Renal Nutrition Forum A PEER REVIEWED PUBLICATION OF THE RENAL DIETITIANS DIETETIC PRACTICE GROUP

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1 Renal Nutrition Forum A PEER REVIEWED PUBLICATION OF THE RENAL DIETITIANS DIETETIC PRACTICE GROUP Volume 37 Number 2 In This Issue 1 Feature Article: Subjective Global Assessment and Nutrition Intake Quality 9 Advances in Practice: Pediatric Case Studies 13 Advances in Practice: Mind Body Medicine 18 App Review 19 Patient Education Handout: Calcium Oxalate Kidney Stones 21 Patient Education Handout: Uric Acid Kidney Stones and Gout 25 Member Survey Update: Policy, MNT and Reimbursement 26 RPG Chair Message 28 CRN Chair Message 29 Calendar of Events 29 Recently Published RPG Executive Committee Members How Far Does the Subjective Global Assessment Reflect Hemo Patients Nutritional Intake Quality? Ragda Barakat, RD, MPH rado_b82@hotmail.com Hadassah Medical Center Jerusalem, Israel Yosef S. Haviv, MD Soroka University Medical Center Diklah Geva, PhD The S. Daniel International Center for Health and Nutrition Department of Public Health Ben-Gurion University of the Negev Hilel Vardi, MPH The S. Daniel International Center for Health and Nutrition Department of Public Health Ben-Gurion University of the Negev Danit R. Shahar, RD, PhD Corresponding Author dshahar@bgu.ac.il The S. Daniel International Center for Health and Nutrition Department of Public Health Ben-Gurion University of the Negev Learning Objectives 1. Identify the differences in dietary intake by day [the day before, the day of, and the day after ] of hemo (HD) patients. 2. Summarize the value of using the Subjective Global [nutrition] Assessment (SGA) for assessing nutritional status among hemo (HD) patients. 3. Identify the best day of the week for a future nutritional intervention program. Key Words: nutritional status, dietary intake, hemo patients, subjective global assessment (SGA) Abstract This is a cross-sectional study among HD patients evaluating dietary intake and quality, and nutritional status using the Subjective Global Assessment (SGA) among hemo (HD) patients. The mean caloric intake for HD patients was ±546.9 Kcal/ day, deviating almost 20% from guideline recommendations for HD patients. The major difference among macronutrients was seen in carbohydrates. Subjects consumed 25% less carbohydrates than the recommended intake for HD patients. When the results were analyzed Continued on page 3. CPE Offering This issue of the Forum has been approved for 2.0 CPEU units. The online CPEU quiz and certificate of completion can be accessed in the Members Only section of the RPG website via the My CPEU link. This CPE offering is available to current RPG members only and the expiration date is April 15, Credits should be entered in your CDR Log under code 740: Web based self-study.

2 according to the day of the week, patients mean energy intake was the highest on a day (1766±745.4 Kcal/day), and the lowest on the day after treatment (1651.5±624.6 Kcal/day). According to the SGA, 71% of patients were well nourished, 23.4% were borderline nourished, and only 1.4% were undernourished. We used a Receiver Operating Characteristic (ROC) model to determine the Area Under the Curve (AUC) for the variables in the regression model, with the following results: mid-arm circumference (MAC) 0.65, weight change 0.69, and carbohydrate intake 0.7, indicating these as good markers. We concluded that the non- day could potentially be the day for a good nutritional intervention program focusing on the carbohydrate restrictions. This study supports the idea that SGA is a good assessment tool for these patients. Introduction Approximately 70% of Chronic Kidney Disease-End Stage Renal Disease (CKD-ESRD) patients suffer from various levels of malnutrition (1,2), presenting the challenge of treating these patients medically and nutritionally. The restricted diet and the multiple macro- and micro-nutrient limitations make CKD-ESRD one of the most challenging medical fields for nutritionists. Therefore, one of the main goals of Medical Nutrition Therapy (MNT) is to prevent malnutrition in these patients, especially in hemo (HD) patients, in order to maintain their quality of life (QOL) and avoid health complications (3,4). The main challenge for MNT is attaining adequate energy intake in order to maintain a reasonable body weight and improve overall health through appropriate food choices both on a regular day (off ) and on a day (usually 3-4 times/week). Nutritional status is an important predictor of complications, increased hospitalization rate, hospital days, and mortality (5). A periodic assessment of the nutritional status should be part of the routine care of ESRD patients to permit early diagnosis and initiation of appropriate therapy. It should be noted that there is no single measurement used to determine the presence of malnutrition (6). The Subjective