A Survey on Nutrition Labeling for Sodium, Potassium, and Phosphorus of Packaged Food and Beverages.

OBJECTIVES: Nutrition labeling is important to guide patients with chronic kidney disease to make informed choices. This study aimed to evaluate the extent and accessibility of nutrition labeling for sodium, potassium, and phosphorus on food and beverage products in a supermarket. METHODS: A cross-sectional survey was conducted in a Malaysian supermarket. Information on sodium, potassium, and phosphorus contents was collected from the nutrition fact panel, while information on food additives containing sodium, potassium, and phosphorus was collected from the ingredient list. RESULTS: The survey included 2,577 foods and beverages, and 79.4% of the products included sodium information in nutrition fact panels, but only 11.7% and 2.0% disclosed potassium and phosphorus content, respectively. Sodium-containing additives were found in 78.6% of products; potassium- and phosphorus-containing additives were reported in 28.5% and 46.9% of products, respectively. Sodium-containing additives were typically listed as "salt," potassium-containing additives as "alternative names," and phosphorus-containing additives as "starch" and "E numbers." Imported products were more likely to include sodium (P < .001) and phosphorus (p = .036) contents, while more locally manufactured products reported sodium- (p = .003) and phosphorus- (P = .004) containing additives. CONCLUSION: There is limited availability of potassium and phosphorus information on nutrition labels in Malaysia food and beverage products, which presents significant challenges for individuals with chronic kidney disease in choosing appropriate products for their dietary needs.

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.

Are Digital Health Technologies and Models of Nutrition Care the Future of Chronic Kidney Disease Management?

People living with chronic kidney disease (CKD) require long-term support at varying levels of individualization, intensity, and frequency. Mobile and digital models of nutrition care can facilitate long-term behavior change, address nutrition issues proactively, reduce travel burden, and reach people without access to health care more easily. However, while traditional health delivery continues to be digitally disrupted, there are many barriers to address before mobile and digitally supported models of nutrition care can become business as usual in nephrology and nutrition care practice. This paper overviews the current evidence base concerning the past and present mobile and digital health programs to improve nutrition in CKD and highlights the novel future trends in this field. The way nutrition and dietetic care can be feasible, safe, and potentially effective when delivered using various digital and virtual technologies, including consultations, assessments, establishment of diagnoses, formulation of plans, and monitoring/reviewing clinical progress is discussed. Of the available evidence to date, these modalities appear to improve dietary sodium intake and diet quality, self-efficacy, interdialytic weight gain, and body weight. Many barriers exist to sustaining the continued and widespread adoption of digital and mobile health-supported nutrition care in CKD. These include patient-, clinician-, and health system-specific and are discussed in detail. Mobile and digital-supported models of nutrition care present an exciting opportunity to assist kidney dietitians deliver patient-centred nutrition care in CKD.

Identifying Challenges and Potential Solutions for Sustainable Kidney Nutrition Care Delivery in Selected Asian Countries.

BACKGROUND: Recent surveys highlight gross workforce shortage of dietitians in global kidney health and significant gaps in renal nutrition care, with disparities greater in low/low-middle income countries. OBJECTIVE: This paper narrates ground experiences gained through the Palm Tocotrienols in Chronic Hemodialysis (PaTCH) project on kidney nutrition care scenarios and some Asian low-to-middle-income countries namely Bangladesh, India, and Malaysia. METHOD: Core PaTCH investigators from 3 universities (USA and Malaysia) were supported by their postgraduate students (n = 17) with capacity skills in kidney nutrition care methodology and processes. This core team, in turn, built capacity for partnering hospitals as countries differed in their ability to deliver dietitian-related activities for dialysis patients. RESULTS: We performed a structural component analyses of PaTCH affiliated and nonaffiliated (Myanmar and Indonesia) countries to identify challenges to kidney nutrition care. Deficits in patient-centered care, empowerment processes and moderating factors to nutrition care optimization characterized country comparisons. Underscoring these factors were some countries lacked trained dietitians whilst for others generalist dietitians or nonclinical nutritionists were providing patient care. Resolution of some challenges in low-to-middle-income countries through coalition networking to facilitate interprofessional collaboration and task sharing is described. CONCLUSIONS: We perceive interprofessional collaboration is the way forward to fill gaps in essential dietitian services and regional-based institutional coalitions will facilitate culture-sensitive capacity in building skills. For the long-term an advanced renal nutrition course such as the Global Renal Internet Course for Dietitians is vital to facilitate sustainable kidney nutrition care.

