To EAT or NOT to EAT At Treatment Debbie Benner, MA, RDN, CSR

Transcription

1 To EAT or NOT to EAT At Treatment Debbie Benner, MA, RDN, CSR June 2016

2 Illinois Connection Ginny Pletzke Karen Graham EAT Co-authors: Brandon Kistler Kenneth Wilund Univ of Illinois, Champaign 2

3 Objectives Participants will be able to: describe the range of practice with EAT (eating at treatment) state 3 common concerns state 3 potential benefits discuss methods to proactively address common concerns describe how eating at treatment relates to integrated kidney care 3

4 EAT and ONS 1980 s Dialysis and EAT DANSE (DaVita Assessment Nutritional Supplement Evaluation) Albumin not significantly improved 2014 analysis demonstrated ONS provided per tx is associated with markedly and significantly better survival and missed treatment rates These data argue persuasively for administration of ONS to hypo-albuminemic dialysis patients 4

5 Publications: Positive Impact of ONS Caglar K, Fedje L, Dimmitt R, Hakim RM, Shyr Y, Ikizler TA: Therapeutic effects of oral nutritional supplementation during hemodialysis. Kidney Int 62: , 2002 Tomayko EJ, Kistler BM, Fitschen PJ, Wilund KR: Intradialytic Protein Supplementation Reduces Inflammation and Improves Physical Function in Maintenance Hemodialysis Patients. J Ren Nutr 25: , 2015 Scott MK, Shah NA, Vilay AM, Thomas J, Kraus MA, Mueller BA: Effects of Peridialytic Oral Supplements on Nutritional Status and Quality of Life in Chronic Hemodialysis Patients. J Ren Nutr, 19: , 2009 Weiner DE, Tighiouart H, Ladik V, Meyer KB, Zager PG, Johnson DS: Oral Intradialytic Nutritional Supplement Use and Mortality in Hemodialysis Patients. Am J Kidney Dis 63: , Lacson E, Jr., Wang W, Zebrowski B, Wingard R, Hakim RM: Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report. Am J Kidney Dis, 60: ,

6 2016 ONS during tx has shown to positively impact mortality and morbidity Yet, EAT (eating at treatment) remains a controversial topic Question to consider: Does the more restrictive practices in US contribute to poorer nutritional status and elevated mortality compared with some other parts of the world? Little published related to in center food practices 6

7 DOPPS data 7

8 2011 and 2014 We sought to understand the variation of practice within our own company There is no corporate policy Facility Governing Body determines what is allowed, not allowed, educated on and ignored 8

9 Methods In 2011, we surveyed RD s regarding clinic practices and clinician (RD, FA, & MD) opinions related to in center food consumption within our LDO After the initial survey, we provided clinicians with educational materials about EAT (eating at treatment) In 2014, we performed a follow-up survey and analyzed differences in practices and opinions 9

10 Results % (343 of 1199 clinics) did not allow eating during tx 18% (222 clinics) did not allow drinking during tx 2% (19 clinics) did not allow eating at the facility before or after tx % (321 of 1422 clinics) did not allow eating during tx 10

11 Comparison of 2011 vs 2014 clinic practices for eating at treatment Percent Not allowed and does not occur Not allowed but does occur Not allowed and does Not allowed not occur but does occur No policy Allowed but not encouraged Allowed and encouraged No policy Allowed but not encouraged Allowed and encouraged 11

12 Why the shift? Of the 178 (6.8%) clinics reporting eating was more allowed in 2014, the main reason given was an increased focus on nutritional status Among clinicians, a higher percent encouraged eating during treatment (53.1% vs 37.4%; P,0.05), and FA and MD s were less concerned about the seven reasons commonly cited for restricting eating at tx in 2014 versus 2011 (P,0.05 for all). 12

13 Clinicians Opinions on EAT Position Year N Strongly Discourage Discourage No Opinion Encourage Strongly Encourage N (%) N (%) N (%) N (%) N (%) RD s FA s MD s , , , , (23.1) 163 (11.6) 316 (31.5) 312 (25.2) 255 (30.8) 235 (24.0) 264 (22.1) 204 (14.5) 238 (23.7) 238 (19.2) 159 (19.2) 156 (16.0) 95 (8.0) 97 (6.9) 131 (13.1) 126 (10.2) 158 (19.1) 169 (17.3) 446 (37.4) 607 (43.1) 250 (24.9) 409 (33.0) 209 (25.2) 293 (30.0) 112 (9.4) 337 (23.9) 68 (6.8) 153 (12.4) 47 (5.7) 125 (12.8) 13

