Underreporting of Energy Intake in Peritoneal Dialysis Patients

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1 RESEARCH BRIEF Underreporting of Energy Intake in Peritoneal Dialysis Patients Ana Paula Bazanelli, MS,* Maria Ayako Kamimura, PhD,* Priscila Vasselai, MS,* Sergio Antônio Draibe, MD, PhD, and Lilian Cuppari, PhD* Objectives: This study aimed to assess the prevalence of underreporting among patients treated by peritoneal dialysis (PD), and to investigate whether the reported energy intake is influenced by overweight status in this population. Design: This was a prospective, observational study. Setting: This study took place at the Dialysis Unit of the Nephrology Division, Federal University of São Paulo- Oswaldo Ramos Foundation, São Paulo, Brazil. Patients: Forty adult patients were recruited: 24 men and 16 women; age, years; body mass index (BMI), kg/m 2 (x6sd); median duration of dialysis, 19 months (range, 3 to 101 months). Only patients on PD.3 months, free of peritonitis for at least 3 months, without catabolic conditions and with normal thyroid function, were included. Methods: Energy intake was evaluated using a 3-day food record. Resting energy expenditure (REE) was measured by indirect calorimetry. Body composition was assessed using dual-energy x-ray absorptiometry. The total energy (TE) offered was considered the sum of energy intake plus energy provided by glucose absorption. All measurements were collected at baseline and after 6 months. Underreporting of energy intake was considered to have occurred when the TE/REE ratio was,1.40. Results: The TE/REE ratio was Twenty-one patients (52.5%) had a TE/REE ratio,1.40. The TE/REE ratio correlated negatively with BMI (r , P,.01), and positively with duration of dialysis (r50.44, P,.01). No correlation was found between TE/REE ratio and any other variables. Patients were divided into two groups according to BMI,25 kg/m 2 and BMI $25 kg/m 2. The majority of patients (83.3%) in the higher BMI group had a TE/REE ratio,1.40. In a logistic regression analysis, using TE/REE ratio,1.40 or $1.40 as the dependent variable, BMI$25 kg/m 2 was the only determinant of energy underreporting. After 6 months of follow-up, no change in either body weight or BMI was evident. Conclusions: This study showed that a significant number of PD patients underreported the energy intake evaluated by 3-day food diaries. This finding was evidenced particularly in overweight patients. Ó 2010 by the National Kidney Foundation, Inc. All rights reserved. AN ACCURATE ASSESSMENT of dietary intake, particularly energy intake, is important, given that reported energy intake is a surrogate *Nutrition Graduation Program, Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil. Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil. Address reprint requests to Lilian Cuppari, PhD, Nutrition Graduation Program, Division of Nephrology, Federal University of São Paulo, Rua Pedro de Toledo 282, São Paulo, São Paulo, Brazil. lilian@dis.epm.br Ó 2010 by the National Kidney Foundation, Inc. All rights reserved /$36.00 doi: /j.jrn measure of total food intake. The majority of studies rely on self-report multiday food diaries, not only to assess energy intake but to evaluate a subject s compliance with treatment or to discover associations between food intake, nutritional status, and health outcomes. The gold standard for assessing the validity of reported energy from food diaries is the doubly-labeled water method, which can accurately assess total energy expenditure. However, because of the high cost of this method, the degree of misreporting of energy intake is most commonly assessed by determining the ratio of reported energy intake and of the estimated or measured resting energy expenditure (REE). Journal of Renal Nutrition, Vol 20, No 4 (July), 2010: pp

