| Abstract|| |
Our objective was to investigate the degree of dietary awareness of Saudi patients on chronic hemodialysis and influencing factors on this awareness. This is an interviewadministered survey-based cross-sectional study carried out on adult dialysis patients at the King Abdulaziz Medical City, Riyadh. The first part of the survey consisted of the collection of demographic data and the second part consisted of questions in the areas of awareness on the dietary influence of sodium, potassium, fluid intake and calcium/phosphorous and lipids. The questions are simply answered as "yes" or "no." The overall awareness score was 79%. The awareness scores were highest in the area of lipids (86.5%) and lowest in the fluid intake area (71.3%). The scores for sodium, phosphorous/calcium and potassium were 80%, 79.6% and 73%, respectively. The degree of awareness was influenced by the number of visits by the dietitian (P = 0.008) and the educational level of the patients (P = 0.02), but not by age, duration on dialysis or gender. In conclusion, our findings suggest that there is a need for better of awareness among our dialysis patients. The highest score for awareness was seen in the cholesterol-related questions and the lowest score was seen in the fluid intake questions area. This is influenced by the number of visits by the dietitian and the educational level of the patients, but not by age, duration on dialysis or gender.
|How to cite this article:|
AlSadhan AA, Hejaili F, Salih SB. Level of dietary awareness among Saudi dialysis patients and the influence of various factors. Saudi J Kidney Dis Transpl 2015;26:544-8
|How to cite this URL:|
AlSadhan AA, Hejaili F, Salih SB. Level of dietary awareness among Saudi dialysis patients and the influence of various factors. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jan 20];26:544-8. Available from: https://www.sjkdt.org/text.asp?2015/26/3/544/157360
| Introduction|| |
Heath education and awareness are important parts of the overall optimal medical care.1 Health literacy has been found to be associated with better health outcomes. , A patient who is educated about his medical condition and treatment is more likely to be compliant with his treatment  and to raise relevant issues in discussions with his physician and more likely to report early if complications occur or his condition worsens.  Such a patient would also be able to take the responsibility for his health as well as that of his family and community.  Health education and literacy are also part of the recently recognized patient centeredness (and patient empowerment in his own care. 
Patients on dialysis are a good example of how patient's education and awareness are crucial for his health and, indeed, quality of life. These patients' quality of life and life itself depend on adherence to treatment protocols and to strict dietary advice. 
Previous reports on dietary awareness of dialysis patients are scarce. In this study, we look at the awareness of Saudi dialysis patients in the appropriate volume of water intake for them and in diets that need to be manipulated in their condition in order to maintain a healthy status. We investigate their knowledge of the contents of these foods and how important are these contents in their health. We also look into the influence of frequency of the dietitian's visits and of certain demographic parameters on the degree of awareness shown.
| Methods|| |
This is an interview-administered surveybased cross-sectional study carried out on adult dialysis patients at the King Abdulaziz Medical City, Riyadh. The patients were chosen by stratified randomization by gender, age and duration on dialysis. Randomization was based on their medical record number (MRN) and performed on computer software (Excel). The same interviewer (AS) performed the study in all the patients.
The purpose of the study was explained to them by the investigator and their oral consent was ascertained. The data were collected anonymously and complete privacy and confidentiality were assured. Only patients willing to partake in the study and who are able to understand the questions were included.
The survey questions were developed by experienced nephrologists and, initially, validated through a pilot testing in 15 patients prior to the actual study.
The survey consisted of two parts; the first collected demographic data (education level, age, sex, duration on dialysis and the number of times seen by a dietitian over the preceding 6 months) and the second part consisted of seven sections on knowledge of diet contents and associated health risks. These seven sections were on (1) foods and drinks rich in potassium, (2) dangers of high blood potassium levels, (3) importance of fluid intake, (4) foods rich in phosphorus intake, (5) foods rich in sodium, (6) dangers of excessive sodium intake and (7) cholesterol and lipids. The questions are simply answers by "yes" or "no."
Every right answer got a score of 1, with a total of possible high score of 34 (highest is 34 and lowest is zero).
The whole process of questionnaire administration and collection took place over a one-week period.
Assuming an awareness of 50%, a type one error of 0.05 and a precision of 10%, the optimal required sample size was calculated as being 97. Descriptive statistics were generated. Responses according to gender, educational levels and duration on dialysis as well the frequency of encounters with the dietitian will be compared using independent samples t test for parametric variables and Pearson's chi square test for non-parametric variables.
