Question 1
Both additional articles discuss the issue of non-compliance of dietary modifications in patients with CKD. With a commonly seen theme today that "there's a pill for every ill" in addition to a lack of evidence showing that a low-protein diet can slow the progression of CKD, how can the RD explain the importance of dietary recommendations, and what techniques can be used to encourage compliance?
Conclusions
Posts from question 1 were quite varied and attempted to examine what motivates the client to comply with diet modifications given to them by the RD. As far as the first half of the question, how can the RD explain the importance of dietary recommendations?, many responses included explaining to the patient how the kidney functions in the body to remove waste producst and how an excessive intake of protein may cause these waste products to build up and cause symptoms related to the condition. In addition, the RD should take into account how much protein the client is currently taking in; if it is already near the recommendations than this point may not need to be stressed as much. Numerous posts also took into account the need to educate the client on the benefits of a healthy balanced diet with foods from all groups.
The second part of the question, what techniques can be used to encourage compliance?, had several interesting responses. Many agreed that possible adverse effects of consuming too much protein need to be emphasized to the patient, and that this may be the main basis for the rationale for the diet prescription. A post mentioned asking the client to think of "food as their medicine"; this post was interesting as it provides a counterpoint to a popular belief that prescription medicines can always be given to help a condition. It seems like many people forget or don't know that food, in place of or in conjuction with medication, can also help our bodies to function as best they can. There was some discussion about using the "scare tactic" with the client by explaining to them the negative things that may occur from consuming too much protein. The "scare tactic" is basically negative reinforcement and it can be difficult for the client to imagine or think into the future about what may happen based on actions taken today. It has been my experience that clients want simple changes that enable them to see immediate results with as little effort on their part. This mentality can make our job very difficult. A very good point was brought up that the RD needs to be able to assess the readiness to change of the client, and that the diet education must be correlated to their stage. Family support, empathy, and encouragement should also be emphasized. The client also needs concrete examples of what to change, how to change it, and how to overcome barriers. I think Lisa F summed it up nicely when she said, "They may understand the reasons why they need to make the changes, but without strategies to make the changes it is less likely that they will comply." Lisa's statement takes into account that the client is less likely to change solely with information about the disease and why excessive protein intake can be harmful, but rather needs specific lifestyle choices and strategies, along with continued support, in order to increase the chances of compliance.
posted by Andrea @ 12:05 PM
55 comments
55 Comments:
I would explain the basis of a low-protein diet for CKD so the patient understands the basic physiological reasons behind protein intake and CKD. I would tell the patient that since their kidneys do not work properly, increased protein consumption will ultimately increase kidney workload and a buildup of ions and waste products which will have adverse effects. Although long-term effects such as progression of CKD are inconclusive, this buildup may cause somewhat more immediate symptoms (fatigue, poor appetite, n/v, edema). I would determine the patient’s individual protein restriction (depending on other conditions present, stage of CKD, labs, wt/ht, etc.), encourage patient compliance by emphasizing possible adverse effects of high protein consumption, and offer meal suggestions or recipe alterations keeping in mind their food preferences.
I do also agree with Vanessa and think that it is important to limit the amount of protein intake in CKD (determined by their individual needs) so that it is not excessive. First though, I would ask the pt what they typically consume. They may not even get enough protein...which, in itself can cause problems. Then I would explain that the pt CAN and SHOULD eat protein foods; especially HBV proteins (like eggs)...simply do not "over indulge" in these (meats, soy, eggs,etc.) items on a daily basis or go on a High Protein (Atkins style) diet without physician recommendation or supervision, as there have been studies that say excessive protein in the diet may worsen CKD. For the most part, if the patient is not overconsuming protein rich foods, I don't believe extremely rigid enforcement of a very low protein diet would be beneficial especially if there is little evidence of compliance. However, I would also suggest keeping their protein needs simple, by saying for example: 1 serving HBV protein per meal and then give them a sheet to identify what a serving of protein consists of and what are good sources of protein.
To promote compliance I would also stress that "Your food is your medicine"...and to keep this in mind when they eat.