2 264 BAZANELLI ET AL In healthy individuals, findings about underreporting of energy intake were summarized in several reviews. 1 3 In general, the prevalence ranges from 20% to 85%. 4,5 A small number of studies investigated this issue in chronic kidney disease (CKD). In three studies, underreports of energy intake were found in approximately 70% of patients. 6 8 Many studies were conducted to identify factors that influence the accuracy of reported energy intake in healthy individuals. The majority of these studies showed that underreporting of energy intake is associated with female sex, 5,9 11 older age, 9,10,12,13 lower levels of education, 9,11,13,14 and mainly overweight status. 9 11,14,15 This latter finding was confirmed in two studies with CKD patients. 6,7 An inverse association between the ratio used to assess the misreporting of energy intake and body mass index was found in CKD patients who were nondialysis-dependent, 7 as well as those on hemodialysis. 6 As far as we can determine, the underreporting of energy intake has not been investigated in patients undergoing peritoneal dialysis (PD), where conditions such as overweight status and obesity are very frequent. Therefore, we sought to assess the prevalence of underreporting among patients treated by PD, and to investigate whether reported energy intake is influenced by overweight status in this population. Patients and Methods Patients Forty PD patients (21 on continuous ambulatory PD, and 19 on automated PD) were recruited from a single dialysis unit. Only patients aged over 18 years, undergoing PD for more than 3 months, free of peritonitis for at least 3 months, without catabolic conditions, and with normal thyroid function were included. Exclusion criteria comprised treatment with corticosteroid or immunosuppressive drugs, and malignant disease. The majority of study patients were sedentary (87.5%). Patients were routinely prescribed a diet containing 30 to 35 kcal/kg/day and 1.2 to 1.3 g/kg/day of protein. Written, informed consent was obtained from each patient. This study was approved by the Ethics and Research Committee of the Federal University of São Paulo. Study Design and Protocol This was a prospective, observational study. All patients underwent a first interview to meet the inclusion criteria, and to give informed consent. On the same day, patients were instructed to fill in a 3-day food diary and to collect dialysate for a 24-hour period. Those patients with residual renal function (urinary volume, $200 ml/24 hours) were also instructed to collect 24-hour urine. One to 3 weeks later, the patients were admitted to the clinic at 7:30 AM after 12 hours of fasting to undergo laboratory tests, REE measurement, and body-composition and nutritional assessment with an emptied peritoneal cavity. All measurements were repeated after 6 months. Nutritional Assessment Anthropometric measurements were performed in the morning by the same researcher, and included body weight and height. Body mass index (BMI) was calculated as body weight divided by square height, and desirable body weight was calculated using the Metropolitan Life Insurance table adapted by Grant et al. 16 Adjusted body weight was calculated according to an equation of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. 17 Body Composition Body fat and lean body mass were measured with dual-energy x-ray absorptiometry, using a scanner DPX model (Lunar Radiation Corp., Madison, WI). Food Diaries All patients had their energy intakes estimated via 3-day food diaries (3 weekdays). Patients were carefully instructed by a dietitian to record all kinds and amounts of food ingested, using household measures. Food diaries were reviewed in detail, with each patient using various models of foods and measuring tools to estimate portion sizes and to improve the accuracy of the registry. Energy was calculated using software (developed by the Federal University of São Paulo) that contains United Stated Department of Agriculture tables as the nutrient database. 18 The nutrient contents of Brazilian food items were included in the software s database. The mean energy intake during 3 days was