Global Assessment (SGA) is a nutritional assessment tool that has been found to be highly predictive of nutrition-associated complications. SGA fulfills the requirements of a desirable system of nutritional assessment by: identifying malnutrition, distinguishing malnutrition from a disease state, predicting outcomes, and identifying patients for whom nutritional therapy can alter outcome (7). This tool depends on several different anthropometric and biochemical measures and is a reliable nutritional assessment tool. Both assessing and optimizing nutritional status are important to improve a patient s QOL and clinical outcomes, and help control care costs. However, despite all the resources committed to the treatment of ESRD and the improvements in the quality of therapy, these patients continue to experience significant mortality and morbidity rates and a reduced QOL as a result of their complicated health and nutritional issues and the difficulty to rehabilitate them. Methods Study Participants A cross-sectional study was performed among current HD patients in Hadassah Medical Center, Jerusalem, Israel (N=105). Patients fed through Total Parenteral Nutrition (TPN) or other internal feeding methods were excluded, leaving a total of N=74 patients who agreed to participate. Data were collected from December 2012 to September The study was approved by the hospital s ethics committee and all participants signed an informed consent. Study Tools A. Data Collection Personal, demographic, and medical data were retrieved from the medical records. Dietary intake was collected using a modified U.S. Department of Agriculture 24-hour recall form (8). The questionnaire comprised food intake for three consecutive days the day before, the day of, and the day after. The 24-hour recall data was collected during an interview or completed independently by the patients at home based on the formal dietitian guidance. The nutritional data was updated by adding medical nutritional supplements that are recommended for HD patients (9). Data was edited and entered into the computerized Nutrition Analysis Program of the S. Daniel Abraham International Center for Health and Nutrition. Dietary intake was calculated both per day and as an average of the 3 consecutive days. All results were compared to the nutritional recommendations for HD patients (10,11). B. Nutritional Status Assessment Anthropometric measurements were obtained at the time of the treatment. These measurements included weight at the beginning of treatment, dry weight, changes in dry weight (WC), height, Body Mass Index (BMI), and mid-arm circumference (MAC). Nutritional status was defined by the SGA, a proven nutritional assessment tool that identifies malnutrition and distinguishes malnutrition from a disease state (7). The SGA score in this study was recoded into two categories (SGA2CUT): malnourished SGA 2 and wellnourished SGA 1. C. Statistical Analysis Analyses were performed using SPSS, ver. 23. Continuous variables were presented as average/median and standard deviation, and qualitative variables were presented as percentages. T-test or Chi square was used to compare between groups using p 0.05 as the significance level. The SGA was analyzed, and given three levels of definitions at first according to points: A mildly malnourished, B moderately malnourished, and C severely malnourished, but the variable was recoded into two categories/dichotomous variable SGA1, 2 afterwards because group C contained only 1 patient. A logistic regression was used to test the relationship between the dependent (SGA) and the independent (personal, demographical, health, and nutritional characteristics) variables. Renal Nutrition Forum 2018 Vol. 37 No. 2 3

3 Table 1. Baseline characteristics of the HD patient cohort (N=74) Sociodemographic (Mean± SD) Age (years) ± 13.3 Male gender, % (N) 63.5 (47) Religion % (N) Jewish Non-Jewish* 62.2 (46) 37.8 (28) Education (years) ± 5.5 Caregiver s help, yes, % (N) 25.7 (19) Country of birth, Israel, % (N) 70.3 (52) Marital status, % (N) [Married] 75.7 (56) Clinical (Mean±SD) Smoking/current, yes, % (N) 10.8 (8) Dry weight (Kg) 74.1 ± 17.9 BMI (kg/m²) (Median) 26.3 ± 4.9 (26) Cardiovascular disease, yes % (N) 47.3 (35) Diabetes, yes % (N) 44.6 (33) Hypertension, yes % (N) 68.9 (51) Average vintage of in years (median) 4.45 ± 4.76 (3) * Non-Jewish refers to all other participants, Muslims, Christians, etc. ROC analysis was used to test the validity of the nutritional status assessment tool among these patients and the independent variables studied. Sensitivity and specificity were calculated based on the ROC. The sensitivity of the model was defined as the percentage of malnourished participants who were correctly identified by the test. Alternately, specificity was defined as the percentage of participants at nutritional risk that were correctly identified. The sum of sensitivity and