Nutrition Education Models for Patients With Chronic Kidney Disease.

Nutrition is an integral component in the management of chronic kidney disease (CKD), and kidney health professionals play a crucial role in educating patients on dietary interventions for CKD. Several dietary modifications are indicated for CKD that require frequent adaptations with CKD progression and with underlying metabolic disturbances. However, poor adherence to dietary interventions is not uncommon among patients with CKD. An effective education program on nutrition intervention consists of providing knowledge and developing skills that are necessary to support behavioral change. The application of theoretical models of behavioral change such as social cognitive theory and the transtheoretical model in nutrition intervention has been reported to be effective in promoting changes in dietary habits. This review summarizes the evidence supporting the application of theoretical models as strategies to enhance nutrition education for patients with CKD. In addition, digital technologies are gaining interest in empowering patients and facilitating nutrition management in patients with CKD. This review also examines the applications of the latest digital technologies guided by behavioral theory in facilitating patients' changes in dietary intake patterns and lifestyle habits.

Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients.

OBJECTIVES: The nutritional adequacy of both animal-based and plant-based low protein diets (LPDs) and moderate protein diets that are recommended for patients with chronic kidney disease have not been well examined. We therefore analyzed the nutrient content of three representative LPDs and moderate protein diets (lacto-ovo vegetarian, omnivorous, and vegan) containing foods that are likely to be prescribed for nondialyzed chronic kidney disease or chronic dialysis patients in the United States to determine the nutritional adequacy at different levels of protein intake. METHODS: Theoretical 3-day menus were developed as per current renal dietary guidelines to model each diet at 7 different levels of protein intake (0.5-1.2 g/kilograms body weight/day [g/kg/d]). The diets were analyzed for their content of essential amino acids (EAAs) and other essential nutrients. RESULTS: At an a priori recognized inadequate dietary protein level of 0.5 g/kg/d, all 3 diets failed to meet the Recommended Dietary Allowances (RDAs) for the following EAAs: histidine, leucine, lysine, and threonine. The omnivorous LPD met both the RDA and Estimated Average Requirement at levels of 0.6 g protein/kg/d or more. The lacto-ovo and vegan diets at 0.6 and 0.8 g protein/kg/d, respectively, were below the RDA for lysine. The amounts of several other vitamins and minerals were not uncommonly reduced below the RDA or Adequate Intake with all 3 LPDs. CONCLUSION: In comparison to omnivorous LPDs, both vegan and lacto-ovo LPDs are more likely to be deficient in several EAAs and other essential nutrients. To provide sufficient amounts of all EAA, vegan and lacto-ovo LPDs must be carefully planned to include adequate amounts of appropriate dietary sources. Supplements of some other essential nutrients may be necessary with all three LPDs.

Nutritional Adequacy of Animal-Based and Plant-Based Asian Diets for Chronic Kidney Disease Patients: A Modeling Study.

Plant-based low protein diets (LPDs) have gained popularity for managing chronic kidney disease (CKD) patients. The nutritional adequacy of these and other LPDs prescribed for CKD patients have not been carefully examined. This study assessed the nutrient composition of such LPDs and moderately high protein diets (MHPDs) that might be prescribed for patients in the Asia Pacific region with CKD who are not dialyzed or undergoing maintenance dialysis. Conventional diets containing at least 50% animal-based proteins and plant-based diets were also planned with protein prescriptions of 0.5 to 0.8 g/kg/day and MHPDs with protein prescriptions of 1.0 to 1.2 g/kg/day. Plant-based, lacto-, ovo-, and lacto-ovo-vegetarian and vegan LPDs and MHPDs were planned by replacing some or all of the animal proteins from the conventional diet. With 0.5 g protein/kg/day, all diets were below the Recommended Dietary Allowances (RDA) for at least one essential amino acid (EAA). At a protein prescription of 0.6 g/kg/day, only the conventional LPD met the RDA for all EAAs. This deficiency with the plant-based LPDs persisted even with several plant food substitutions. With a protein prescription ≥0.7 g/kg/day, all the plant-based and vegetarian LPDs provided the RDA for all EAA. The plant-based and vegetarian diets also contained relatively greater potassium, phosphorus, and calcium content but lower long-chain n-3 polyunsaturated fatty acids and vitamin B-12 than the conventional diet. Other essential micronutrients were commonly below the RDA even at higher protein intakes. The low contents of some essential micronutrients were found in both animal-based and plant-based diets. Prescription of all LPDs for CKD patients, especially plant-based and vegetarian LPDs, requires careful planning to ensure the adequacy of all nutrients, particularly essential amino acids. Consideration should be given to supplementing all animal-based and plant-based LPDs and MHPDs with multivitamins and certain trace elements.