3 UNDERREPORTING OF ENERGY INTAKE IN PD 265 Table 1. Main Characteristics of Patients and Data Related to Total Energy Offered and Resting Energy Expenditure (n 5 40) Gender (male/female) 24/16 Age (y) Body mass index (kg/m 2 ) Duration of dialysis (mo)* 19 (3 101) Body fat (%) Male Female Serum creatinine (mg/dl) Serum urea (mg/dl) Serum glucose (mg/dl) TSH (miu/ml) Energy Intake (kcal/day) Glucose absorbed (kcal/day) TE (kcal/day) TE(kcal/kg/day) REE (kcal/day) TE/REE ratio TE/REE ratio,1.40, n (%) 21 (52.5) Values are mean 6 standard deviation. TSH, thyroid-stimulating hormone; TE, total energy offered; REE, resting energy expenditure. *Median and range. P,.001, male vs. female. considered for analysis. Energy intake was normalized according to desirable body weight. Resting Energy Expenditure The REE was measured by indirect calorimetry, using an open-circuit, ventilated, computerized metabolic system (Vmax series 29 n, Sensor Medics Corp., Yorba Linda, CA). Initially, the flow sensor was calibrated with a syringe piston, to allow for measurements of high and low inspiratory and expiratory flows. Oxygen and carbon dioxide sensors were then calibrated before each REE measurement, using mixed reference gases of known composition. All subjects were instructed to maintain their regular medications, to refrain from any unusual physical activity for 24 hours before the test, and to maintain their usual sleep schedule on the night before REE measurement. They were admitted to the clinic at 7:30 AM after an overnight fast of 12 hours. After resting for 30 minutes in a recumbent position, subjects breathed for 30 minutes through a clear plastic canopy placed over their heads in a quiet, dimly lit, thermo-neutral room. They were instructed to avoid hyperventilation, fidgeting, or falling asleep during the test. Oxygen consumption and carbon dioxide production were measured at 1-minute intervals, and the mean of the final 20 minutes was used to calculate REE, according to the equation of Weir, 19 without using urinary urea nitrogen level: Basal metabolic rateðbmrþðkcal=minþ 53:9½VO 2 ðl=minþš11:1½vco 2 ðl=minþš where VO 2 is volume of oxygen and VCO 2 is volume of carbon dioxide. We then applied: REEðkcal=dayÞ5BMR31440 minutes: Laboratory Parameters Blood samples were drawn after an overnight fast of 12 hours. Levels of serum and dialysate creatinine, urea, and glucose were determined using a standard autoanalyzer. Thyroid-stimulating hormone (normal range, 0.4 to 4.0 miu/ ml) and thyroxine (normal range, 0.7 to 1.5 ng/dl) were measured using immunofluorometric assays. The amount of glucose drained during 24 hours was measured. Peritoneal glucose absorption was calculated by subtracting the 24-hour amount of drained glucose from the total glucose content of 24-hour dialysate instilled. Underreporting Analysis Total energy offered (TE) was considered the sum of energy intake plus the energy provided by the measured glucose absorbed. The ratio of TE and REE (TE/REE) was used to assess the accuracy of the reported energy intake. 20 In a person with a sedentary lifestyle, the minimum daily energy requirement to maintain body weight is estimated as 1.40 times the REE. 21 Therefore, a TE/ REE ratio below 1.40 was considered indicative of underreporting energy intake. Statistical Analysis Data are expressed as means 6 standard deviations for normally distributed variables, and as medians and ranges for variables that did not present a normal distribution. The c 2 test and Student s t-test for matched samples or for independent samples were applied as appropriate.

