NUTRITION LITERACY AND ITS ASSOCIATION WITH DIETARY ADHERENCE AND

HOSPITALIZATION AMONG CHRONIC KIDNEY DISEASE PATIENS ON HEMODIALYSIS

Charity Dianne M. Jocame MD, Maricris B. Araneta MD

INTRODUCTION

Chronic Kidney Disease (CKD) has been recognized as a global health problem. In
2017, approximately 697 million cases of CKD have been recorded with a global prevalence of
9.1%. worldwide in 2017. Consistent with this, the burden of CKD also continues to rise in the
Philippines with a prevalence of more than nine million, a 13.2% increase in the age-
standardized rates between 1990 and 2017.
In CKD, there is a progressive decline in the function of the kidney over time. This
translates to a diminished capacity of the kidney to remove waste products from the
bloodstream. Eventually, the disease will progress to end-stage renal disease where renal
replacement therapy (RRT) is inevitable to sustain life. In addition to RRT and drug therapy,
medical nutrition therapy is equally important in the management of CKD; restriction of intake of
certain nutrients particularly carbohydrates, protein, sodium, potassium, phosphorus and fluids
are necessary to prevent the further decline of kidney function reduce risk for morbidity and all-
cause mortality.
Adherence is defined as the extent to which a person’s behavior in taking medication,
following a diet, and/or executing lifestyle changes corresponds with agreed recommendations
for their disease condition. Low rates of adherence to the recommended dietary and fluid intake
among CKD patients have been documented in previous studies with a mean of 31.5% and
65.8% respectively. Several factors have been reported to influence adherence such as the
restrictive and complex diet, presence of social support, socio-economic status, positive attitude
and nutrition literacy. Nutrition literacy is defined as the degree to which individuals have the
capacity to obtain, process, and understand nutrition information and skills needed in order to
make appropriate nutrition decisions. Low nutrition literacy leads to poor adherence on the
prescribed diet, however evidence on this is limited. The aim of this study therefore is to study
the association between nutrition literacy and dietary adherence.
GENERAL OBJECTIVE

To determine the association between nutrition literacy and adherence to dietary and fluid
prescription and hospitalization among chronic kidney disease patients on hemodialysis

SPECIFIC OBJECTIVES

1. Describe the socio-demographic characteristics of chronic kidney disease patients on

hemodialysis in terms of
a. Age
b. Sex
c. Monthly family income
d. Marital status
e. Educational attainment
f. Employment status
g. Comorbidities
i. Hypertension
ii. Diabetes
h. Dialysis vintage this may not be applicable as most of the patients (99%) don’t get
the benefit of transplantation
2. Determine the level of nutrition literacy among chronic kidney disease patients on
hemodialysis how do you measure this?
3. Determine the association between the socio-demographic characteristics and nutrition
literacy among chronic kidney disease patients on hemodialysis
4. Determine the percent of adherence to dietary and fluid prescription among chronic
kidney disease patients on hemodialysis
5. Determine the association between nutrition literacy and adherence to dietary and fluid
prescription among chronic kidney disease patients on hemodialysis
6. Identify the factors associated with non-adherence to dietary and fluid prescription of
chronic kidney disease patients on hemodialysis
7. Determine the rate of hospitalization among chronic kidney disease patients on
hemodialysis this has many confounding factors. You may want to narrow down as to
the cause of hospitalization.
 8. Determine the association between nutrition literacy and rate of hospitalization among
chronic kidney disease patients on hemodialysis. What are the parameters for you to
assess adequate nutrition in these patients? You may want to check on it. But this
would require funding because this will entail laboratory examination.

CONCEPTUAL FRAMEWORK

Age
Sex Dietary
Monthly family income Adherence
Marital status
Educational attainment Nutrition
Employment status Literacy

Comorbidities
Dialysis vintage Hospitalization
 METHODOLOGY

Study Design

This will be a prospective cohort study that will evaluate the association between
nutrition literacy and adherence to dietary and fluid prescription and hospitalization among
chronic kidney disease patients on hemodialysis

Study Setting

This study will be conducted on selected hemodialysis units in Bacolod City.

Study Period

This study will be conducted from February 2021 to June 2022.

