|Year : 2020 | Volume
| Issue : 3 | Page : 604-613
|Effects of dietary counseling on sodium restriction in patients with chronic kidney disease on hemodialysis: A randomized clinical trial
Amanda Brito de Freitas1, Bruna Bellincanta Nicoletto2, Karina Sanches Machado d'Almeida3, Nícia Maria Romano de Medeiros Bastos4, Roberto Ceratti Manfro5, Gabriela Corrêa Souza6
1 Nutrition Graduate Course, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
2 Knowledge Areaof Life Sciences, Universidade de Caxias do Sul, Caxias do Sul, Brazil
3 Nutrition Graduate Course, Universidade Federal do Pampa, Itaqui, Brazil
4 Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
5 Division of Nephrology, Hospital de Clínicas de Porto Alegre; Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, Brazil
6 Department of Nutrition, School of Medicine, Universidade Federal do Rio Grande do Sul; Food and Nutrition Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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|Date of Submission||04-Dec-2018|
|Date of Acceptance||14-Jan-2019|
|Date of Web Publication||10-Jul-2020|
| Abstract|| |
Reducing dietary sodium has the potential to benefit patients with chronic kidney disease on hemodialysis (HD). This study was aimed to evaluate the effects of dietary counseling on sodium restriction and its relationship with clinical, dietary, and quality of life parameters in patients on HD treatment. This study was designed as a randomized clinical trial. The study included 87 patients on HD, divided into intervention (n = 47) and control (n = 40) groups. Anthropometric, clinical, sodium intake, and quality of life data were evaluated in both groups at four-time points: baseline (T0), 90 days (T3), 180 days (T6), and 365 days (T12). The intervention group received dietary counseling at the beginning and throughout the study. There were no between-group differences regarding anthropometric, clinical, and quality of life data at any of the time points. The mean age was 59 ± 14 years, and most of the patients were men (61%) and had hypertension (90%). Total sodium (g) and processed meat (mg sodium) intake significantly decreased in both groups [intervention: T0 = 3.5 (2.3–4.7); T12 = 2.0 (0.7–2.5); P <0.0001; control: T0 = 3 (1.5–4.9); T12 = 2.0 (0.8–3.3); P = 0.001; and intervention: T0 = 78 (25–196); T12 = 21 (0–78); P = 0.003; control: T0 = 97 (31–406); T12 = 44 (0–152); P = 0.004, respectively] . There was a significant decrease in the consumption of packaged seasonings (mg sodium) [T0 = 130 (0–854); T12 = 0 (0–0); P = 0.015] and instant noodles [T0 = 19 (0–91); T12 = 0 (0–0); P = 0.017] in the intervention group. Dietary counseling was effective in changing dietary habits. In both groups, there was a reduction in total sodium intake, which was greater in the intervention group. Moreover, a decrease in the intake of salty foods, such as packaged seasonings and instant noodles, was only observed in the intervention group.
|How to cite this article:|
de Freitas AB, Nicoletto BB, Machado d'Almeida KS, Romano de Medeiros Bastos NM, Manfro RC, Souza GC. Effects of dietary counseling on sodium restriction in patients with chronic kidney disease on hemodialysis: A randomized clinical trial. Saudi J Kidney Dis Transpl 2020;31:604-13
|How to cite this URL:|
de Freitas AB, Nicoletto BB, Machado d'Almeida KS, Romano de Medeiros Bastos NM, Manfro RC, Souza GC. Effects of dietary counseling on sodium restriction in patients with chronic kidney disease on hemodialysis: A randomized clinical trial. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jun 17];31:604-13. Available from: https://www.sjkdt.org/text.asp?2020/31/3/604/289447
| Introduction|| |
Chronic kidney disease (CKD) results from many conditions and can lead to a progressive and irreversible loss of renal function. Currently, CKD is considered a public health problem, affecting 5% to 7% of the world population. Diabetes and hypertension (HTN) are among the main causes of CKD onset and progression, and cardiovascular diseases are among the main causes of mortality in end-stage renal disease.
Patients on hemodialysis (HD) have complex care needs, including the use of prescribed medications and nutritional care, including dietary sodium intake. The sodium intake has been directly related to the increase of water intake and, consequently, to the increase of blood pressure and inter-dialytic weight gain (IDWG), which are risk factors for morbidity and mortality in this population. Studies indicate that reducing dietary sodium intake may lead to improvement in intra-dialytic symptoms and better results from long-term treatment., The dietary recommendation of sodium for patients in the dialysis state is <2.0 g/day or 5.0 g of sodium chloride, emphasizing that this should be individualized, taking into consideration the water balance. Patients should be instructed to add a little amount of salt while cooking, and to avoid processed meat, canned foods, and packaged seasonings.