4 266 BAZANELLI ET AL BMI (kg/m 2 ) ,50 1,00 1,50 2,00 2,50 3,00 TE/REE ratio Figure 1. Total energy offered/resting energy expenditure (TE/REE) versus body mass index (BMI) (n540, r520.52, P,.01). Pearson correlation coefficients were used to test variables that were associated with TE/REE ratios. Logistic regression analysis was performed to identify the determinants of underreporting. Differences at P #.05 were considered statistically significant. Statistical analyses were performed using SPSS software, version 15.0 (SPSS, Inc., Chicago, IL). Results The main characteristics of patients and data related to TE and REE are listed in Table 1. The majority of patients were male, and their age ranged from 22 to 83 years. Body mass index was.25 kg/m 2 in 45% of patients, and,18.5 kg/m 2 in only 2.5% of patients. The main causes of CKD were hypertensive nephrosclerosis (32.5%) and diabetic nephropathy (15%). Other causes of CKD and undetermined causes were found in 15% and 37.5% of patients, respectively. Normalized TE was determined according to the recommendation of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative 17 (30 to 35 kcal/kg/day) in 42.5% of patients. By using a TE/REE of 1.40, underreporting was evident in 21 patients (52.5%). A detailed analysis revealed that the mean of the TE/REE ratio of underreporters was , versus of valid reporters (P,.01). The TE/REE ratio was inversely associated with BMI (r , P,.01; Fig. 1), and positively associated with duration of dialysis (r , P,0.01). No correlation was found between TE/REE ratio and any of the other variables studied. To evaluate whether overweight status could influence the underreporting of energy intake, patients were divided into two groups in terms of BMI,25 and BMI $25 kg/m 2 (Table 2). Energy intake as well as TE and TE/REE were lower in the group with higher BMIs. The energy provided by absorbed glucose did not differ between groups. In addition, the majority of patients (83.3%) in the higher BMI group had a TE/REE ratio,1.40. A multiple logistic regression analysis was applied, using TE/REE ratios,1.40 or $1.40 as the dependent variable. The final model indicated that BMI $25 kg/m 2 was the only determinant of energy underreporting (Table 3). Table 4 illustrates that after 6 months of followup, body weight and body compartments remained unchanged in both BMI groups, except for body fat, which increased in the group with lower BMIs. The TE/REE ratio of groups was maintained after follow-up. Table 2. Entire Group Analyzed According to BMI BMI,25 kg/m 2 (n522) BMI $25 kg/m 2 (n518) P Gender (male/female) 15/7 9/9.40 Age (y) BMI (kg/m 2 ) ,.01 Dialysis modality (CAPD/APD) 12/10 9/9.97 Duration of dialysis (mo)* 16.5 (4 109) 22 (3 76).63 Body fat (%) ,.01 Energy (kcal/kg/day) Intake Glucose absorbed TE REE (kcal/kg/day) ,.01 REE (kcal/day) ,.01 TE/REE ratio ,.01 TE/REE ratio,1.40, n (%) 6 (27.3) 15 (83.3),.01 Values are mean 6 standard deviation. BMI, body mass index; TE, total energy offered; REE, resting energy expenditure. *Median and range.

5 UNDERREPORTING OF ENERGY INTAKE IN PD 267 Table 3. Multiple Logistic Regression Analysis, Using TE/REE Ratio,1.40 or $1.40 as Dependent Variable Discussion b SE P Constant Age (y) Gender BMI.25 (kg/m 2 ) BMI, body mass index; SE, standard error. This study showed that a large percentage (52.2%) of patients treated by PD underreported their energy intake. This finding is in agreement with observations in the general population, where energy underreporting was shown to range from 20% 4 to 85% 5 in a number of studies. In CKD patients, few studies have evaluated this issue, and to the best of our knowledge, no study was performed using PD patients. Kloppenburg et al. 6 found that the majority of 38 hemodialysis patients (61%) underreported energy intake, according to 7-day food diaries and a predictive equation to estimate REE. In 131 patients with nondialysis-dependent CKD, using a 4-day food diary and indirect calorimetry, Avesani et al. 7 demonstrated that 72.5% of these patients were underreporting energy intake. Similar results were obtained by Fassett et al., 8 who found that 70.8% of 113 nondialysisdependent CKD patients underreported their energy intake according to 4-day food diaries and a predictive equation to estimate REE. Several cut points for the energy intake/ree ratio were suggested for identifying underreporters. However, there is no consensus regarding the most appropriate value. It was suggested that sample size and number of days reported should be used to determine the cut point for underreporting. 