Effects of tocotrienols supplementation on markers of inflammation and oxidative stress: A systematic review and meta-analysis of randomized controlled trials.

Studies investigating the effects of tocotrienols on inflammation and oxidative stress have yielded inconsistent results. This systematic review and meta-analysis aimed to evaluate the effects of tocotrienols supplementation on inflammatory and oxidative stress biomarkers. We searched PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception until 13 July 2020 to identify randomized controlled trials supplementing tocotrienols and reporting circulating inflammatory or oxidative stress outcomes. Weighted mean difference (WMD) and corresponding 95% confidence interval (CI) were determined by pooling eligible studies. Nineteen studies were included for qualitative analysis, and 13 studies were included for the meta-analyses. A significant reduction in C-reactive protein levels (WMD: -0.52 mg/L, 95% CI: -0.73, -0.32, p < 0.001) following tocotrienols supplementation was observed, but this finding was attributed to a single study using δ-tocotrienols, not mixed tocotrienols. There were no effects on interleukin-6 (WMD: 0.03 pg/mL, 95% CI: -1.51, 1.58, p = 0.966), tumor necrosis factor-alpha (WMD: -0.28 pg/mL, 95% CI: -1.24, 0.68, p = 0.571), and malondialdehyde (WMD: -0.42 µmol/L, 95% CI: -1.05, 0.21, p = 0.189). A subgroup analysis suggested that tocotrienols at 400 mg/day might reduce malondialdehyde levels (WMD: -0.90 µmol/L, 95% CI: -1.20, -0.59, p < 0.001). Future well-designed studies are warranted to confirm the effects of tocotrienols on inflammatory and oxidative stress biomarkers, particularly on different types and dosages of supplementation. PROSPERO registration number: CRD42020198241.

Circulating fatty acid profiles are associated with protein energy wasting in maintenance hemodialysis patients: a cross-sectional study.

The metabolic impact of circulating fatty acids (FAs) in patients requiring hemodialysis (HD) is unknown. We investigated the associations between plasma triglyceride (TG) FAs and markers of inflammation, insulin resistance, nutritional status and body composition. Plasma TG-FAs were measured using gas chromatography in 341 patients on HD (age = 55.2 ± 14.0 years and 54.3% males). Cross-sectional associations of TG-FAs with 13 markers were examined using multivariate linear regression adjusted for potential confounders. Higher levels of TG saturated fatty acids were associated with greater body mass index (BMI, r = 0.230), waist circumference (r = 0.203), triceps skinfold (r = 0.197), fat tissue index (r = 0.150), serum insulin (r = 0.280), and homeostatic model assessment of insulin resistance (r = 0.276), but lower malnutrition inflammation score (MIS, r = - 0.160). Greater TG monounsaturated fatty acid levels were associated with lower lean tissue index (r = - 0.197) and serum albumin (r = - 0.188), but higher MIS (r = 0.176). Higher levels of TG n-3 polyunsaturated fatty acids (PUFAs) were associated with lower MIS (r = - 0.168) and interleukin-6 concentrations (r = - 0.115). Higher levels of TG n-6 PUFAs were associated with lower BMI (r = - 0.149) but greater serum albumin (r = 0.112). In conclusion, TG monounsaturated fatty acids were associated with poor nutritional status, while TG n-3 PUFAs were associated with good nutritional status. On the other hand, TG saturated fatty acids and TG n-6 PUFAs had both favorable and unfavorable associations with nutritional parameters.