I would explain that through a properly balanced diet, one may help prevent or alleviate the symptoms of CKD. It is important to figure the protein needs based on the individual and find out what is best for him or her. I would explain to the patient that studies have found that high protein diets have been found to accelerate CKD complications and with proper protein portions and servings and a healthy diet, he or she might be able to slow or prevent CKD symptoms without the use of medication. I would make sure the patient understands this, offer them food ideas and help them fix and maybe change their current diet.
I would explain the importance of a nutritionally balanced diet on health and mortality risk. I would also explain that excessive protein intake is especially difficult on the kidneys. So, therefore I would discuss with the patient what their current intake of protein and try and come up with suggestions that modify their current diet with one that is nutritionally adequate but not overly stressful on the body. I would mention that there may be some benefit of protein from non-animal sources and no matter what type, not to overdo it. I would also suggest that the patient really listen to they body and use their food choices to guide their health. If the protein intake that they are consuming is making them feel worse then we could work to modify it. I would not however recommend really restricting protein intake as I believe they would likely be better off in a well-nourished state.
As an RD working with this type of renal patient, I would initially figure protein requirements based on his/her weight, height and activity factor. I would then figure the amount of protein they are usually consuming on a daily basis. Depending on the situation and the patient, I would from here come up with an amount that would provide adequate nutrition for him/her, keeping in mind the fact that they probably should not be on an increased protein diet. In our meeting, I would discuss with the patient the reasoning behind the lower protein intake. I could explain to the patient that high protein intake when you are a renal patient can accelerate the adverse effects of CKD, because your kidneys cannot take the workload and uric acids, phenols, ions, and other metabolic products can accumulate in the kidneys. Next I would explain that most symptoms of CKD are caused by protein intolerance, as suggested by research, and so this is the reasoning behind the lower protein diet. Keeping individual food preferences in mind, I could come up with menus and recipes that would fit into this type of diet therapy.
Nisa,
You make a great point that it is important to ask the patient what they typically consume, because they may not even be consuming enough protein. Many renal patients suffer from protein malnutrition because of not getting enough protein in his/her diet. It is important to find the balance between providing adequate nutrition and causing adverse effects.
One way to explain to the patient the importance of the correct dietary recommendations is to explain to the patient the extent of his/her CKD. The patient may not understand the extent of his condition and it is up to the RD to help the patient understand the role of the kidney and nutrition. I would analyze the needs of the patient and explain to him/her that protein is going to most likely be restricted. The kidneys work very hard to process the protein when it is eaten, and since the kidneys are not working properly with CKD, protein needs to be restricted in order to put less strain on the kidneys. A technique to make sure they understand is to explain to them the severity of the situation and give them other food options to make up for the lack of protein.
-Pam Moore (having problems logging in)
Though there is a lack of evidence showing that a low-protein diet can slow the progression of CKD, there are statistics concerning the reduction of symptoms caused by protein intolerance. Similarly, the article points out that a high protein diet accumulates waste products which can accelerate renal deterioration. Symptoms are as much of a concern to a patient as the condition itself; therefore most patients will make changes in hopes of reducing those symptoms whether or not research says it’s true.
Vanessa,
You make a great point. It is important to offer meal suggestions and recipe alterations while keeping in mind a patient’s food preference. As dietitians, we are able to explain several dietary modifications that will offer improvement; however, if the patient doesn’t know how to do this, it’s meaningless.
I would begin by explaining the functions of the kidneys in removing waste products from the blood. The patients can then begin to understand why a kidney that is not functioning properly results in certain signs and symptoms. Then it is a fairly easy concept that if the kidneys can’t properly filter waste products out of the blood, patients may need to reduce the intake of those foods that create the highest amounts of wastes (aka- proteins!). As Vanessa stated earlier, the build-up of those nitrogenous substances in the blood, uremia, can lead to very immediate symptoms, so this can further motivate the patient to comply with the low-protein diet. I would definitely provide the patient with tools to help them follow the low-protein diet, such as guidelines for protein levels in commonly consumed foods, recipe ideas and food alternatives to high protein items.
If the individual I was counseling had only mild kidney disease or was just at risk for kidney disease, I would certainly educate the individual about how a high protein diet exceeding the RDA recommendations can accelerate the CKD process. I would also inform the individual that a diet rich in variety from all the macronutrient groups with the least amount of calories coming from protein is ideal for his or her general health. If the individual was in the end stage of renal disease, I would investigate the situation very carefully before making any dietary recommendations. If the individual was very advanced in age, severely depressed, and just suffering through life, I would question if significant dietary intervention is appropriate.