This study was approved by the Institutional Review Board of the King Abdullah International Medical Research Center.
| Results|| |
Ninety-seven patients were included in the study; 51% were male; 21% were illiterate, 35% had primary education only, 37% had secondary education and 7% had higher education. The mean duration on dialysis was 28.4 ± 23.4 months (median 21).
Half of the patients stated that they did not get any visits by a dietitian over the previous six months and a further 36.1% were visited only once [Table 1].
The majority of the patients were aware that oranges, bananas and dates were rich in potassium and 80% knew that high potassium level in the blood can cause cardiac arrest; 70% knew that it can cause heart rhythm abnormality. On the other hand, over one-thirds each of the responders thought that high potassium causes strokes or itching.
Regarding knowledge about fluids and the dangers from excessive fluid intake, almost all the patients realized that their fluid intake should be monitored and that they should include all fluids and not only water intake, but only 35% were aware that the fluid intake allowed is related to the amount of urine passed and 59.8% knew that excessive fluid intake can cause breathlessness.
Almost all the patients were aware that high phosphorus and calcium levels can be dangerous and 85% knew that the phosphate binder calcium carbonate (caltrate) should be taken during meals and 58.8% were aware that dairy products are rich in phosphorus. The majority of the responders realized that fish, pickled foods and cheese were rich in sodium, but over 2/5ths of them thought that rice and eggs were also rich in this element.
Only 3% and 12.4% of the responders thought that too much sodium in the diet causes low blood pressure and makes one diabetic, respectively, whereas 60.8% and 85.6% of them, respectively, were aware that too much sodium intake increases one's body weight and makes one thirsty.
Almost all the patients knew that the cholesterol level can be reduced by exercise, that red meat is rich in cholesterol, that high blood cholesterol is not good for the heart and that bread is not rich in cholesterol, but only 53.6% were aware that patients on dialysis are more likely to have high cholesterol levels.
Gender, duration on dialysis or age did not affect the degree of awareness, but the educational level and dietitian visit numbers did (P = 0.02 and 0.008, respectively).
The overall awareness score was 79%. The awareness scores were highest in the cholesterol area (86.5%) and lowest in the fluid intake area (71.3%) [Table 2].
|Table 2: Degree of awareness in the different dietary areas investigated.|
Click here to view
| Discussion|| |
Almost half of the American adults find it difficult to assimilate the medical and health information given to them.  Emphasis on health literacy as an important component in health policies is increasing, as evidenced by the fact that it had been specifically mentioned as an area of priority action in the European Commission's Health Strategy 2008 - 2013.  In this study, we addressed health literacy in diet in Saudi dialysis patients. Proper diet management is important in patients on chronic dialysis to reduce morbidity, hospitalization rate,  mortality and quality of life. 
Sodium intake in patients on hemodialysis needs to be reduced and monitored to avoid hypertension and fluid overload; potassium intake needs to be reduced to avoid hyperkalemia with its associated danger of causing ventricular fibrillation and cardiac arrest and phosphorus intake is important in relation to mineral and bone metabolism. The patient needs to be aware of these facts and the foods that contain these minerals. He/she should also monitor the fluid intake he is allowed to avoid hypertension and fluid overload. He should also be aware that he is at an increased risk of developing ischemic heart disease and should take proper diet to avoid this. Dialysis patient education in the areas of diet, exercise, life style modification and the importance of regular dialysis and follow-up was found to be beneficial in improving the quality of life of the patients. 
In this study, we attempt to find out how aware Saudi patients, who were dialyzed at a tertiary university hospital, about their issues and whether any demographic characteristic has any influence on their degree of awareness.
The availability of a trained full-time renal dietitian is essential in the management of these patients. Access to full-time dieticians was reported as being correlated to the oneyear survival of new dialysis patients (r = 0.294, P = 0.023). Disappointingly, we found that the dietitian's visits was not adequate, with over 50% of the patients not having been seen at all in the six months preceding the study. Perhaps it is not surprising that we found that dietitians visits influenced the degree of awareness (P = 0.008).
Another factor that also influenced the degree of awareness in our study was the respondents' level of education (P = 0.02). This was also found in a study from the USA, which showed that there is a relationship between general literacy and health awareness.  Similarly, in a study from Eastern Saudi Arabia, diabetic patients were found to have poor knowledge of diabetic risk factors and preventive measures and, in this group, the level of education and age were important predictors of knowledge. 