22 For this reason, cutoff values ranging from 1.05 to 1.55 were used in different reports. 12,23,24 In all three previously mentioned studies of CKD, a cutoff of 1.27 was used for the identification of underreporters. This value was proposed by the World Healthy Organization in 1985 as the minimum ratio for survival in a situation of total inactivity. 25 However, more recently, a group of experts pointed out that a value of 1.27 was too low and proposed a cutoff of 1.40, which represents the lower limit of a sedentary lifestyle. 21 Therefore, we chose this value to identify energy underreporting here. A number of reports demonstrated that demographics and clinical factors are associated with underreporting. Many studies indicated that energy underreporting occurs more often in females, 5,9 11 the elderly, 9,10,12,13 subjects with less education, 9,11,13,14 and overweight or obese subjects. 9 11,14,15 In the present study, BMIs but not gender or age were associated with underreporting. In our univariate analysis, the TE/REE ratio was inversely correlated with BMI, and in the multiple regression analysis, a BMI $25 kg/m 2 was the only determinant of energy underreporting. In addition, when our PD patients were divided according to BMI, the mean TE/REE ratio of the overweight group was significantly reduced ( ) compared with that of patients with lower BMIs ( ), whose value was indeed consistent with a sedentary lifestyle. 21 Our results are in accordance with those of Avesani et al., 7 who reported that the frequency of energy underreporting was higher in their group of patients with BMIs $25 kg/m 2. Table 4. Body Composition and Data Related to TE and REE According to BMI After 6 Months of Follow-Up BMI,25 kg/m 2 (n522) BMI $25 kg/m 2 (n518) Before After P Before After P Body weight (kg) Lean body mass (kg) Body fat (kg) Energy (kcal/kg/day) Intake Glucose absorbed TE REE (kcal/kg/day) TE/REE ratio Values are mean 6 standard deviation. BMI, body mass index; TE, total energy offered; REE, resting energy expenditure.

6 268 BAZANELLI ET AL A number of reasons were proposed for the association between obesity and underreporting. Because many obese individuals possess previous knowledge about foods with high energy content, they frequently omit the ingestion of these foods. 23 Moreover, the fear of gaining weight and of excessive dieting are important features of overweight subjects that may also be involved in the increased number of underreporters among subjects with high BMIs. 5,26,27 Thus, our overweight patients may have been intentionally eating foods with less energy, to help them lose weight. If this situation had occurred, a decrease in body weight would be expected. However, after 6 months of follow-up, even while maintaining the same amount of energy intake and glucose absorption, no change in body parameters was evident. This finding is highly indicative that patients with higher BMIs were indeed underreporting their energy intake. Because continuous glucose absorption is a characteristic of PD therapy, the energy provided by this source could have interfered with the findings of the present study. However, the energy provided by glucose absorbed did not differ between the two groups of BMI ranges. Given that energy intake is a surrogate measure of total food consumption, if energy intake is underreported, then the ingestion of several nutrients is also likely to be underreported. Thus, dietary conclusions can be significantly altered by the inclusion or exclusion of underreporters. Fassett et al. 8 found that not only energy, but also intakes of nutrients such as dietary fiber, calcium, and zinc, were lower than recommended in a group of nondialysis-dependent CKD patients when dietary diaries were interpreted without excluding the underreporters. In conclusion, the results of this study provide evidence of a high prevalence of underreporting of energy intake in PD patients, particularly among overweight patients. This finding highlights the importance of a careful interpretation of dietary-report data when analyzing associations between intake and outcomes. Acknowledgments This study was supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico and the Oswaldo Ramos Foundation. References 1. Schoeller DA: Validation of habitual energy intake. Public