I would begin by simplifying all the information that I wanted to convey to the patient. I feel that this is the time to set realistic expectations and nutrition goals. I would have the patient write out 3 goals. One goal for the next week, another for the next month and their goal at the end of the year. Next, I would have the patient write out three life goals that he/she wants to do within the next week, the next month and the next year. I would explain to the patient that by following a low-protein diet they will be able to live a much longer, healthier life. I believe that by having the patient actually write out goals it enforces the idea of committing to a healthy lifestyle. I would explain that these dietary recommendations are by no means intended to restrict one's life but rather takes a different approach to enjoyable living.
Annie,
I completely agree with your statement on concerning how critical it is not to over-do it. I think that nutrition lesson would really benefit the patient more than anything else. I would also provide hints on ways to not over-do protein intake. One way could be to fill one's plate with vegetables and complex carbs and only leave a small portion for the protein.
Protein can be tricky for CKD patients. Although protein is a necessary nutrient, CKD patients are often faced with the dilemma of having to limit protein intake. I would explain to the patient the effect a high protein diet can have on their CKD condition and the importance to reduce the amount in their diet. I would first explain to the patient how protein is associated with the kidneys. When protein is ingested and used by the body, protein waste products are created. Healthy kidneys have millions of nephrons that can filter this waste and remove it from the body in urine. Healthy kidneys can easily remove protein waste, even when very large amounts of protein are eaten. On the other hand, unhealthy kidneys lose the ability to remove protein waste. I would then explain the harm of this lack of ability to remove protein waste from the body. Protein waste starts to build up in the blood and as kidney function continues to decline, more waste accumulates resulting in nausea, loss of appetite, fatigue and illness. Too much protein waste in the blood can become toxic. A lower protein diet may help reduce waste accumulation and even help slow the progression of kidney disease in some people. The degree of restriction will be individualized based on the stage of CKD they are currently in and labs that show how well their kidneys are functioning. Hopefully the education would promote some compliance and motivate them to want to put effort into modifying their diet. I would then proceed to collect a diet recall as well as gather their food preferences and offer them advice on how to use alternatives to consume a restricted protein diet and still enjoy some of their favorite foods.
I would first find the patient's protein requirements. I would then tell them not to exceed this amount. The most important thing would be for the patient to receive proper nutrition and not have nutrition deficits. I would look at the patients current diet to access their level of protein intake. Possibly switching some protein to non-animal protein sources may prevent some protein intolerance. The patient needs to pay attention to their individual case, it will vary depending on the severity of the disease. There is not enough evidence to be sure that a low-protein diet will slow CKD so until then concentrating on overall nutrition and individual reactions to protein is something to focus on.
Nisa,
I agree that it is important to first ask the patient what they typically consume to see whether they are even consuming much protein and enough protein to begin with. If they aren't then it would not be a good idea to place them on a low-protein diet. There are chances that they can already be protein malnourished. I agree with you that if this were to happen, that as a dietitian, we should recommend they eat HBV proteins and just do not over induldge in these items for they may worsen CKD. I also think by telling the patient "your food is your medicine" is a great way to try to promote compliance.
I would start by talking with the CKD patient and explaining the importance of a diet low in protein. I would explain how the kidneys are at decreased function and that diets high in protein can cause extra stress on the kidneys. I would stress the importance of maintaining this diet to help manage CKD. I would also try to get a feel of what type and how much protein the patient eats. If the patient is eating a lot of protein, then I would try to get them to slowly decrease the amount of protein they are eating. It is important to make them aware of what foods are high in protein so that they can abstain from eating these foods often. Providing the patients with education and easing them into a low-protein diet will hopefully prevent the non-compliance with the diet
Jessie-
I like your idea about goal setting for the patients. Goal setting reminds people of what they want to work for and how they want to accomplish their goals. I think it is also beneficial to make the nutrition education individualized. Getting the patient involved with their own recommendations will most likely help them with maintaining their diet.
I would try to understand the individuals needs before I gave them any protein restrictions or recommendations. Hopefully in understanding their needs and what has been working for them and what has not, I would be able to tell them what studies have shown regarding CKD and protein and then applying that to their individualized diet.