On the other hand, we found that gender and duration on dialysis had no influence on the degree of dietary awareness among our dialysis patients. Conversely, in a study among Gulf Council countries about stroke awareness in the general population, it was found that younger age, higher level of education and female gender better predicted stroke recognition. It was also found that stroke knowledge was poorest among the groups that were at the highest risk for stroke. 
Studies on health awareness and health literacy in Saudi Arabia are scanty. In one study on mothers of asthmatic children, the risk factors identified for poor knowledge and among mothers were female sex of the child, illiterate mother and young age of the mother. 
In another study on Saudi asthmatics visiting the emergency department, it was found that only about half of them received no information about their disease and that 40.7% received no education on the use of asthma medication. The authors concluded that the lack of education about asthma and uncontrolled asthma are the two major factors leading to frequent emergency department visits (three or more visits/year). 
We have previously reported on the Saudi kidney patients' knowledge of (a) the biology of the kidney, (b) kidney diseases and (c) available national kidney patients support facilities.  In that study, we found an overall correct score of only 45.9%, with peritoneal dialysis patients having the highest correct score (54.4%) followed by hemodialysis patients (44.3%) and, finally, post-transplant patients (35.1%). 
In conclusion, our findings suggest that there is less than optimal level of awareness among our dialysis patients about dietary issues important to their lives. This is influenced by the number of visits by the dietitian and the educational level of the patients.
Conflict of Interest: None declared.
| References|| |
Parker R. Health literacy: A challenge for American patients and their health care providers. Health Promot Int 2000;15:277-83.
Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and Health Outcomes: A Systematic Review of the Literature. J Gen Intern Med 2004;19:1228-39.
Taggart J, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract 2012;13:49.
In Health and modernity. In: McQueen D, KI Potvin L, Pelikan JM, Balbo L, Abel Th, editors. Springer: The Role of Theory in Health Promotion; 2007.
European Commission: Together for health: A strategic approach for the EU 2008-2013. Com (2007) 630 final 2007.
Abraham S, Venu A, Ramachandran A, Chandran PM, Raman S. Assessment of quality of life in patients on hemodialysis and the impact of counseling. Saudi J Kidney Dis Transpl 2012;23:953-7.
Davis T, Wolf MS. Health literacy: Implications for family medicine. Fam Med 2004;36: 595-8.
Berkman ND PM, Sheridan SL, Lohr KN, et al: Literacy and Health Outcomes: Evidence Report/Technology Assessment. In Literacy and Health Outcomes: Evidence Report/Technology Assessment Agency for Healthcare Research and Quality.) Publication No. 04-E007-2, Rockville; 2004.
Ogata S, Kenji W, Kunitoshi I, Yoshiharu T. Influence of diet, exercise, and dietician's on the incidence and survival of Japanese dialysis patients. Kidney Res Clin Pract 2012;31:A62.
Kutner M, Jin E, Paulsen C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). National Center for Education Washington DC: U.S. Department of Education; 2006.
Aljoudi AS, Taha AZ. Knowledge of diabetes risk factors and preventive measures among attendees of a primary care center in eastern Saudi Arabia. Ann Saudi Med 2009;29:15.
Kamran S, Bener A, Deleu D, et al. The level of awareness of stroke risk factors and symptoms in the Arabian Gulf Cooperative Countries: Gulf Cooperation Council stroke Awareness Study. QNRS Repository 2011, no. 1 (2011).
Al-Binali AM, Mahfouz AA, Al-Fifi S, Naser SS, Al-Gelban KS. Asthma knowledge and behaviours among mothers of asthmatic children in Aseer, south-west Saudi Arabia. EMHJ 16, no. 11 (2010).
AL-Jahdali H, Anwar A, Al-Harbi A, et al. Factors associated with patient visits to the emergency department for asthma therapy. BMC Pulm Med 2012;12:80.
Hejaili FF, Tamim H, Ghamdi GA, et al. Level of health awareness of Saudi patients on renal replacement therapy. Saudi Med J 2007;28:747-51.
Dr. Abdulmajeed A AlSadhan
College of Medicine, King Saud University, P. O. Box 2925, Riyadh 11461
Kingdom of Saudi Arabia
[Table 1], [Table 2]