New Insights Into Dietary Approaches to Potassium Management in Chronic Kidney Disease.

Potassium disorders are one of the most common electrolyte abnormalities in patients with chronic kidney disease (CKD), contributing to poor clinical outcomes. Maintaining serum potassium levels within the physiologically normal range is critically important in these patients. Dietary potassium restriction has long been considered a core strategy for the management of chronic hyperkalemia in patients with CKD. However, this has been challenged by recent evidence suggesting a paradigm shift toward fostering more liberalized, plant-based dietary patterns. The advent of novel potassium binders and an improved understanding of gastrointestinal processes involved in potassium homeostasis (e.g., gastrointestinal potassium wasting) may facilitate a paradigm shift and incorporation of heart-healthy potassium-enriched food sources. Nevertheless, uncertainty regarding the risk-benefit of plant-based diets in the context of potassium management in CKD remains, requiring well-designed clinical trials to determine the efficacy of dietary potassium manipulation toward improvement of clinical outcomes in patients with CKD.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status.

PURPOSE: To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients. METHOD: Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model. RESULTS: MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024). CONCLUSION: Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m2, better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

Benchmarking Diet Quality to Assess Nutritional Risk in Hemodialysis Patients: Applying Adequacy and Moderation Metrics of the Hemodialysis-Healthy Eating Index.

OBJECTIVES: This study modified Healthy Eating Index (HEI) based on hemodialysis (HD)-specific nutritional guidelines and investigated associations between the diet quality (DQ) and nutritional risk in HD patients. METHODS: The HD-HEI tool adapted the Malaysian Dietary Guidelines 2010 framework according to HD-specific nutrition guidelines. This HD-HEI was applied to 3-day dietary records of 382 HD patients. Relationships between HD-HEI scores and nutritional parameters were tested by partial correlations. Binary logistic regression models adjusted with confounders were used to determine adjusted odds ratio (adjOR) with 95% confidence interval (CI) for nutritional risk based on HD-HEI scores categorization. RESULTS: The total HD-HEI score (51.3 ± 10.2) for this HD patient population was affected by ethnicity (Ptrend < .001) and sex (P = .003). No patient achieved "good" DQ (score: 81-100), while DQ of 54.5% patients were classified as "needs improvement" (score: 51-80) and remaining as "poor" (score: 0-51). Total HD-HEI scores were positively associated with dietary energy intake (DEI), dietary protein intake (DPI), dry weight, and handgrip strength, but inversely associated with Dietary Monotony Index (DMI) (all P < .05). Individually, scores for refined grain, total protein, and animal protein were positively associated with DEI (all P < .05), while total, animal, fish, and vegetable proteins indicated positive associations with DPI (all P < .05). Moderating metrics for convenience meals, saturated fats, sodium, and fluid negatively correlated toward DEI with similar trends for DPI excepting convenience meals and fluids. "Poor" DQ was associated with DMI ≥ 29.2 (adjOR 18.83, 95% CI 9.36-37.86, P < .001), Malnutrition Inflammation Score ≥ 5 (adjOR 1.78, 95% CI 1.01-3.15, P = .045), and protein energy wasting (adjOR 1.96, 95% CI 1.14-3.34, P = .031), but became nullified with covariate adjustments. "Poor" DQ was also associated with low lean tissue mass (<32.6 kg) in men (adjOR 2.38, 95% CI 1.01-5.58, P = .046) but not women. CONCLUSION: "Poor" DQ was associated with poor nutritional status in Malaysian HD patients, who should be targeted for nutritional counseling.