I would explain the science behind the low protein diet for CKD. I would explain how the kidneys work and how protein overload can lead to an accumulation of waste products. I would take a look at the patients diet through some sort of diet recall to see how much protein they were ingesting on a typical day. I would then tell them to experimentally try the low-protein diet and see if it relieved any symptoms. I think experience would be the best way to convince this type of patient that low protein will benefit the kidneys and thus the overall well-being of the patient.
Suzanne,
I agree with you that it is important to first address the patients nutrition needs to avoid malnutrition and then assess if protein restriction is necessary.
I would explain to the pt that high protein diets place unnecessary strain on the kidneys due to the accumulation of waste products. Taking in too much protein will accelerate their complications. Next I would inform them on taking in proteins with a high biological value and make a list of foods the meet the criteria. Since they will not be ingesting very much protein it is important that the protein that they do take in is high quality. Finally I would inform them that their diet is the first line of defense in preventing CKD and that taking medication should only be considered if conditions continue to worsen.
Brittney,
I agree with you when you stated that we need to keep the individuals food preferences in mind. This is one thing that may be over looked when giving diet education. It is easy to tell people what to eat but adjusting it too fit their needs and preferences could become more difficult. In addition, they will be more likely to comply with the prescribed diet if we include foods that they normally consume.
I would probably explain to the patient why this diet is beneficial to them. Generally, when patients understand what will happen if they do not comply then they are more likely to follow the diet that the RD & patient agree upon. I guess in a way I am saying that the "scare tactic" is the way to go. Although, you must be careful to not make the patient feel as if their life is doomed because of the illness they have. It is a fine line that needs to be established so the patient knows that they can definitely live healthfully with this disease/disorder but if they do not make some changes it may make their lifestyle hard to continue. In my eyes a visit with a dietitian should not make a patient more confused and frustrated but should in the end help the patient understand their condition better and help them to see how they can to some extent take their treatment into their own hands.
Jamie said...
First, the RD needs to make sure the patient is aware of his/her health status and disease state. Then, the specific dietary recommendations should be delivered to the patient in a way he/she understands. This can be done by way of interactive counseling, videos, pamphlets, and support groups.
Jamie said...
In addition, protein intake should be addressed and have the patient understand how high protein intake can harm the kidneys - having them work harder than they are able to at this point.
When introducing a patient to a new diet, it may be hard for them to understand why their diet has worked so long for them and now they need to change. I think it would be beneficial to explain to the patient why their old diet did not work and why they need to adopt the new diet. This can give them some perspective about how this new diet will help. I believe that an RD needs to explain the consequences of not following the diet, but at the same time not make the patient feel bullied or lectured about not following it. Since they are having problems following the diet, maybe set up a goal with the patient that will gradually meet the needs of the diet. I believing setting personalized goals is the best form of encouraging compliance with a patient.
Lauren,
You make an excellent point about patient compliance. Using the "scare tatic" can work in some situations but we don't want to make the patients feel like they are doomed with this disease, as she stated. I agree that gradually working the patient into a difficult diet is the way to go.
I would emphasize the importance of following a low protein diet and as a few people have noted it is essential to briefly explain the role of the kidneys and why they are so important to the body. It is sad that so many people think that with the advancement of technology in health care that many people do not feel the urgency to make changes to improve their health. I wish we could get across the point a little more clearly, if they want to live longer... they better listen up and make changes...bold I know but sometimes people need the scare tactic.
First I would try to keep it simple, because lots of patients can be easily confused when an RD uses certain terms. I would explain the importance of consuming a diet lower in protein. Then I would provide a handout giving some high protein foods items and some lower protein foods to eat more often. Then I would provide the patient with a protein goal to try to stay within each day. Lastly I would comment that by consuming a lower protein diet it will hopefully prolong the need for dialysis.
I would explain to a patient how the kidney works on removing waste from our system and then explain what CKD can do to a person’s kidney. Once the patient has the process of what the kidney does then I would go into how high protein in ones diet can affect a CKD patient. This can then lead to talking about how much protein this patient is eating and then talking about either lowering this intake or keeping it the same.