specificity were defined as the validity (AUC) of the specific malnutrition assessment topics. Results Characteristics of the Study Population A total of 74 HD patients participated in the study with a mean age of 63±3.3 (range 20-85) years and forty-seven participants (63.5%) were men. However, in terms of the main clinical characteristics collected, 38 (51.4%) of the patients had a BMI >25 and only three (4.1%) patients had a BMI <19. Thirty-three patients (44.6%) were diabetic, 51 (68.9%) had hypertension (HTN), 35 (47.3%) had cardiovascular disease (CVD), and the mean average years on was 4.5±4.76 years (Table 1). The average values of the patients blood test results were close to target levels. The main variables of interest from a nutritional point of view, such as albumin (3.86±0.44 g/dl) that indicates a wellnourished population as well as a treated and compliant population are seen in Table 2. Table 2. Average blood test levels in HD patients compared to normal range values Blood Test Albumin (g/l) Mean ± SD (n=74)* 38.6 ± ± 0.44 Normal Range >40 >4 Creatinine 7.5 ± Urea 20.4 ± Potassium (mmol/ l) 5 ± Calcium (mmol/l) Phosphorus (mmol/l) 2.2 ± ± ± ± Hemoglobin (g/dl) 11.5 ± 1.1 Women Men URR (%) 71.3 ± 6.9 (73) >70% HgbA1C (%) (Median) 7.76 ± 1.4 (28) (7.77) 7 * n=74 unless otherwise noted in ( ) Part 1. Average Dietary Nutrient Intake The mean daily dietary intake for 3 consecutive days was calculated and compared with the recommendations for HD patients. The results are shown in Table 3. The study patients mean intake was almost 20% lower than the mean daily intake recommended for carbohydrates, protein, and overall energy. The macronutrient showing the least deviation from the general recommendation was fat, with a mean intake deviation of 11.5% among study participants. A bimodal distribution of micronutrients intake - either much more or much less than recommended is shown in Table 4. Part 2. Assessment of Dietary Intake Stratified by Days Participants dietary intake and diet quality were evaluated for 3 consecutive days (day before, day of and day after ). According to the results shown in Table 5, the actual intake was always lower than the recommendations, with no differences in results between individual days and the average of the three days together. The highest deviation from the recommendations was seen in the patients carbohydrate intake (25%) while the fat intake (11.5%) deviated the least from the recommendations. Reasons for these findings are discussed in the discussion section of this paper. When looking at differences between days, energy and carbohydrate intakes showed the greatest deviation from recommendations on the day after the session (least mean intake ±624.6 Kcal/day, 191.8±81 g/day) compared to the day (1766±745.4 Kcal/day, 193±104.5 g/day) and the day before the (1661.5±628.2 Kcal/day, 212.8±79.7 g/day). 4 Renal Nutrition Forum 2018 Vol. 37 No. 2

4 Table 3. Macronutrient intake of the HD patients in comparison with dietary recommendations Macronutrient Dietary recommendations for HD patients Mean dietary recommendations* Mean intake of our HD patients % Deviation from recommendations Energy (kcal) kcal/ kg/ day ± ± % Carbohydrate (g) 50% of total calories ± 72-25% Protein (g) Fat (g) g / kg/ day (20% of total calorie intake) 30% of total calorie intake ± % ± % Saturated fats (g) 33.3% of total fat ± % MUFA** (g) 33.3% of total fat ± % PUFA** (g) 33.3% of total fat ± % * The mean dietary recommendations were calculated according to an average weight of 65 Kg, as clinically accepted. **M/PUFA- mono/ poly unsaturated fatty acids. Table 4. Micronutrient intakes for HD participants in comparison to recommendations for daily intake Micronutrient Recommendations for HD patients HD patient mean intake % Deviation from recommendations* Calcium (Ca) (mg) ± % Phosphorus (P) (mg) ± % Potassium (K) (mg) ± % Iron (Fe) (mg) 8 for men 14.5 ± % 18 for women 10.5 ± % Magnesium (Mg) (mg) 420 for men ± % 320 for women 201 ± % Sodium (Na) (mg) ± 1012 Normal Vitamin D (µg) Individual 72 ± 61 (1µg = 40 IU vitamin D) Vitamin B12 (µg) ± % Folic acid (µg) > ± % * Nutrients and vitamins which don t have a daily recommendation were equated to the Recommended Daily Allowance (RDA) for healthy adults. The results presented in Table 4 show that the phosphorus and potassium mean intake is higher than the recommended amounts with a deviation of 46% and 11.7% respectively. The higher blood levels of phosphorus and potassium are expected as a complication of ESRD. The higher means seen in the vitamin intake may have resulted from the nutritional supplements that patients often take. Of note, magnesium intake for all and iron intake for women was well below recommended intake. The intakes on the day after were similar to the intakes on the day before unless it was a weekend. Average Macronutrient Intake Stratified by SGA The SGA did not identify