Study Population

Inclusion Criteria

● Chronic Kidney Disease patients on Hemodialysis at least twice a week for more than 6
months
● Age >/= 19 years old
● Willing and able to provide written informed consent

Exclusion Criteria

● Patients who are unable to fill up the questionnaire (e.g., those with dementia or intellectual
disability)
● Patients with terminal illness who are undergoing palliative hemodialysis

Sampling Procedure
 Multistage cluster sampling will be employed in this study.

Data Collection Tools

Dietary adherence. Dietary adherence will be assessed using the dialysis diet and fluid non‐
adherence questionnaire (DDFQ). This is a validated tool developed by Vlaminck et al. which
has been used to measure nonadherence to diet and fluid restrictions of CKD patients on
Hemodialysis within the past 14 days. This questionnaire has four items and nonadherence to
diet and fluid restriction is rated on a 5-point likert scale ranging from 0 to 4 (no nonadherence =
0, mild nonadherence= 1, moderate nonadherence = 2, severe nonadherence = 3 and very
severe nonadherence = 4). The higher the score is, the higher the patient’s nonadherence.

Nutrition Literacy. This will be assessed using the Dialysis Specific Nutrition Literacy Scale
(DSLNS).

Will you provide dietary guidance/lectures for these patients? Because most HD centers don’t
adhere to dietary counseling. And if dietary counseling is done, not all patients are able to have
it. I suggest you adopt a dialysis unit, get necessary permission from the unit. Hira a
nutritionist, or make the nutritionist a co-author. Then conduct dietary counseling for a certain
period. Then after the dietary counseling part is done, conduct your research as to how many of
those who received dietary counselling are still adherent to the regimen and the factors
influencing the compliance.

Data Collection Method

A cover letter explaining the purpose of this study will be distributed among selected
hemodialysis units in Bacolod City. Participants will be recruited from each of these
hemodialysis units. First, they will be asked to sign an informed consent. Next, they will fill up
the data collection form, to assess the social and demographic profile of each participant, the
DDFQ to assess their dietary adherence and the DSNLS to assess their nutrition literacy. Follow
up will be done every 3 months via phone call with the primary caregiver to check for
hospitalization.
Data Analysis

Frequency table and percentage will be used to summarize the socio-demographic

characteristics of the study population. Percentage will be used to measure the level of dietary
adherence and nutrition literacy of CKD patients. Linear regression analysis will be used to
determine the association between

Ethical Considerations

This study will undergo approval from the Corazon Locsin Montelibano Memorial Regional
Hospital Ethics Review Committee. The investigators will perform the study in accordance to the
ethical principles laid down in the declaration of Helsinki. Informed consent will be obtained prior
to data collection. Each participant will be assigned a unique identification number. Any data,
forms, reports and other records will only be identified using the identification number and only
the investigators will have access to this. Answered questionnaires be placed in a locked filing
cabinet. Information will not be released without written permission of the participant.

Data Ownership and Publication

All data, results, reports and any other information collected is owned by the investigators.
They have full rights of publication based on data from this study.
 APPENDIX 1. THE DIALYSIS DIET AND FLUID NON-ADHERENCE QUESTIONNAIRE

Vlaminck H, Maes B, Jacobs A, Reyntjens S, Evers G. The dialysis diet and fluid non-
adherence questionnaire: validity testing of a self-report instrument for clinical practice. J Clin
Nurs. 2001 Sep;10(5):707-15. doi: 10.1046/j.1365-2702.2001.00537.x. PMID: 11822521.
 APPENDIX 2. DIALYSIS SPECIFIC NUTRITION LITERACY SCALE (DSNLS)
Dialysis Specific Nutrition Literacy Scale (DSNLS) Poor Fair Good
1. How would you rate your ability to obtain information on diet-related health
complications from health-care personnel?
1 2 3
Please specify:
a) Medical doctor b) Nurse c) Medical assistant d) Dietitian
e) Others: _____________
2. How would you rate your understanding on diet-related health complications
in dialysis on printed education materials?

a. Diet low in energy & protein b. Diet high in sodium

1 2 3
c. Diet high in potassium d. Diet high in phosphorus

*Please rate “3” if you know at least three complications; rate “2” if you know at least
two complications; otherwise please rate “1”.
3. How would you rate your ability to evaluate your diet-related health risk
with reference to your laboratory results? 1 2 3

4. How would you rate your ability to obtain tips on dialysis diet from health-
care professionals?

Please specify:
1 2 3
a) Medical doctor b) Nurse c) Medical assistant d) Dietitian
e) Others: _____________
5. How would you rate your ability to understand the concept of dialysis diet
on printed education materials?

a. Types of nutrient that need to be consumed sufficiently.

b. Types of nutrient that need to be limited. 1 2 3
c. Dietary modification to reduce minerals content of foods.