The RD can explain the importance of dietary recommendations by explaing what the kidney actually does for the body. Also what foods help the kidney to work more efficiently and what foods can put a lot of work on the kidney. Then I would explain why putting a lot of work on the kidney would be a bad idea in their condition. And that the proff would be to try the balenced diet and you will see your symptoms and discomfort get better. The proof is in the pudding!
Annie,
Thats a good idea to talk about the benefit of protein sources from plant and animal. I think a minimal intake would be neccessary. Small intake would at least give some complete animal proteins that the body needs and maybe it will decrease the malnutrition of excreting nitrogen.
The issue of non-compliance is observed with the renal diet as well as with other restrictive diets. When I first began to offer education to verbally non-compliant patients in the hospital, I felt like a complete failure for not "showing them the light" toward behavior change (a feeling that I had to quickly get over). An educational handout does not translate in to behavior change. Explaining the importance of dietary compliance to avoid complications may be motivation to change or it may not be. Motivate the patient by showing them that given their life (food preferences/availability, daily schedules, family situations) they can make the necessary changes. When speaking to the patient, always explain 'why' to any diet recommendation. As dietitians we must listen to their verbal and non-verbal cues to examine their readiness for change, provide them with the necessary tools (simple materials, encouragement, empathy), and also promote family support (if applicable).
As the RD I would determine the pt's protein needs (in g/kg and adjust for condition). I would discuss the importance of a balanced diet and stress that excess consumption of any one nutrient is not necessary. That would go for protein as well, especially today when everyone thinks more is better. I would explain the stress that protein digestion would put on the kidneys in removing waste products which could potentially worsen their condition. I would also recommend plant protein sources and sources of the protein that provide excess protein that is not necessary.
First I think it is important to find out what the individual patient’s protein requirements are so that I am not trying to restrict it too much or giving them more than they really need. I would explain what CKD is and why it is important use a low-protein diet. I would encourage compliance by explaining what could happen if they did not follow the diet. I would also suggest foods and different meal options that could help them stay on track of this diet.
Karlie,
I agree with your approach to start with educating the patient about how important his or her kidney really is. If the patient can understand the importance of the kidney and the severity of complications associated with CKD, he or she will be more apt to listen to you and truly try to make lifestyle changes.
Jamie said…
Mary Ellen – I think it is interesting that you mention patients not taking their health seriously, especially after they just had a triple-bypass surgery, kidney transplant, stoke, etc. Proper nutrition is especially critical after events such as these; however, many do not take nutrition seriously. This may have to do with the idea that “drugs can cure all.”
I would explain to the patient the importance of a balanced diet and how it is especially important with their CKD. I would calculate their protein needs and explain to them that it is important to stick with it in order to not put any additional strain of their kidneys. I would tell them that consuming high amounts of protein causes wastes to accumulate in their bodies and can speeds up the deterioration of their kidneys. I would also remind them of the important of taking care of their bodies through the foods they eat.
One important thing to remember when providing a patient with diet education is to put yourself in their shoes. It is important to see how they feel about making the changes, so that you have a understanding of where they are in the stages of change model. Then it is important to provide them with the education and then ask them what is going to be the most challenging thing about the diet. Next talk with them on how to overcome those obstacles. As RD's it is important for us to really use our counseling skills to help changes be made.
Lauren, I agree with you on the “scare-tactic”. That sounds like a horrible way to approach a pt; however they do need to fully understand the implications of their actions. Sometimes the only way to truly get pts to listen to a diet order is to get them to understand what could possibly happen/not happen (which is what could be potentially frightening for a pt) if the diet were to be ignored.
Calculating protein recommendation for patients with CKD is tricky because you want to alleviate possible symptoms of protein overload (edema, hypertension, etc.) but also you do not want to promote malnutrition from not receiving enough protein sources. I would first and foremost individualize the recommendations for diet based on the tolerance level of the patient. Some patients may handle a high load of protein while other will have to use high caloric diets to prevent muscle/tissue wasting. If a patient is having symptoms from the foods they eat, that is pretty good encouragement to develop a diet that will work with their bodies to make them feel better. I believe that some people will listen and work with the RD to modify and be able to follow their diets in order to lead a healthier lifestyle, and others (no matter how hard you try to motivate them to eat healthier choices) will eat whatever they like. In order to try to persuade these people to follow dietary recommendations for CKD as compared to what their diet is currently, I would list off possible benefits, the main one being reducing the progression of CKD, and then see it they want to comply.