Health Nutr 5: , Hill RJ, Davies PS: The validity of self-reported energy intake as determined using the doubly labelled water technique. Br J Nutr 85: , Livingstone MB, Black AE: Markers of the validity of reported energy intake. J Nutr 133(Suppl 3): , Martin LJ, Su W, Jones PJ, et al: Comparison of energy intakes determined by food records and doubly labeled water in women participating in a dietary-intervention trial. Am J Clin Nutr 63: , Novotny JA, Rumpler WV, Riddick H, et al: Personality characteristics as predictors of underreporting of energy intake on 24-hour dietary recall interviews. J Am Diet Assoc 103: , Kloppenburg WD, de Jong PE, Huisman RM: The contradiction of stable body mass despite low reported dietary energy intake in chronic haemodialysis patients. Nephrol Dial Transplant 17: , Avesani CM, Kamimura MA, Draibe SA, et al: Is energy intake underestimated in nondialyzed chronic kidney disease patients? J Ren Nutr 15: , Fassett RG, Robertson IK, Geraghty DP, et al: Dietary intake of patients with chronic kidney disease entering the LORD trial: adjusting for underreporting. J Ren Nutr 17: , Briefel RR, Sempos CT, McDowell MA, et al: Dietary methods research in the third National Health and Nutrition Examination Survey: underreporting of energy intake. Am J Clin Nutr 65(Suppl):1203S-1209S, Hirvonen T, Mannisto S, Roos E, et al: Increasing prevalence of underreporting does not necessarily distort dietary surveys. Eur J Clin Nutr 51: , Dwyer J, Picciano MF, Raiten DJ: Estimation of usual intakes: what we eat in America NHANES. J Nutr 133: , Johansson L, Solvoll K, Bjorneboe GE, et al: Under- and overreporting of energy intake related to weight status and lifestyle in a nationwide sample. Am J Clin Nutr 68: , Zhang J, Temme EH, Sasaki S, et al: Under- and overreporting of energy intake using urinary cations as biomarkers: relation to body mass index. Am J Epidemiol 152: , Klesges RC, Eck LH, Ray JW: Who underreports dietary intake in a dietary recall? Evidence from the Second National Health and Nutrition Examination Survey. J Consult Clin Psychol 63: , Lafay L, Basdevant A, Charles MA, et al: Determinants and nature of dietary underreporting in a free-living population: the Fleurbaix Laventie Ville Sante (FLVS) Study. Int J Obes Relat Metab Disord 21: , Grant JP, Custer PB, Thurlow J: Current techniques of nutritional assessment. Surg Clin North Am 61: , National Kidney Foundation/DOQI: Clinical practice guidelines for nutrition in chronic renal failure: K/DOQI, National Kidney Foundation. Am J Kidney Dis 35(Suppl 2):1-140, United States Department of Agriculture Human Nutritional Service. Composition of Foods. Raw, Processed, Prepared Agriculture Handbook, No. 8, Series 1 16, Revised. Washington, D.C. Agricultural Research Service, Weir JB: New methods for calculating metabolic rate with special reference to protein metabolism. J Physiol (Lond) 109:1-9, 1949

7 UNDERREPORTING OF ENERGY INTAKE IN PD Goldberg GR, Black AE, Jebb SA, et al: Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr 45: , Food and Agriculture Organization/World Health Organization/United Nations University. Human energy. Report of a joint FAO/WHO/ONU meeting. Roma, October, Food Nutr Bull 26:166, Black AE: Critical evaluation of energy intake using the Goldberg cut-off for energy intake: Basal metabolic rate. A practical guide to its calculation, use and limitations. Int J Obes Relat Metab Disord 24: , Lafay L, Mennen L, Basdevant A, et al: Does energy intake underreporting involve all kinds of food or only specific food items? Results from the Fleurbaix Laventie Ville Sante (FLVS) Study. Int J Obes Relat Metab Disord 24: , Olendzki BC, Ma Y, Hebert JR, et al: Underreporting of energy intake and associated factors in a Latino population at risk of developing type 2 diabetes. J Am Diet Assoc 108: , Food and Agriculture Organization/World Health Organization/United Nations University. Energy and protein requirements. Report of a joint FAO/WHO/ONU meeting. Geneva, World Health Organization, 1985, Technical Report Series No Provencher V, Drapeau V, Tremblay A, et al: Eating behaviours, dietary profile and body composition according to dieting history in men and women of the Quebec Family Study. Br J Nutr 91: , Tooze JA, Subar AF, Thompson FE, et al: Psychosocial predictors of energy underreporting in a large doubly labeled water study. Am J Clin Nutr 79: , 2004

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