Association of dietary patterns with serum phosphorus in maintenance haemodialysis patients: a cross-sectional study.

Sources of dietary phosphate differentially contribute to hyperphosphatemia in maintenance haemodialysis (MHD) patients. This cross-sectional study in Malaysia investigated association between dietary patterns and serum phosphorus in MHD patients. Dietary patterns were derived by principal component analysis, based on 27 food groups shortlisted from 3-day dietary recalls of 435 MHD patients. Associations of serum phosphorus were examined with identified dietary patterns. Three dietary patterns emerged: Home foods (HFdp), Sugar-sweetened beverages (SSBdp), and Eating out noodles (EO-Ndp). The highest tertile of patients in HF (T3-HFdp) pattern significantly associated with higher intakes of total protein (p = 0.002), animal protein (p = 0.001), and animal-based organic phosphate (p < 0.001), whilst T3-SSBdp patients had significantly higher intakes of total energy (p < 0.001), inorganic phosphate (p < 0.001), and phosphate:protein ratio (p = 0.001). T3-EO-Ndp patients had significantly higher intakes of total energy (p = 0.033), total protein (p = 0.003), plant protein (p < 0.001), but lower phosphate:protein ratio (p = 0.009). T3-SSBdp patients had significantly higher serum phosphorus (p = 0.006). The odds ratio of serum phosphorous > 2.00 mmol/l was significantly 2.35 times higher (p = 0.005) with the T3-SSBdp. The SSBdp was associated with greater consumption of inorganic phosphate and higher serum phosphorus levels.

Dietary fatty acid intake in hemodialysis patients and associations with circulating fatty acid profiles: A cross-sectional study.

OBJECTIVES: The aims of this study were threefold: first, to assess the dietary fatty acid (FA) intake and blood FA status in Malaysian patients on hemodialysis (HD); second, to examine the association between dietary FA intakes and blood FA profiles in patients on HD; and third, to determine whether blood FAs could serve as a biomarker of dietary fat intake quality in these patients. METHODS: Using 3 d of dietary records, FA intakes of 333 recruited patients were calculated using a food database built from laboratory analyses of commonly consumed Malaysian foods. Plasma triacylglycerol (TG) and erythrocyte FAs were determined by gas chromatography. RESULTS: High dietary saturated fatty acid (SFA) and monounsaturated fatty acid (MUFA) consumption trends were observed. Patients on HD also reported low dietary ω-3 and ω-6 polyunsaturated fatty acid (PUFA) consumptions and low levels of TG and erythrocyte FAs. TG and dietary FAs were significantly associated respective to total PUFA, total ω-6 PUFA, 18:2 ω-6, total ω-3 PUFA, 18:3 ω-3, 22:6 ω-3, and trans 18:2 isomers (P < 0.05). Contrarily, only dietary total ω-3 PUFA and 22:6 ω-3 were significantly associated with erythrocyte FAs (P < 0.01). The highest tertile of fish and shellfish consumption reflected a significantly higher proportion of TG 22:6 ω-3. Dietary SFAs were directly associated with TG and erythrocyte MUFA, whereas dietary PUFAs were not. CONCLUSION: TG and erythrocyte FAs serve as biomarkers of dietary PUFA intake in patients on HD. Elevation of circulating MUFA may be attributed to inadequate intake of PUFAs.

Blood Fatty Acid Status and Clinical Outcomes in Dialysis Patients: A Systematic Review.

Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP.

Clinical efficacy and feasibility of whey protein isolates supplementation in malnourished peritoneal dialysis patients: A multicenter, parallel, open-label randomized controlled trial.