a significant difference in macronutrient intake between the well-nourished and malnourished groups (Table 6). The results show a trend in that those who are at lower risk for malnutrition status (the SGA 1 group), have higher macronutrients intake, but this result was not statistically significant. Except for the total energy intake on the day after treatment (p = 0.04) there were no significant differences in macronutrient intake on specific days. The data also showed nutrient intakes to be the highest on the day of as well as higher for the SGA 1 group on all of the days. After testing the univariate relationships between dietary intake, diet quality (according to the macro and micronutrients Renal Nutrition Forum 2018 Vol. 37 No. 2 5

5 Table 5. Assessment of the nutrient intake stratified by days Macronutrient intake stratified by days Intake Macronutrients Dialysis day* Day before Day after Mean intake (g ± SD) Mean dietary recommendations for HD patients % Deviation from recommendations Energy (kcal) 1766 ± ± ± ± ± % Carbohydrates (g) 193 ± ± ± ± % (50% of calories) Protein (g) 89.9 ± ± ± ± % (20% of calories) Fat (g) 63.5 ± ± ± ± % (30% of calories) Saturated Fats (g) 22 ± ± ± ± % MUFA (g) 23.9 ± ± ± ± % PUFA (g) 12.9 ± ± ± ± % Micronutrient (minerals and vitamins) intake stratified by days Intake Micronutrient / Minerals Dialysis day* Day before Day after Mean intake Mean dietary Recommendation for HD patients % Deviation from RDA Ca (mg) 691 ± ± ± ± % P (mg) ± ± ± ± % K (mg) 2345 ± ± ± ± % Fe (µg) 14.7 ± ± ± ± men 18 women Mg (mg) ± ± ± ± men 320 women % % Na (mg) ± ± ± ± % Intake Micronutrients/ Vitamins Vitamin D (µg) 72 ± ± ± ± 99 Individual (1µg = 40 IU vitamin D) Vitamin B12 (µg) 8.1 ± ± ± ± µg + 35% Folic acid (µg) 67.2 ± ± ± ± 202 > % * Patients are offered intradialytic nutrition Table 6. Average Macronutrient Intake for SGA groups, SGA1, 2* Macronutrient SGA Mean ± SD SGA 1 (N=53) SGA 2 (N=19) p value Energy (Kcal) ± ± ± Protein (g) 98.6± ± ± Carbohydrates (g) 85.4± ± ± Fats (g) 62.5± ± ± * The SGA variable was recoded into two categories/dichotomous variable SGA1, 2. SGA 1 represents patients that were at low risk for malnutrition and SGA 2 is the group of patients at high risk for malnutrition as defined according to the SGA tool. 6 Renal Nutrition Forum 2018 Vol. 37 No. 2

6 Figure 1. Presents a Receiver Operating Characteristic (ROC) analysis for the SGA with weight change, MAC, and carbohydrate intake. intake described above) and health status indicator. The resulting data was tested for the correlation between the relevant independent variables (MAC, WC, and carbohydrate intake) and the dependent SGA using a logistic regression; no significant relationship between the studied independent variables was found. The test result variable(s): weight change and mid-arm circumference have at least one tie between the positive actual state group and the negative actual state group. The ROC analysis demonstrates that the MAC with an AUC of 0.65, the WC with an AUC of 0.69, and carbohydrate intake with an AUC of almost 0.7, can moderately account for SGA categories. Discussion In this cross-sectional study among 74 ESRD patients on HD, we evaluated dietary intake of the patients using three 24-hour recalls in order to capture daily differences in dietary intake by collecting data extending over three days, a day before, a day of and a day after the treatment. We found that HD patients are at high risk for nutritional deficiencies compared to the recommendation for HD patients. Our results indicate that energy intake was significantly lower than the daily recommendation for energy intake along with lower than recommended intake of carbohydrates. Similar results were reported by Delgado et al (12), who observed that HD patients who suffer from obesity may also experience malnutrition. In obese CKD patients, there is a loss of muscle mass, a condition known as sarcopenic obesity (13,14), which is considered as one of the major risk factors correlated with morbidity and mortality in patients in particular. Moreover, they showed that the highest dietary intake was on the day of, the same as our findings suggest, taking in consideration that our patients do receive a meal during their treatment. Moreover, when looking at differences between days as mentioned in Table 5, energy and carbohydrate intakes showed the greatest deviation from recommendations on the day after the session compared to both the day and the day before the, the same as the micronutrients. This seems to be a new finding as to the best of our knowledge no studies have so far reported this. The results of this study are comparable with previous studies suggesting that HD patients are at high risk for malnutrition (15), because of the low intake of macronutrients. Our study findings suggest that the non- days may be optimal for an intervention program so as to improve these