14 Reasons Given for Non-Support of EAT Position Year N Facility Policy Infection Control Hypotension Choking GI Distress Reduce d Kt/V Spills/ Pests N (%) N (%) N (%) N (%) N (%) N (%) N (%) RD s (32.3) 114 (31.1) 383 (71.1) 268 (73.0) 363 (67.3) 253 (68.9) 436 (80.1) 275 (74.9) 402 (74.6) 263 (71.1) 55 (10.2) 48 (13.1) 339 (62.9) 206 (56.1) FA s (37.7) 149 (27.1) 398 (71.8) 368 (66.9) 390 (70.4) 358 (65.1) 415 (74.9) 382 (69.5) 338 (61.0) 300 (54.5) 107 (19.3) 77 (15.4) 343 (61.9) 290 (52.7) MD s (39.1) 95 (24.3) 259 (62.6) 180 (46.0) 305 (73.7) 243 (62.1) 302 (72.9) 220 (66.3) 246 (59.4) 171 (43.7) 81 (19.6) 48 (12.3) 212 (51.2) 134 (34.3) 14

15 Reasons Given by RD s that Support EAT Position Year n Meeting Caloric Needs Blood Glucose Difficulty Enforcing Policy Teaching Opportunity RD s N (%) 423 (76.4) 784 (83.1) N (%) 489 (88.3) 756 (80.1) N (%) 226 (40.8) 323 (34.2) N (%) 410 (74.0) 668 (70.8) Top Reasons: Meeting caloric needs Blood Glucose Teaching Opportunity 15

16 Survey Conclusions Practices and clinician opinions are shifting toward allowing patients to eat. We found that 28.6% (2011) and 22.6% (2014) of clinics within the US restricted eating during treatment, a rate more than double that found in an international cohort. What are practices internationally? 16

17 2014 Germany. 17

18 Internationally We developed an 11-item survey Surveys were distributed to attendees during the 2014 International Society of Renal Nutrition and Metabolism Conference in Wurzburg, Germany Data were analyzed and partial responses were included in the analysis 18

19 Distribution of 73 Respondents by Continent Africa Asia Australia Europe North America South America 19

20 Survey Respondents Continent 73 Number (%) Africa 3 (4.1) Asia 7 (9.6) Australia 5 (6.8) Europe 39 (53.4) North America 9 (12.3) South America 10 (13.7) Position Number (%) Dietitian 52 (71.2) Nephrologist 19 (26.0) Other (Researcher) 2 (2.7) Practice Type Number (%) Hospital 46 (63.0) Outpatient 33 (45.2) Research 12 (16.4)

21 Policies regarding eating during hemodialysis

22 Does your facility provide food? Does your facility provide supplements? Yes No 0 Yes No 22

23 Reasons Given to Allow/Provide EAT Yes No Additional Energy 55 (88.7%) 7 (11.3%) Blood Glucose Control Teaching Opportunities Difficulty Enforcing No Eating Policy 20 (32.3%) 42 (67.7%) 29 (46.8%) 33 (53.2%) 10 (16.1%) 52 (83.9%) 23

24 Clinician Experience with Six Commonly Cited Reasons to Not Allow Eating At Treatment Never Rarely Sometimes Often Postprandial Hypotension (n=53) 18 (34.0%) 15 (28.3%) 18 (34.0%) 2 (3.8%) Gastrointestinal Symptoms (n=52) 14 (26.9%) 23 (44.2%) 15 (28.8%) 0 (0.0%) Treatment Efficiency (n=45) Spills or Pests (n=46) Choking (n=46) 42 (93.3%) 2 (4.4%) 1 (2.2%) 0 (0.0%) 31 (67.4%) 7 (15.2%) 5 (10.9%) 3 (6.5%) 39 (84.8%) 6 (13.0%) 1 (2.2%) 0 (0.0%) Infection Control Issues (n=46) 42 (91.3%) 2 (4.3%) 2 (4.3%) 0 (0.0%)

25 If facility allows eating do you agree with this policy Yes No 25

26 Percent of clinics that provide food by continent Africa Asia Australia Europe N.A. S.A. 26

27 Percent of clinics that provide supplements by continent Africa Asia Australia Europe N.A. S.A. 27

28 EAT Guidelines Knowing Patients are Eating at Treatment we developed and have available tips and guidelines which include: Teammate EAT Education Tips Patient EAT Guidelines Practical Aspects Tips/ Suggested Snacks to Bring 28

29 EAT Eating At Treatment Guidelines For practical reasons, you should bring food that does not need to be heated at the center does not have a strong odor or leave a mess can be eaten with one hand / does not require help to open or eat will not make you thirsty Remember to take your phosphate binders when you eat during or after dialysis. 29

30 EAT Eating At Treatment Guidelines Foods eaten during dialysis should be kidneyfriendly. Potassium and phosphorus eaten at treatment will not reach the bloodstream until after dialysis where it builds up until the next treatment. Patients who bring food to the clinic should only bring food that is securely sealed or wrapped to prevent leakage and does not require refrigeration or heating at the facility. 30

31 EAT Eating At Treatment Guidelines If you have any of these symptoms you can eat after your treatment instead of during dialysis: Low blood pressure Coughing or choking Diarrhea Vomiting Nausea You should eat in an upright position to decrease the chance of choking 31

32 Integrated Kidney Care Prevent Hospitalization More holistic and preventative care Food and Eating are Quality of Life Aspects Well being and nutritional status contribute to better quality of life and reduced mortality 32

33 Stay Curious.. My Friend! 33