Habitual Dietary Patterns of Patients on Hemodialysis Indicate Nutritional Risk.

OBJECTIVE: This study aimed to (i) determine habitual dietary patterns of Malaysian patients on hemodialysis (HD) and (ii) examine their association with nutritional status. METHODS: An à posteriori approach examined 3-day dietary recalls of 382 multiethnic Malaysian patients on HD, leading to short-listing of 31 food groups. Dietary patterns were derived through principal component analysis. Sociodemographic and lifestyle characteristics together with nutritional parameters were examined for associations with specific dietary patterns. RESULTS: Four dietary patterns emerged, namely, "Home Food," "Eating Out (EO)-Rice," "EO-Sugar sweetened beverages," and "EO-Noodle." Younger patients, male gender, Malay, and patients with working status were more likely to follow "EO-Rice" and "EO-Sugar sweetened beverages" patterns, while Chinese patients were more likely to consume "EO-Noodle" pattern (all P values < .05). The EO frequency was directly associated with "EO-Rice" (P = .030), "EO-Sugar sweetened beverages" (P = .040), and "EO-Noodle" (P = .001) patterns. The highest tertile of the "Home Food" pattern related to higher handgrip strength (T3 = 21.3 ± 0.74 vs. 18.0 ± 0.73 kg, P = .006), higher serum albumin (T3 = 3.99 ± 0.04 vs. T1 = 3.84 ± 0.04 g/dL, P = .027), and lower Malnutrition-Inflammation Score (T3 = 4.9 ± 0.36 vs. T1 = 6.4 ± 0.34, P = .010), along with lower Diet Monotony Index (T3 = 29.0 ± 1.1 vs. T1 = 33.0 ± 1.0, P = .030). while "EO-Rice" and "EO-Sugar sweetened beverage" patterns were associated only with higher energy intake (all P values < .001). CONCLUSIONS: These results indicated that a home-based diet inclusive of healthy food choices was associated with better nutritional status in this HD population.

The state of nutrition care in outpatient hemodialysis settings in Malaysia: a nationwide survey.

BACKGROUND: This study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients' outcomes. METHODS: A 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector. RESULTS: Dedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 µmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 µmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m2 compared to government centers. Private centers were 62% less likely (p <  0.001) while NGO centers were 56% less likely (p <  0.001) to achieve serum phosphorus control compared to government centers. Patients from centers with a shared/visiting dietitian had 35% lower probability (p <  0.001) to achieve serum phosphorus levels below 1.78 mmol/L compared to centers without access to a dietitian. CONCLUSIONS: There were clear discrepancies in nutritional care in Malaysian HD centers. Changes in stakeholder policy are required to ensure that dietitian service is available in Malaysian HD centers.

Investigating the impact of dietary guidelines transition on cardiometabolic risk profile: a forensic analysis using diet quality metrics.