Adherence to nutritional therapy by HD patients is challenging, and individual and environmental factors have been suggested as important determinants to patient’s attitude toward adopting certain behavior., The aim of dietary counseling is to identify problems, suggest ways to deal with difficulties and to facilitate the understanding and control by patient. In this context, nutritional education plays a crucial role in helping patients to make right food choices.,
Although the importance of controlling sodium intake on HD is known, the available evidence on the effects of dietary counseling is still sparing and limited, lacking a clear consensus on the benefits of sodium restriction in patients with CKD.,, The aim of this study was to assess the effects of dietary counseling on sodium restriction on clinical and dietary parameters and quality of life in patients on HD.
| Subjects and Methods|| |
This is a randomized clinical trial that included 87 patients on HD, recruited in a university hospital, and a satellite dialysis clinic both located in Porto Alegre in the southern region of Brazil. Clinically, stable patients of both sexes, aged older than 18 years, on HD treatment participated in the study. Patients with reduced cognitive abilities, psychiatric disorders, and acute or infectious diseases were excluded. The study was approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre and registered at clinicaltrials.gov (NCT01896882). All patients were informed on study’s purpose and signed an informed consent form.
Participants were randomized to the intervention and control groups using a computer-generated random number which generated a list with numbers, divided into A for the intervention group and B for the control group. After inclusion of the participants in the study, allocation was made through the telephone contact of the researcher with the center of randomization. Data were collected during HD sessions over a period of one year. Both groups received regular treatment from the medical and nursing staff and were followed-up by a nutritionist at least twice a year.
Anthropometric, clinical, and dietary sodium intake data were obtained after HD sessions at four-time points: at inclusion in the study (T0, baseline), at 90 days (T3), at 180 days (T6), and at 365 days (T12) after intervention. Data on quality of life were collected at T0, T6, and T12.
At T0, after data collection, the intervention group received additional dietary counseling by a registered dietitian regarding dietary sodium restriction, which was reinforced 30 days after the initial intervention and at T3 and T6. All dietary interventions were performed by the same nutritionist.
The orientation in the intervention group was individualized during the HD sessions, lasting approximately 60 min. Before starting the conversation, a food frequency questionnaire specific for sodium (FFQ-So) and a usual food recall were used as a method to evaluate food consumption and to identify eating habits. Afterward, with the aid of a graphic material prepared and available by the Nutrition and Dietetics Service of the university hospital, nutritional counseling was carried out for a sodium-restricted diet. Dietary counseling was based on exposure in each food group (cereals, meats, and eggs, milks and derivatives, oils and fats, fruits, vegetables, and beverages); foods that should have been avoided because they contain high amounts of sodium, and equivalent foods of the same group that had their permitted consumption. In addition, during the conversation, they addressed the processed and ultra-processed foods that should have their consumption avoided and the use of natural condiments to replace cooking salt and industrialized seasonings. At the end of each orientation, based on individual eating habits, some goals were established for the next meetings, from the detection of possible inadequate dietary behaviors and in agreement with the patient, to favor adherence to the diet and the motivation of the same. Goal follow-up was carried out during orientation-enhancing visits through a new food consumption assessment. At the reinforcement meetings, the main difficulties for adherence to the proposed diet were discussed with each patient.
Sodium intake was assessed by a Brazilian FFQ-So, which was developed for hypertensive patients and has also been used to estimate sodium intake in patients in HD. The FFQ-So included 15 food sources of sodium and added salt. The FFQ-So is a practical tool for assessing the long-term sodium intake, in addition to highlighting the contribution of some items such as processed spices and other important sources of sodium, which often cannot be obtained by other methods such as 24-h dietary recall and 72-h food records.
Body mass index (BMI) was calculated from weight and height and classified according to the World Health Organization criteria. Since hydration status may affect BMI values, the index was calculated using the dry (post-dialysis) body weight. Weight was measured with patients wearing as less clothes as possible, in standing position, using an electronic scale (Filizola® with weighing capacity to 150 kg in 100g increments. Height was measured using a wall-mounted stadiometer.
Demographic and clinical variables
Sociodemographic and clinical data on the underlying disease, comorbidities, time of dialysis, arterial pressure, and IDWG were obtained from patients’ medical records.