*Please rate “3” if you know all the three concepts; rate “2” if you know at least two
concepts; otherwise please rate “1”.
6. How would you rate your ability to judge the nutrient levels (high sodium,
potassium & phosphorus content) in food items? 1 2 3

7. How would you rate your ability to obtain information on dialysis diet from
sources other than healthcare personnel?

Please specify: 1 2 3
a) Internet b) Family members b) Peers/Friends;
c) Others: ______________
8. How would you rate your ability to judge if the information on dialysis diet
from non-medical sources (e.g. internet, friends and etc.) is reliable? 1 2 3

APPENDIX 3. DIALYSIS-RELATED DIETARY KNOWLEDGE QUESTIONNAIRE (DDKQ)

1. Excess intake of potassium _____________

(1) is harmful to bone (3) raise blood pressure
(2) is harmful to heart (4) not sure

2. Excess intake of sodium _____________

(1) is harmful to bone (3) raise blood pressure
(2) increase body weight (4) not sure

3. Excess intake of phosphate _____________

(1) is harmful to bone (3) causes breathing difficulty
(2) raise blood pressure (4) not sure

4. Which of the following food item(s)/beverage(s) is/are high in potassium?

Items Yes No Not sure
a. Chocolate beverages 1 2 0
 b. Syrup drinks 1 2 0
c. Coconut water 1 2 0
d. Bean sprout 1 2 0
e. Sawi 1 2 0
f. Petai 1 2 0
g. Potato 1 2 0
h. Banana 1 2 0
i. Grapes 1 2 0
j. Apple 1 2 0
k. Durian 1 2 0
5. Which of the following food item(s)/beverage(s) is/are high in phosphate?
Food Items Yes No Not sure
a. Teh Tarik 1 2 0
b. Milk 1 2 0
c. Orange juice 1 2 0
d. Instant noodle 1 2 0
e. Roti Canai 1 2 0
f. Kuey Teow 1 2 0
g. Egg white 1 2 0
h. Fish 1 2 0

6. Which of the following food(s) is/are high in sodium?

Food Items Yes No Not sure
a. Anchovy 1 2 0
b. Sausage 1 2 0
c. Fast food 1 2 0
End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ)
This survey asks for your opinion about how well you follow your dialysis treatment schedule
and about medical recommendations related to medication, diet, and fluid intake. This
information will help us to understand if you have difficulty following your dialysis treatment,
medication regimen, fluid restriction, and recommended diet. Please answer every question by
marking the appropriate box. If you are unsure about how to answer, please choose one best
answer that applies to you.
Note: Numbers in parentheses are the response codes.

IV. Fluid

29 When was the last time a □ This week(1)

. medical professional (your
doctor, nurse or dietician or
other medical staff) spoke to
you about your fluid
restrictions?
□ Last week(2)
□ One month ago(3)
□ More than a month ago(4)
□ When I began dialysis treatment(5)
□ Never(6)
□ Other (Specify)(7): _____________

30 How often does a medical □ Every dialysis treatment(1)

. professional (your doctor,
nurse, dietician or other
medical staff) talk to you about
the importance of fluid
restriction?
□ Every week(2)
□ Every month(3)
□ Every 2 to 3 months(4)
□ Every 4 to 6 months(5)
 □ When I have abnormal blood or other (for example,
blood pressure) test results(6)
□ Rarely(7)
□ Irregularly(8)
□ Never(9)
□ Other (Specify)(10): _____________

31 During the past week, how □ All of the time(1)

. often have you followed □ Most of the time(2)
the fluid
restriction recommendations? □ About half of the time(3)
□ Very seldom(4)
□ None of the time(5)

32 How important do you think it □ Highly important(1)

. is to limit your fluid intake? □ Very important(2)
□ Moderately important(3)
□ A little important(4)
□ Not important(5)

