38-day shorter length of stay (saving $79,425 per hospitalization).
Providing medically-tailored meals significantly increases dietary adherence above 90% and allows patients to realize significantly better chronic disease control. Through this, patients could experience fewer complications (CV events, hospital readmissions and dialysis), resulting in significant annual US healthcare cost reduction of $27–48 billion.
Global Renal Internet Course for Dietitians (GRID Course)
2022, Journal of Renal Nutrition

View all citing articles on Scopus

: Funding Support: J.J.C. acknowledges grant support from the Swedish Medical Research Council. The other authors declare that they have no relevant financial interests.

View full text

Original ResearchCan Renal Nutrition Education Improve Adherence to a Low-Protein Diet in Patients With Stages 3 to 5 Chronic Kidney Disease?

Objective

Design and Methods

Subjects

Intervention

Main Outcome Measure

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Practical Application

Acknowledgments

Am J Clin Nutr

J Ren Nutr

Am J Kidney Dis

Am J Kidney Dis

J Am Diet Assoc

J Ren Nutr

J Ren Nutr

J Am Diet Assoc

J Am Diet Assoc

J Chronic Dis

Prim Care

Am J Clin Nutr

J Am Coll Cardiol

J Ren Nutr

Kidney Int

J Ren Nutr

J Ren Nutr

Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline

Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation

Am J Kidney Dis

Original Research
Can Renal Nutrition Education Improve Adherence to a Low-Protein Diet in Patients With Stages 3 to 5 Chronic Kidney Disease?