Quality of life
Quality of life was assessed using the Brazilian version of the Kidney Disease and Quality-of-Life Short-Form, translated into Portuguese, adapted and validated to the Brazilian population. The questionnaire is applicable to patients on dialysis treatment; it consists of 80 items divided into 19 dimensions related to the concerns of CKD patients, composed of physical and mental function domains estimated by 0–100 scales (%). Median values equal to or lower than 50 in each domain indicated the low quality of life.
| Statistical Analysis|| |
Data were processed using the Statistical Package for the Social Sciences version 18.0 (SPSS Inc., Chicago, IL, USA). Between- group comparisons of baseline variables were performed by Student’s t-test or Mann–Whitney test for continuous variables and Chi-square test for categorical variables. The generalized estimating equation analysis or the Mann–Whitney test (anthropometric and quality of life data) was used to compare the variables over time, and the Friedman test was used to compare sodium intake between the groups over time. Significance level was set at P <0.05.
| Results|| |
Eighty-seven patients were included in the study, 47 in the intervention group and 40 in the control group. During follow-up, five patients died, two dropped out of the study, one was hospitalized, nine underwent kidney transplantation, five were transferred to another dialysis center, one had complications and two dropped out of the HD treatment [Figure 1].
Sociodemographic and clinical characteristics of patients are presented in [Table 1]. Mean age of patients was 59 ± 14 years and 61.6% were males. The main underlying disease was diabetes (15.1%), and HTN was the main comorbidity (89.7%) and most of the patients (72.4%) were receiving antihypertensive drugs. The mean BMI was 25.7 kg/m2; according to the BMI classification, 50% (n = 40) of the patients were considered as having normal weight, 42.5% (n = 34) were overweight and 7.5% (n = 6) were underweight. During the four moments of the study, there were also no significant changes in IDWG, BMI, and blood pressure over time or between groups (data not shown). There were no differences in baseline characteristics between groups.
|Table 1: Sociodemographic, clinical and anthropometric characteristics of chronic kidney disease patients on hemodialysis.|
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Detailed sodium intake is shown in [Table 2]. The median baseline sodium intake was 3.5 g (2.3–4.7) in the intervention group and 3.0 g (1.5–4.9) in the control group (P = 0.300). Compared to T0, total sodium intake significantly decreased at T3 (P = 0.003), T6 (P = 0.005) and T12 (P = 0.0001) in the intervention group, whereas in the control group, a statistically significant difference was observed only at T12 (P = 0.001). This result indicates a significant reduction in sodium intake within three months of dietary counseling. In the intervention group, there was a significant decrease in packaged seasonings (P = 0.015), processed meat (P = 0.030) and instant noodles (P = 0.017). Moreover, the control group also reported a decrease in processed meat intake (P = 0.030). However, a significant decrease in the use of added salt was observed in the control group (P = 0.004) and did not occur in the intervention group [Table 2].
Changes in quality of life in the domains mental and physical over time are shown in [Table 3]. The mean scores obtained over time were lower or close to 50 in each domain, indicating poor quality of life in the intervention and control group. Despite the increase in quality of life scores over time in the intervention group, which might indicate an improvement in quality of life, this change did not reach statistical significance.
|Table 3: Zero-100 scale values of quality of life-related physical and mental domains in hemodialysis patients.|
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| Discussion|| |
The present study showed that dietary counselling affected total sodium intake, by reducing the intake of salty foods, including packaged seasonings, processed meat and instant noodles in a sample of patients on renal replacement therapy with HD. Among the food items listed in the FFQ-So, salt-based seasonings contributed most to sodium intake. A reduction in reported sodium intake in the control group was also detected, and, although observed in both groups, this effect was detected at three months in the intervention group and continued throughout the observation period only in the intervention group. However, the decrease in dietary sodium intake had no significant effects on anthropometric, clinical, and quality of life parameters.
Previous studies using similar methodology have reported a sodium intake higher than dietary recommendations, i.e., 2.0 g/day., In two of them in which FFQ-So was used to estimate sodium intake in patients in dialysis, total sodium intake was 10.6 ± 6.3 g/day and 8.6 ± 5.4 g/day (higher than our findings), and added salt contributed to 72% and 82% of total sodium intake, respectively., Similar to these studies, the item that accounted most to sodium intake in our study was added salt. However, since the FFQ-So does not discriminate the place where the meals were eaten, either at home or out, added salt intake might have been underestimated.
