Exploring Problems in Following the Hemodialysis Diet and Their Relation to Energy and Nutrient Intakes: The BalanceWise Study

Abstract

Objective To identify the problems experienced by hemodialysis (HD) patients in attempting to follow the HD diet, and their relation to energy and nutrient intakes. Design Cross-sectional analysis of baseline data from the BalanceWise Study. Setting Community-dwelling adults recruited from outpatient HD centers. Subjects After excluding participants with incomplete dietary analyses (n = 50), 140 community-dwelling African American and white (40/60%) men and women (52/48%) on chronic intermittent HD for at least three months (median three years) were included. Intervention Participant responses, on a 5-point Likert scale ranging from “not at all a problem” to “a very important problem for me”, to 34 questions pertaining to potential barriers to following the HD diet in the previous two months were classified as either a problem (1) or not a problem (2–5). Main Outcome Measure Energy and nutrient intakes determined using the Nutrition Data System for Research® based on three, non-consecutive, unscheduled, two-pass 24-hour dietary recalls collected on one dialysis and one non-dialysis weekday, and one non-dialysis weekend day. Results More than half of participants reported having problems related to specific behavioral factors (e.g., feeling deprived), technical difficulties (e.g., tracking nutrients) and physical condition (e.g., appetite), but issues of time and food preparation, and behavioral factors tended to be most deterministic of reported dietary intakes. Longer duration of HD was associated with lower intakes of protein, potassium, and phosphorus (p <0.05). Conclusion Registered dietitian nutritionists should consider issues of time and food preparation, and behavioral factors in their nutrition assessment of HD patients, and should continually monitor HD patients for changes in protein intake that may occur over time.

Nutrient Non-equivalence: Does Restricting High-Potassium Plant Foods Help to Prevent Hyperkalemia in Hemodialysis Patients?

“…replacing tomatoes in spaghetti or chili), and the vigilance required to follow the many components of the renal diet (low-salt, low-phosphorus, low-potassium, high-protein), may overwhelm patients causing them to either give up, or to adopt a very simple diet from which they derive little pleasure or nutrition. When asked about factors that make adherence to the HD diet difficult (rated ≥3 on a 5-point Likert scale), many BalanceWise participants reported that the diet is bland and tasteless (59/140) and too complicated (49/139), and that it is hard to keep track of nutrient intakes (64/140) 49 . In addition to potentially impairing nutrition status and quality of life 50 , advising HD patients to limit or avoid many plant-based foods, especially fruits and vegetables, may contribute to adverse metabolic states (e.g., oxidative stress, inflammation, metabolic acidosis, dyslipidemias) and conditions (e.g., constipation, hypertension) that negatively impact the health of HD patients.…”

Reexamining the Phosphorus–Protein Dilemma: Does Phosphorus Restriction Compromise Protein Status?

“…Further, choosing foods prepared without phosphorus additives may increase food costs by ~$2.00/day 20 . While cost may not be a deterrent for some patients, roughly one-third of HD patients in the BalanceWise study reported that their income did not meet their needs (32%), and/or that they had difficulty affording a healthy diet in the previous two months (39%) 24 .…”

“…As an added benefit, this approach limits commercially-prepared foods, which tend to be high in sodium 21,23,26 , and wet cooking methods also help remove potassium from foods 27 . Unfortunately, preparing meals from scratch is not the cultural norm in many regions facing high incidence rates of CKD, and may be difficult to sustain, particularly given that most HD patients report being too tired to cook (59%) 24 .…”

“…Indeed, when vegetarian and meat diets containing equal amounts of phosphorus and protein were compared in patients with stage 3–4 CKD, serum phosphorus and fibroblast growth factor-23 concentrations were lower after consuming the vegetarian diet. 30 Importantly, too many substitutions may become overwhelming, as many HD patients report difficulty keeping track of nutrients (56%), uncertainty about foods they should be eating (26%), and problems with finding the dialysis diet too complicated (49%) 24 …”

Diet for the Management of Patients With Chronic Kidney Disease; It Is Not the Quantity, but the Quality That Matters

“…It should come as no surprise that the quality of the diet of CKD patients is suboptimal. [1][2][3][4] This may be explained by a myriad of factors, including financial and social barriers often linked to CKD, an emphasis on restriction of sodium, potassium, and phosphorous at the expense of compromising overall diet quality, [5][6][7] and simply global dietary changes toward western diets, with convenience, fast, and ultra-processed foods. In the recent years, through observational studies, we are learning that dietary quality may also influence the fate of patients with CKD.…”