Explain the kidney functions and the role that CRF has on kidney function. Explain to the pt what is happening to them, what they have control over, and the choices they have and consequences to those decisions. Explain the side effects (N/V, fatigue, and weakness). Encourage adherence by helping pt to understand they will feel better (decreasing the side effects of CRF) the closer they follow the diet. This might be all that it takes to motivate them to adhere to the diet. Work with pt to plan meals with foods that are within protein requirements and food preferences.
Breine-
I completely agree with you that
handouts do not magically create change in patients and that taking into account the various aspects of their life may help them to see that these goals may be a little more realistic than they thought. Like you said, it is also very important to listen to BOTH verbal and non-verbal cues to find out where they are, how they really feel, etc. and to include their family in the plan.
I would explain to the patient the effect a high protein diet can have on their CKD condition and the importance to reduce the amount in their diet. I would stress the importance of keeping a low protein diet. A lower protein diet may help reduce waste accumulation and can help slow the progression of kidney disease in some people. I would look at the patients current diet to access their level of protein intake. After reviewing their diet I would explain to them what they need to include in their diet and help them set goals to reach.
Lisa,
I think it’s interesting that you mention the importance of the symptoms of these diseases. I never really thought about how all the terrible symptoms affect these people and by figuring out what types of foods and medicines are bothering them the symptoms can be relieved. If people hear there is a chance of lowering their symptoms they will be more willing to adapt and follow recommendations.
As a RD, I would spend a little time simply talking about the patients “average daily intake” and how that compares to the different food recommendations. Then I would explain how the diet affects CKD. If the patient understands why eating a high protein diet might overload the kidneys and cause them additional complications then the patient would be more likely to adhere to the modifications.
Sara,
I agree with you that it is very important to make sure that the patient understands the importance of complying to the diet and the effect of the diet on their kidneys.
JoAnna
I agree with you that we should try to work with the patient on an individual basis and work witht heir protein levels to find out what works best with their body. I'm glad you brought up the fact that some patients may not comply as hard as you try. This can be a challenge, but working on explaining the benefits of a lower protein diet on slowly CKD progression may help!
Steph,
I agree with you in your approach to explain that more is not necessarily better. These days, it seems that "more is better" is the mind set. Some people do not know the problems that can arise from overconsuming protein or other nutrients such as vitamins. I think education in this area is very crucial.
larusk85 said...
Jessie,
I thought it was interesting that you thought to include goals into your method of counseling. Getting the patient involved in their own planning and execution of their new life style is crucial. I also agree with simplifying the information to better educate the individual.
Sometimes there is not much you can do to get patients to comply to dietary changes. The renal diet is hard to follow, there are many restrictions of foods that enjoy. However, I think that it is important that patients understand why they need to avoid certain foods. Alternatives should be given for foods that patients commonly enjoy, but are not allowed on a renal diet. For example, I had a patient who was in the hospital with renal problems, he was currently drinking half a gallon of milk a day. After, talking to him I was trying to think of possilbe alternatives for milk that he could have and discovered that rice milk is low in potassium. So, I think that the diet needs to be individualized. Find out what the patient is currently eating and give suggesstions to make changes. They may understand the reasons why they need to make the changes, but without stratgies to make the changes it is less likely that they will comply.
Vanessa,
I believe that you have outlined a very good educational program for a patient who has CKD. There are many important aspects with regards to following the diet with CKD patients. If you make them realize the consequences, as you have, they may realize that this is a serious problem that can lead to other complications and serious problems. Also, CKD is a type of disease that is not stable, but may progress if the client continues to lead the same lifestyle, so stressing the facts and consequences, and helping to manage the disease is necessary!
JoAnna,
I agree with a lot of what you said. As a dietitian you want to alleviate symptoms in cases of protein overload but also make sure your patient receives proper nutrition. I also agree that it is important to individualize the recommendations for diet based on the tolerance level of the patient.
Breine-
I agree with you in that it is a good idea to listen and to watch a patient’s verbal and non-verbal cues. Even though a patient might being saying that they are ready to change their diet their body language could be telling you that they are just agreeing with you to get the meeting over with. It is also good to understand that you are not going to be able to make everyone change their ways, but at least you know that you tried to help them.
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