It has being shown that health counseling and health awareness are important to meet HD patients’ needs, and are associated with better outcomes. In a study that evaluated health awareness on diet in HD patients and the influence of the frequency of visits by the dietitian on demographic parameters showed that the awareness score for sodium intake was 80%, and the degree of awareness was influenced by the number of visits by the dietitian and educational attainment of patients. There is little evidence showing previous knowledge about dietary sodium in CKD patients and lower knowledge contributes to inadequate sodium intake in this population. Patients point out that although health-care providers instruct them to follow a low-sodium diet, there is usually a lack of adequate counseling by these professionals to achieve this recommendation. In this context, an individualized nutrition education, with a balanced approach and without strict restrictions, has a crucial role in the success of the intervention and adoption of necessary dietary restrictions., The dietitian, as a nutrition counselor, is not only an instructor but also a facilitating agent, who should provide emotional support and cognitive tools for changes. This may have contributed to the maintenance of lower sodium intake for a long period of follow-up in the intervention group in our study.
In this study, we showed a decrease in the intake of total sodium, packaged seasonings, processed meat, and instant noodles. Similarly, a randomized clinical trial assessed the effect of nutritional education provided by a dietitian on dietary sodium restriction in heart failure patients. After 90 days of hospitalization, there was a significant reduction in sodium intake from 2.80 ± 0.30 to 2.14 ± 0.23 g/day. Nevertheless, different from our study, a decrease in sodium intake was not observed in control subjects. Our control group reported a reduction in total sodium and processed meat intake, which may be explained, at least in part, by the difficulty in limiting the communication between the groups. In fact, this is one limitation of our study; since both groups underwent HD in the same facilities, the possibility that these patients shared information along the study, and this cannot be ruled out.
The adherence to a low-sodium diet is undoubtedly one of the most important factors for treatment success and well-being of patients in dialysis. Nonadherence may contribute to increased mortality in this population. Several evidences support the beneficial effects of sodium restriction in HD patients, including the IDWG and arterial blood pressure control.,, In the current study, no changes in these variables were observed, despite the decrease in sodium intake. Similar to our results, it was reported in another randomized clinical trial that although the sodium intake decreased over eight weeks, the IDWG did not differ in patients who received dietary guidelines on HD plus behavioral counseling based on cognitive theories.
We should also consider that the difference between patients’ previous sodium intake and sodium restriction in studies with positive results was larger than that in ours. It is well known that the IDWG is usually associated with sodium and water overload, and may be affected by sodium intake and other factors such as sex, age, time of HD, and nutritional status. It is possible that the degree of reduction in sodium intake by our study group was not large enough to influence this parameter. Similarly, in a randomized study, dietary sodium reduction had no significant effect on blood pressure and body water. Furthermore, our sample size was small to detect these differences, and there were dropouts during the study.
HD therapy may have a negative effect on patients’ quality of life. The quality of life in the context of the chronic renal patient refers to the patient’s perception of their mental and physical health, as well as how CKD interferes with their daily activities. Several factors may be associated with lower quality of life scores, including vascular access, co-morbidities, educational level, and lack of occupation. Some studies have demonstrated that the quality of life of HD patients also depends on adherence to treatment protocol and dietary counseling., It is expected that with the restriction of dietary sodium intake, there will be a decrease in the signs and adverse symptoms experienced during dialysis, especially those related to an excessive IDWG, which influence directly and mutually on the physical and psychological aspects of patients. A study that assessed the impact of nutrition education on quality of life of 70 patients on HD, divided into two groups, showed that the group that received dietary counseling had higher scores of physical and mental domains as compared with the group that did not receive the intervention. In the present study, we also observed a small and not significant improvement in the mean scores after the intervention.
Diet-related effects are difficult to be accurately determined; for this reason, our results should be interpreted with caution, taking into account the limitations of the study. First, since many patients had their meals out of home, we had difficulties in precisely determining the intake of added salt by the FFQ-So and may have underestimated it. The second limitation was that the intervention and control groups could not be separated in the dialysis room, which may have contributed to the decrease in sodium intake reported also by the control group. This cannot be excluded and confirms the positive effect of nutritional counseling, but it should also be considered as a limitation of the study design.
| Conclusion|| |
In summary, this randomized clinical trial showed that dietary counseling for sodium restriction had positive effects on the diet, but had no significant effects on clinical outcomes or quality of life, which may be influenced by several factors. A low salt diet is beneficial for the whole population but has particular advantages for HD patients because of the role of salt restriction in the management of HTN and IDWG. Therefore, further studies with sample size and longer follow-up time are necessary to assess the impact of sodium restriction on clinical aspects and quality of life.
Conflict of interest: None declared.
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Gabriela Corrêa Souza
Department of Nutrition, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre
[Table 1], [Table 2], [Table 3]
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