Evaluating dietary guidelines using diet quality (DQ) offers valuable insights into the healthfulness of a population's diet. We conducted a forensic analysis using DQ metrics to compare the Malaysian Dietary Guidelines (MDG-2020) with its former version (MDG-2010) in relation to cardiometabolic risk (CMR) for an adult Malaysian population. A DQ analysis of cross-sectional data from the Malaysia Lipid Study (MLS) cohort (n = 577, age: 20-65yrs) was performed using the healthy eating index-2015 (HEI-2015) framework in conformation with MDG-2020 (MHEI2020) and MDG-2010 (MHEI2010). Of 13 dietary components, recommended servings for whole grain, refined grain, beans and legumes, total protein, and dairy differed between MDGs. DQ score associations with CMR, dietary patterns and sociodemographic factors were examined. Out of 100, total DQ scores of MLS participants were 'poor' for both MHEI2020 (37.1 ± 10.3) and MHEI2010 (39.1 ± 10.4), especially among young adults, males, Malays, and those frequently 'eating out' as well as those with greatest adherence to Sugar-Sweetened Beverages pattern and lowest adherence to Food Plant pattern. Both metrics shared similar correlations with CMR markers, with MHEI2020 exhibiting stronger correlations with WC, BF%, TG, insulin, HOMA2-IR, and smallLDL than MHEI2010, primarily attributed to reduced refined grain serving. Notably, participants with the highest adherence to MHEI2020 scores exhibited significantly reduced odds for elevated TG (AOR 0.44, 95% CI 0.21-0.93, p = 0.030), HOMA2-IR (AOR 0.44, 95% CI 0.21-0.88, p = 0.022), and hsCRP (AOR 0.54, 95% CI 0.31-0.96, p = 0.040, compared to those with the lowest adherence. Each 5-unit increase in MHEI2020 scores reduced odds for elevated BMI (- 14%), WC (- 9%), LDL-C (- 32%), TG (- 15%), HOMA2-IR (- 9%) and hsCRP (- 12%). While MHEI2020 scores demonstrated better calibration with CMR indicators, the overall sub-optimally 'poor' DQ scores of this population call for health promotion activities to target the public to achieve adequate intake of healthful fruits, non-starchy vegetables and whole grain, and moderate intake of refined grain, added sugar and saturated fat.

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.

Impact of Dietary Fructose and High Salt Diet: Are Preclinical Studies Relevant to Asian Societies?

Fructose consumption, especially in food additives and sugar-sweetened beverages, has gained increasing attention due to its potential association with obesity and metabolic syndrome. The relationship between fructose and a high-salt diet, leading to hypertension and other deleterious cardiovascular parameters, has also become more evident, especially in preclinical studies. However, these studies have been modeled primarily on Western diets. The purpose of this review is to evaluate the dietary habits of individuals from China, Japan, and Korea, in light of the existing preclinical studies, to assess the potential relevance of existing data to East Asian societies. This review is not intended to be exhaustive, but rather to highlight the similarities and differences that should be considered in future preclinical, clinical, and epidemiologic studies regarding the impact of dietary fructose and salt on blood pressure and cardiovascular health worldwide.

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on 'Access to pharmacist and dietitian at HD units' (2.65 ± 0.21) and 'Access to continuous medical education on managing PEW patients on HD' (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

Provision of renal-specific nutrition knowledge for changing dietary practice in Bangladeshi hemodialysis patients.

Objective: Studies show that provision of nutrition knowledge help renal patients make informed food choices. This study aimed to evaluate the impact of nutrition knowledge for changing dietary practice among Bangladeshi dialysis patients. Methods: Following development of a renal-specific nutrition booklet, a pilot study was conducted among 50 hemodialysis patients from a single dialysis setting. Demographic, anthropometric, clinical, biochemical, dietary data, and a 10-item MCQ on renal-specific nutrition information were collected before and 3 months after the provision of the booklet. Results: 52% of the participants were male, 54% had twice weekly dialysis, age 53 ± 12 years, and dialysis vintage was 46 ± 25 months. Serum potassium and phosphorous, dietary potassium, phosphorous, and phosphorous to protein ratio were significantly reduced after the provision of the booklet. Additionally, patients consuming >3 meals/day increased to 66% while adherence to renal-specific cooking method and vegetable preference were significantly increased to 70% and 62%, respectively. Conclusion: Provision of knowledge via renal-specific nutrition booklet was able to improve patients' dietary practice and enhance their dietary adherence to renal specific recommendations. Innovation: The booklet was developed using locally available food items in local language and was found beneficial in low-resource settings where overall health care facilities, including nutrition support are limited.