patients nutritional intake. Interestingly, macronutrient and micronutrient intake was the highest on the day compared with the non- days, with no significant differences found between the three days. It is important to clarify that the day after the is actually the same day as the day before the (in the middle of the week), because the treatment is done every other day. Unless it s a weekend, in that case the time between treatments is longer, which causes a difference between the days. No significant correlation was found between the nutritional elements and the health status measurement tool studied, the SGA. In addition, the results showed no significant differences in any of the macronutrients when compared according to it. Moreover, when the ROC analysis for the SGA was run, it did succeed moderately in explaining such an important assessment tool with a major nutritional element the carbohydrates. Simply, it succeeded in explaining the SGA groups with an AUC of almost 0.7, and the tool s group accuracy division between the malnourished- SGA2 and the well-nourished SGA1 and their classification. Limitations of our study included several points. The first is the low sample size, although taking into consideration the number of studied variables, the ratio is statistically accepted. Additionally, we used the 24-hour recall method, which is known to underestimate intake as it s a self-reported questionnaire and relies on memory which makes it more prone to information bias as well as social desirability bias (16). The micronutrients results did not take into consideration the supplements our patients take on a daily basis, which might affect our results. The unique results of this study showed that HD patients were consuming close to 25% less than the recommended carbohydrate intake for this population. Furthermore, the study also showed that patients eat less on the day after the HD session, suggesting that intervention should be focused on increasing HD patient intake (quality and quantity), with special focus on simple carbohydrates as an energy source on the day after the HD session. This is a major variable predicting and explaining the SGA making it a vital component for evaluating patients nutritional status. Renal Nutrition Forum 2018 Vol. 37 No. 2 7

7 References 1. Stenvinkel P. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant. 2000; 15: Alpers DH. Manual of Nutritional Therapeutics, 4th ed. Philadelphia: Lippincott Williams and Wilkins; Locke EA, Latham GP, Erez M. The determinants of goal acceptance and commitment. Acad Manage Rev. 1988; 13(1): National Kidney Foundation. KDOQI clinical practice guidelines for CVD in patients. Am J Kidney Dis. 2005;4(Suppl 3):S1. 5. United States Renal Data System. USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and ESRD in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Espahbodi F, Khoddad T, Esmaeili L. Evaluation of malnutrition and its association with biochemical parameters in patients with ESRD undergoing hemo using SGA. Nephrourol Mon. 2014; 6(3):e Mutsert R, de Grootendorst DC, Boeschoten EW, et al. Netherlands Cooperative Study on the Adequacy of Dialysis-2 Study Group. Subjective global assessment of nutritional status is strongly associated with time dependent mortality in chronic patients. Am J Clin Nutr. 2009;89(3): Shahar DR, Shai I, Vardi H, Fraser D. Dietary intake and eating patterns of elderly people in Israel: Who is at nutritional risk? Eur J Clin Nutr. 2003;57(1): Shai I, Vardi H, Shahar DR, Azrad A, Fraser D. Adaptation of international nutrition databases and data entry system tools to a specific population. Public Health Nutr. 2003;6(4): Jenkins K, Mahon A, eds. Chronic Kidney Disease (stages 4-5). A Guide to Clinical Practice. Beaumaris, Victoria, Australia: Renal Society of Australasia Journal; National Kidney Foundation. KDOQI. Celebrating 20 Years. Available at: March, Delgado C, Ward P, Chertow GM, et al. Calibration of the brief food frequency questionnaire among patients on. J Ren Nutr. 2014;24(3): Imen G, Madiha M, Mounira E, Fathi Y, Taieb A. Obesity in hemo patients. Int J Clin Med. 2015;6(9): Panzetta G, Abaterusso C. Obesity in and reverse epidemiology: true or false? G Ital Nefrol. 2010;27(6): Todd A, Carroll R, Gallagher M, Meade A. Nutritional status of haemo patients: comparison of Australian cohorts of Aboriginal and European descent. Nephrology (Carlton). 2013;18(12): Castell GS, Majem LS, Ribas LB. What and how much do we eat? 24- hour dietary recall method. Nutr Hosp. 2015;31(Suppl.3): NEWLY ELECTED RPG OFFICERS Thanks to all the members who voted in the February online elections. Congratulations to the newly elected officers whose terms begin June 1, Chair-Elect: Kyle J. Lamprecht, MS, RD, CSP, CSR, CD-N Secretary: Sue Steiner RD, CSR, LMNT, CDE Nominating Committee Chair-Elect: Michele Damon, RDN 8 Renal Nutrition Forum 2018 Vol. 37 No. 2