33 Why do you think it is □ Because I fully understand that my kidney condition

. important for you to limit your
fluid intake? (Please choose
one best answer that applies
to you.)
requires limiting fluid intake(1)
□ Because limiting fluid intake is important to keep my
body healthy(2)
□ Because a medical professional (my doctor, nurse,
dietician, or other medical staff) told me to do so(3)
□ Because I got sick after I drank lots of fluid(4)
□ Because I was hospitalized after I drank lots of
fluid(5)
□ I don't think limiting fluid is very important to me(6)
□ Other (Specify)(7): _____________

34 Have you had any difficulty □ No(1)

. with limiting your fluid intake? □ Yes(2)

35 How much difficulty have you □ No difficulty(1)

. had following your fluid □ A little difficulty(2)
restriction recommendations?
□ Moderate difficulty(3)
□ A lot of difficulty(4)

36 If you had difficulty following
. your fluid restriction
recommendations, what type
of difficulty have you had?
37 During the past week, how
. many times have you weighed
yourself at home (outside
dialysis center)?
38 How important do you think it
. is to weigh yourself daily?
V. Diet
39 When was last time a medical
. professional (your doctor,
nurse, dietician, or other
medical staff) talked to you
about your diet?
40 How often does a medical
. professional (your doctor,
nurse, dietician or other
medical staff) talk to you about
the importance of following a
proper diet?
□ I was unable to follow any recommendations at all(5)
□ No difficulty(1)
□ Not interested(2)
□ I was unable to control fluid intake(3)
□ I don't understand how to follow the fluid restriction(4)
□ Other(5): ____________
□ More than 3 times(1)
□ 3 times(2)
□ Twice(3)
□ Once(4)
□ None of the time(5)
□ Other(6): ____________
□ Highly important(1)
□ Very important(2)
□ Moderately important(3)
□ A little important(4)
□ Not important(5)
□ This week(1)
□ Last week(2)
□ One month ago(3)
□ More than a month ago(4)
□ When I first began dialysis treatment(5)
□ Never(6)
□ Other (Specify)(7): ____________
□ Every dialysis treatment(1)
□ Every week(2)
□ Every month(3)
□ Every 2 to 3 months(4)
□ Every 4 to 6 months(5)

41 How important do you think it
. is to watch the types of food
you eat each day?
42 Why do you think it is
. important for you to watch
your diet daily? (Please
choose one best answer that
applies to you.)
43 Have you had any difficulty
. following your dietary
recommendations?
44 How much difficulty have you
. had following your dietary
recommendations?
45 What type of difficulty have
. you had keeping your dietary
recommendations?
□ When I have abnormal blood or other (for example,
blood pressure) test results(6)
□ Rarely(7)
□ Irregularly(8)
□ Never(9)
□ Other (Specify)(10): ____________
□ Highly important(1)
□ Very important(2)
□ Moderately important(3)
□ A little important(4)
□ Not important(5)
□ Because I fully understand that my kidney condition
requires to watch my diet(1)
□ Because watching my diet is important to keep my
body healthy(2)
□ Because a medical professional (my doctor, nurse,
or dietician) told me to do so(3)
□ Because I got sick after eating certain food that I
was not supposed to eat(4)
□ Because I was hospitalized after eating certain food
that I was not supposed to eat(5)
□ I don't think watching my diet is important to me(6)
□ Other (Specify)(7): ____________
□ No(1)
□ Yes(2)
□ No difficulty(1)
□ A little difficulty(2)
□ Moderate difficulty(3)
□ A lot of difficulty(4)
□ I was unable to follow any recommendations at all(5)
□ Not applicable: No difficulty(1)
□ I was not willing to control what I want to eat(2)
□ I was unable to avoid certain unrecommended food(3)
 □ I don't understand what type of diet to follow(4)
□ Other (Specify)(5): ____________

46 During the past week, how □ All of the time(1)

. many times have you followed
the diet recommendations?
□ Most of the time(2)
□ About half of the time(3)
□ Very seldom(4)
□ None of the time(5)

Kim Y, Evangelista LS, Phillips LR, Pavlish C, Kopple JD. The End-Stage Renal Disease Adherence
Questionnaire (ESRD-AQ): testing the psychometric properties in patients receiving in-center
hemodialysis. Nephrol Nurs J. 2010 Jul-Aug;37(4):377-93. PMID: 20830945; PMCID:
PMC3077091.