Paes-Barreto JG, Barreto Silva MI, Qureshi AR, Bregman R, Cervante VF, Carrero JJ, Avesani CM.

J Ren Nutr

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 m(2) 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.

Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Link to abstract

V. Bellizzi, G. Bedogni, G. Quintaliani

Giornale italiano di nefrologia

Direct evaluation of the compliance with nutritional therapy is possible only in clinical trials while indirect methods such as self-reporting and interviews are used in clinical practice. Dietary history is the best method to evaluate nutritional habits in clinical practice; the same holds true for the compliance with low-protein diets in patients with chronic kidney disease.

Other indexes to assess dietary compliance should be simple and easy to use in the clinical practice. Some of such functional and biological markers are blood urea nitrogen and serum phosphate levels (indirect markers of dietary intake), weight and body mass index (indirect markers of energy intake), and daily urinary excretion of nitrogen and sodium (indirect markers of protein and salt intake). The compliance with a low-protein diet in patients with chronic kidney disease is strongly influenced by psychosocial factors (e.g., satisfaction and comprehension), and thus by the supporting role of the physician and the dietitian, but also by the level of renal function and food characteristics. It must be pointed out that even a protein intake reduction of 0.2 g/kg/day improves blood urea nitrogen, phosphate levels, and acidosis.

Link to abstract