Effectiveness of a Nutritional Mobile Application for Management of Hyperphosphatemia in Patients on Hemodialysis: A Multicenter Open-Label Randomized Clinical Trial.

This study aims to determine the effectiveness of a phosphate mobile app (PMA), MyKidneyDiet-Phosphate Tracker ©2019, on hemodialysis (HD) patients with hyperphosphatemia. A multicenter, open-label, randomized controlled trial design allowed randomization of patients with hyperphosphatemia to either the usual care group (UG; receiving a single dietitian-led session with an education booklet) or the PMA group (PG). Thirty-three patients in each intervention group completed the 12-week study. Post-intervention, serum phosphorus levels were reduced in both groups (PG: −0.25 ± 0.42 mmol/L, p = 0.001; UG: −0.23 ± 0.33 mmol/L, p < 0.001) without any treatment difference (p > 0.05). Patients in both groups increased their phosphate knowledge (PG: 2.18 ± 3.40, p = 0.001; UG: 2.50 ± 4.50, p = 0.003), without any treatment difference (p > 0.05). Dietary phosphorus intake of both groups was reduced (PG: −188.1 ± 161.3 mg/d, p < 0.001; UG: −266.0 ± 193.3 mg/d, p < 0.001), without any treatment difference (p > 0.05). The serum calcium levels of patients in the UG group increased significantly (0.09 ± 0.20 mmol/L, p = 0.013) but not for the PG group (−0.03 ± 0.13 mmol/L, p = 0.386), and the treatment difference was significant (p = 0.007). As per phosphate binder adherence, both groups reported a significant increase in Morisky Medication Adherence Scale scores (PG: 1.1 ± 1.2, p < 0.001; UGa: 0.8 ± 1.5, p = 0.007), without any treatment difference (p > 0.05). HD patients with hyperphosphatemia using the PMA achieved reductions in serum phosphorus levels and dietary phosphorus intakes along with improved phosphate knowledge and phosphate binder adherence that were not significantly different from a one-off dietitian intervention. However, binder dose adjustment with meal phosphate content facilitated by the PMA allowed stability of corrected calcium levels, which was not attained by UC patients whose binder dose was fixed.

A Mobile App for Triangulating Strategies in Phosphate Education Targeting Patients with Chronic Kidney Disease in Malaysia: Development, Validation, and Patient Acceptance.

Hyperphosphatemia afflicts end-stage chronic kidney disease (CKD) patients, contributing to comorbidities and mortality. Management strategies are dialysis, phosphate binder, and limiting dietary phosphate intake, but treatment barriers are poor patient compliance and low health literacy arising from low self-efficacy and lack of educational resources. This study describes developing and validating a phosphate mobile application (PMA). The PMA development based on the seven-stage Precaution Adoption Process Model prioritized titrating dietary phosphate intake with phosphate binder dose supported by educational videography. Experts (n = 13) first evaluated the PMA for knowledge-based accuracy, mobile heuristics, and clinical value. Adult HD patients validated the improved PMA using the seven-point mHealth App Usability Questionnaire (MAUQ). Patient feedback (n = 139) indicated agreement for ease of use (69.2%), interface and satisfaction (69.0%), and usefulness (70.1%), while 72.7% said they would recommend this PMA. The expectation confirmation for 25 PMA features ranged from 92.1% (lifestyle) up to 100.0% (language option); and the utilization rate of each feature varied from 21.6% (goal setting and feature-based log) to 91.4% (information on dietary phosphate and phosphate binder). The Conclusions: MyKidneyDiet-Phosphate Tracker PMA was acceptable to adult Malaysian HD patients as part of clinical phosphate management in low-resource settings.

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka, Bangladesh.

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000−40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60−90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.

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.

A Food Frequency Questionnaire for Hemodialysis Patients in Bangladesh (BDHD-FFQ): Development and Validation.

Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh.