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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 145-152
Comparison between brief food frequency questionnaire and food record to assess the energy and protein intake of hemodialysis patients at Dr. Sardjito Hospital in Indonesia


1 Department of Nutrition and Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
2 Department of Internal Diseases, Faculty of Medicine, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia

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Date of Web Publication15-Feb-2018
 

   Abstract 

Dietary assessment is absolutely necessary to meet the dietary requirements of hemodialysis (HD) patients. A food record is the most commonly used method; however, it is not routinely performed. The weakness of this method is that it is burdensome for some respondents and requires more time to complete data entry. Meanwhile, the brief food frequency questionnaire (BFFQ) is a quicker and simpler method to assess individual dietary intake. We aimed to compare the BFFQ and food records as assessment methods of energy and protein intake for HD patient in Dr. Sardjito Hospital in Indonesia. This study was conducted on March to April 2015 in HD Unit of Dr. Sardjito Hospital, Indonesia, as an observational study. This was a cross-sectional study. Data were collected from 103 patients, who were selected using a purposive sampling method. All participants’ dietary intakes were assessed using a food record and the BFFQ to obtain total protein and energy intakes. Wilcoxon test was used for the statistical analysis. There was a significant difference (P <0.0001) between the methods used to assess energy intake in HD patients at Dr. Sardjito Hospital. However, there was no significant difference (P = 0.732) between the two methods used to assess protein intake among patients. This difference was caused by a missing list in the BFFQ about snacks that were usually consumed by patients as energy sources. The BFFQ can be used as a protein intake assessment tool in HD patients. However, the BFFQ is not suitable to assess energy intake in patients.

How to cite this article:
Wulandari H, Susetyowati, Prasanto H. Comparison between brief food frequency questionnaire and food record to assess the energy and protein intake of hemodialysis patients at Dr. Sardjito Hospital in Indonesia. Saudi J Kidney Dis Transpl 2018;29:145-52

How to cite this URL:
Wulandari H, Susetyowati, Prasanto H. Comparison between brief food frequency questionnaire and food record to assess the energy and protein intake of hemodialysis patients at Dr. Sardjito Hospital in Indonesia. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Oct 27];29:145-52. Available from: https://www.sjkdt.org/text.asp?2018/29/1/145/225196

   Introduction Top


Chronic kidney disease (CKD) describes an abnor-mality of kidney function or structure, which is measured by a glomerular filtration rate of <60 mL/min/1.73 m2 for more than three months.[1] At the end stage of the disease, hemodialysis (HD) is required to maintain a stable condition. Nevertheless, suboptimal nutritional status often occurs in patients followed by an increase in morbidity, health care costs, and even mortality.[2] Protein-energy malnutrition is an etiologic factor that contributes to comorbid conditions, such as cachexia, decrease of physical activity, frailty, and aging.[3] The prevalence of protein-energy malnutrition among HD patients is high (18%–75%).[4],[5],[6],[7] Low intake of protein and energy is the main factor for malnutrition in chronic kidney disease.[8]

A previous study showed that dietary intake among patients is significantly different on HD and non-HD treatment days.[9] This difference is due to increased catabolism, which includes protein breakdown into urea and uremic toxins, resulting in a decrease in appetite, anorexia, nausea, and vomiting.[10]

Therefore, an assessment of energy, protein consumption, and nutritional status is indispensable. Food recall, a food record, and a food frequency questionnaire (FFQ) are the most commonly used methods for HD patients.[11] However, a food record is the most frequently used because it provides a longer period of assessment than the food recall method and troubleshoots a variety of foods each day.[12] Compared to the other methods, such as the food recall and the FFQ, the food record is also the most reliable method.[13] The limitations of this method are that it is quite burdensome for some respondents and requires more time to complete the data entry.[14],[15]

Compared with the food record, the brief FFQ (BFFQ) is a simpler and quicker method of assessment. Based on this background, our research was conducted to determine whether the consumption of energy and protein estimated by the BFFQ has the same value as the three-day food record for HD patients.


   Subjects and Methods Top


An observational study with a cross-sectional design was carried out. Data were collected from 103 patients between March and April of 2015. Participants were selected using a purposive sampling method, and the inclusion criteria were as follows: willingness to be a participant and sign the informed consent, mental competence, age ≥18 years, undergoing regular HD (twice a week) for ≥3 months, and ability to communicate well in oral and written form; the exclusion criterion included patients who were hospitalized.

The independent variables were the energy and protein consumption that were measured using the BFFQ while the dependent variables were the energy and protein consumption that were measured using the food record. The food record questionnaire was completed by the respondents three times every 24 h on the HD treatment day, the day after HD treatment, and the day before the next HD treatment. The training provided to the patient on how to complete the food record by enumerators. Household size was used to measure the edible portion. Enumerators, who had been given training beforehand by researcher, completed the BFFQ. The food list of the BFFQ consists of the following seven food groups: staple foods, animal side dishes, vegetable side dishes, vegetables, fruits, drinks, and snacks, with a total of 21 items of food. This questionnaire and the list of foods were based on the questionnaire that is usually used and the foods consumed in Indonesia, which have already been validated in the literature. The method and tools used to calculate energy and protein intake of the patient’s diet records are Nutrisurvey.

Differences in both methods were analyzed using the Wilcoxon test because of the nonnormal distribution of the data.


   Results Top


Participant characteristics

Most participants were males, aged 41–60 years old, with a history of hypertension who underwent HD treatment for <4 years [Table 1].
Table 1: Participant characteristics.

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Overview of energy and protein consumption

We found that the highest energy and protein consumption of participants were on the HD treatment days, followed by a decrease after the HD treatment day and an increase on the day before the next HD treatment. The average intake of energy after three days was 23.23 kcal/kg ideal body weight, and the average intake of protein was 0.82 g/kg ideal body weight [Figure 1] and [Figure 2].
Figure 1: The average energy using food record

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Figure 2: The average protein using food record.

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As shown in [Table 2], we found that almost all of the energy sources were from staple foods. Only 13% of the energy sources were contributed by snacks. Meanwhile, the protein source was largely from animal and vegetable side dishes, and 10% was contributed by milk. If quantified, the average consumption of the participants using the BFFQ would be 19.72 kcal/kg ideal body weight for energy and 0.87 g/kg ideal body weight for protein.
Table 2: The average of energy and protein consumption using BFFQ.

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Comparison of energy and protein consumption using the brief food frequency questionnaire and food record

As shown in [Table 3], most participants consumed the energy sources within the range of 18.5–27.1 kcal/kg ideal body weight or 3.94 servings/day. This range was quite insufficient because it was below the dietary recommendation for HD maintenance, which is 35 kcal/kg ideal body weight.[8]
Table 3: Distribution of energy consumption.

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As shown in [Table 4], most participants consumed the protein source within the range of 0.58–0.88 g/kg ideal body weight or 3.90 serving/ day. This range was also quite insufficient because it was under the dietary recommendation for HD maintenance, which is 1.1 g/kg ideal body weight.[16]
Table 4: Distribution of protein consumption.

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As shown in [Table 5], there was a significant difference in energy consumption (P <0.05) between the BFFQ and the food record. This difference is shown by the average intake using the BFFQ, which is lower than the food record (the minimum intake using the BFFQ was 5.40 and that using the food record was 9.80 kcal/kgIBW; the maximum intake using the BFFQ was 39.5 and that using the food record was 44.3 kcal/kgIBW). The higher range of energy consumption using the food record should be followed by a higher amount of servings of energy sources using the BFFQ. However, as shown in this table, in the range of 35.9–44.3 kcal/kg ideal body weight, the average servings of energy sources were decreasing.
Table 5: Comparison of energy and protein consumption.

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Moreover, there was no significant difference in protein consumption (P >0.05) between the BFFQ and the food record. The average intake of both of these methods was quite the same (the minimum intake using the BFFQ was 0.2 and that using the food record was 0.3 g/kgIBW; the maximum intake using the BFFQ was 2.3 and that using the food record was 1.5 g/kgIBW). When we compared the range of protein consumption using the food record and the servings of protein sources using the BFFQ, the higher range was found using the food record, and the higher servings were found using the BFFQ.


   Discussion Top


This study shows that the average energy and protein consumption using the three-day food record were less than the dietary recommendations, which were 23.22 kcal/kg ideal body weight for energy and 0.82 g/kg ideal body weight for protein. A low intake of food can affect the low intake of protein and is mostly caused by a loss of appetite, changes in the sense of taste, or gastrointestinal disturbances.[17]

There was a difference in the total consumption by participants on the HD treatment day, the day after treatment, and the day before the next treatment. The highest consumption was during the HD treatment day while the lowest consumption was on the day after treatment. These results contrast those of a previous study.[10] Normally, dietary consumption on the HD treatment day is lower than on a non-HD treatment day due to increased metabolism and physiological and metabolic functions, including protein breakdown into urea and uremic toxins[10]. At an extreme condition, urea and uremic toxins lead to a decrease in appetite, anorexia, nausea, and vomiting. Therefore, usually, the dietary consumption of participants also declines.[11]

On the day before a HD treatment day, appetite is also usually decreased because the toxins that have not been excreted eventually accumulate in the body.[18] On the day after a HD treatment day, the body is associated with anabolic effects, and the toxins have been excreted from the body, resulting in an appetite of that returns to normal.[19]

The higher energy and protein consumption on the HD treatment day in this study may be due to patients feeling at ease with eating more than usual when undergoing HD. Several patients also claimed that the level of daily dietary consumption depends on the availability of food at home. The consumption of food on non-HD treatment days is lower because patients are afraid to eat after HD. However, the average intake, even on the HD treatment day, is relatively lower than the requirements.[18]

Therefore, nutritional counseling to increase the dietary consumption of patients is necessary. Nutritional counseling appears to be the most important and cost-effective tool for improving the nutritional status of HD patients.[20] Periodic assessments of dietary intake are important to provide appropriate counseling and also have a fundamental role in the clinical outcomes of HD patients.[21]

To simplify the energy and protein assessment, we compared the most frequently used food record with the simpler and quicker BFFQ. Based on the statistical analysis, there was no significant difference between the methods used to estimate protein consumption, but there was a significant difference in energy consumption. The difference was determined by the energy consumption on the BFFQ, which was lower than the food record. The data show that the BFFQ captured approximately 85% and 106% of the energy and protein consumption, respectively, that were reported in the food record.

The lower intake on the BFFQ indicated that there was an underestimation during the measurement of energy consumption.[22] This finding was evidenced by food items mentioned by the patients on the food record, which were not listed in the BFFQ. The food items included snacks or traditional foods that mostly contain carbohydrates, such as cassava, potatoes, and crackers. Therefore, it can be concluded that the BFFQ is an appropriate tool for estimating protein intake.

Further, if the servings on the BFFQ compared with the range of dietary consumption in the food record, it should be noted that the higher range of energy and protein consumption, the higher the servings of the participants. Based on this study, the protein estimation showed a matched result, whereas the energy estimation was not comparable. Therefore, it can be concluded that the BFFQ is an appropriate method for estimating protein intake.

Previous studies that also compared the two methods in dialysis patients had the same results. Energy consumption using the BFFQ was significantly lower (P <0.0001) than the food record, whereas protein consumption was not significantly different (P = 0.60).[9] Another study found that compared with consecutive sevendays of dietary records, more than 50% of participants underestimated their energy intake by more than 10% when using the brief diet history questionnaire.[23]

There is a limitation of this research because it was based on the dietary intakes of patients from several areas in Indonesia; there may be some variance in the types of traditional foods that are usually consumed. Therefore, it is quite difficult to input the food items into the list of the BFFQ.

The underestimation or overestimation of the energy and protein assessments depend on the accuracy of the food list in the FFQ.[24] The BFFQ can be used as a protein intake assessment tool in HD patients; however, it is not suitable for assessing the energy intake of patients. Since the energy intake is a surrogate measure of total food consumption, the ingestion of several nutrients is also likely to be underestimated if the total consumption is underestimated.[25] Therefore, the underestimation in energy use with the BFFQ indicates that the BFFQ needs to be modified by adding snack items and traditional foods to the questionnaire.


   Acknowledgement Top


This research is sponsored by Faculty of Medicine, Universitas Gadjah Mada. The results and interpretations presented here are the author’s responsibility. This study obtained permission from the Medical and Health Research Ethics Committee, Faculty of Medicine, Universitas Gadjah Mada, and the permission number was KE/FK/364/EC/2016.

Conflict of interest: There is no conflict of interest.

 
   References Top

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Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: Causes and consequences. Am J Kidney Dis 2003;42:864-81.  Back to cited text no. 4
    
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Pupim LB, Flakoll PJ, Yu C, Ikizler TA. Recombinant human growth hormone improves muscle amino acid uptake and whole-body protein metabolism in chronic hemodialysis patients. Am J Clin Nutr 2005;82:1235-43.  Back to cited text no. 19
    
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Bazanelli AP, Kamimura MA, Vasselai P, Draibe SA, Cuppari L. Underreporting of energy intake in peritoneal dialysis patients. J Ren Nutr 2010;20:263-9.  Back to cited text no. 25
    

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Correspondence Address:
Dr. Susetyowati
Department of Nutrition and Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta
Indonesia
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DOI: 10.4103/1319-2442.225196

PMID: 29456221

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    Abstract
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   Subjects and Methods
   Results
   Discussion
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