BACKGROUND AND AIMS: Poor dietary intake is commonly associated with malnutrition in the dialysis population and oral nutritional supplementation is strategized to redress dietary inadequacy. Knowledge on clinical efficacy of whey protein supplementation (WPS) as an option to treat malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients is limited. METHODS: This multicenter, parallel, open-label, randomized controlled trial investigated the clinical efficacy of WPS in 126 malnourished CAPD patients with serum albumin <40 g/L and body mass index (BMI) <24 kg/m2. Patients randomized to the intervention group (IG, n = 65) received protein powder (27.4 g) for 6 months plus dietary counseling (DC) while the control group (CG, n = 61) received DC only. Anthropometry, biochemistry, malnutrition-inflammation-score (MIS), dietary intake inclusive of dialysate calories, handgrip strength (HGS) and quality of life (QOL) were assessed at baseline and 6 months. Clinical outcomes were assessed by effect size (Cohen's d) comparisons within and between groups. RESULTS: Seventy-four patients (n = 37 per group) completed the study. Significantly more IG patients (59.5%) achieved dietary protein intake (DPI) adequacy of 1.2 g/kg per ideal body weight (p < 0.001) compared to CG (16.2%) although difference in the adequacy of dietary energy intake between groups was non-significant (p > 0.05). A higher DPI paralleled significant increases in serum urea (mean Δ: IG = +2.39 ± 4.36 mmol/L, p = 0.002, d = 0.57 vs CG = -0.39 ± 4.59 mmol/L, p > 0.05, d = 0.07) and normalized protein catabolic rate, nPCR (mean Δ: IG = +0.11 ± 0.14 g/kg/day, p < 0.001, d = 0.63 vs CG = +0.001 ± 0.17 g/kg/day, p > 0.05, d = 0.09) for IG compared to CG patients. Although not significant, comparison for changes in post-dialysis weight (mean Δ: +0.64 ± 1.16 kg vs +0.02 ± 1.36 kg, p = 0.076, d = 0.58) and mid-arm circumference (mean Δ: +0.29 ± 0.93 cm vs -0.12 ± 0.71 cm, p = 0.079, d = 0.24) indicated trends favoring IG vs CG. Other parameters remained unaffected by treatment comparisons. CG patients had a significant decline in QOL physical component (mean Δ = -6.62 ± 16.63, p = 0.020, d = 0.47). Using changes in nPCR level as a marker of WPS intake within IG, 'positive responders' achieved significant improvement in weight, BMI, skinfold measures and serum urea (all p < 0.05), while such changes within 'negative responders' were non-significant (all p > 0.05). CONCLUSION: A single macronutrient approach with WPS in malnourished CAPD patients was shown to achieve DPI adequacy and improvements in weight, BMI, skin fold measures, serum urea and nPCR level. CLINICAL TRIAL REGISTRY: www.clinicaltrials.gov (NCT03367000).

Efficacy of Nutritional Interventions on Inflammatory Markers in Haemodialysis Patients: A Systematic Review and Limited Meta-Analysis.

Low-grade chronic inflammation is prevalent in patients undergoing haemodialysis (HD) treatment and is linked to the development of premature atherosclerosis and mortality. The non-pharmacological approach to treat inflammation in HD patients through nutritional intervention is well cited. We aimed to assess the efficacy of different nutritional interventions at improving inflammatory outcomes in HD patients, based on markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α). We searched PubMed, Cochrane Library, and Embase for randomized controlled trials (RCT) published before June 2017. Inclusion criteria included RCTs on adult patients on maintenance HD treatment with duration of nutritional interventions for a minimum 4 weeks. Risk of bias was assessed using the Jadad score. In total, 46 RCTs experimenting different nutritional interventions were included in the review and categorized into polyphenols rich foods, omega-3 fatty acids, antioxidants, vitamin D, fibres, and probiotics. Meta-analyses indicated significant reduction in CRP levels by omega-3 fatty acids (Random model effect: -0.667 mg/L, p < 0.001) and vitamin E (fixed model effect: -0.257 mg/L, p = 0.005). Evidence for other groups of nutritional interventions was inconclusive. In conclusion, our meta-analysis provided evidence that omega-3 fatty acids and vitamin E could improve inflammatory outcomes in HD patients.