Using Technology to Improve Dietary Adherence in Chronic Kidney Disease

At a Glance

  • Patients with stage 1-4 chronic kidney disease must follow a regimented diet aimed at preserving existing kidney function to delay the later stages of the disease.
  • Dietary counseling typically involves giving patients multiple hand-outs that are hard for patients to adhere to.
  • Physician-researchers at NewYork-Presbyterian/Columbia University Irving Medical Center a cross-sectional study among patients with stage 4 and 5 CKD to identify factors that may make it difficult to take control of their very specific nutritional requirements.

“Our goal was to first figure out what the barriers are for patients in following a kidney diet and then to use technology to create something that will help them adhere to it.”

— Dr. Maya K. Rao

In order to slow the progression of chronic kidney disease (CKD), a key element of care is dietary restriction – easier said than done, according to Maya K. Rao, MD, Director of the Chronic Kidney Disease Program in the Division of Nephrology at NewYork-Presbyterian/Columbia University Irving Medical Center.

“We don’t have that many medicines that slow the progression. But we do know that diet is important; recent research has shown that diets high in sodium and potassium for individuals with advanced kidney disease are associated with progression, morbidity, and mortality,” says Dr. Rao. “However, the recommended diet for patients with pre-dialysis chronic kidney disease – which can include low sodium, low potassium, and low phosphorous – is very complex and patients have a hard time adhering to it.”

The many dietary restrictions often leave patients bewildered and frustrated, notes Dr. Rao. They are being asked to adhere to and negotiate multiple restrictions, and compliance is almost immediately undermined by the anticipated burden of organizing a meticulous, measurement-guided diet.

“Many patients have diabetes, and they’re told to follow a diabetic diet as well. So you’re talkingabout a lot of information that at times conflicts with each other,” says Dr. Rao. “They may be able to eat one thing on one diet, but are not supposed to eat that on another diet. They get the feeling that there’s nothing they can eat and end up not following it because it’s too complicated.

“Current dietary counseling is not effective,” says Dr. Rao. “We give patients multiple hand-outs of recommendations and expect them to be able to put it all together. In addition, there is a lot of math involved. For example, we recommend a patient have no more than 2,000 milligrams of potassium in a day and expect a patient to calculate their potassium intake, accounting for serving size. It becomes impossible.”

In an effort to address this nutritional dilemma, Dr. Rao undertook a project that harnesses technology to help patients make dietary changes. “Our goal was to first figure out what the barriers are for patients in following a kidney diet and then to use technology to create something that will help them adhere to it,” she says.

With support from a grant from the Irving Institute for Clinical and Translational Research at Columbia, Dr. Rao and her colleagues launched a cross-sectional study among English and Spanish-speaking patients with stage 4 and 5 CKD, many who live in the Dominican community surrounding the Hospital, are older, and for whom English is their second language.

Patients provide answers to a series of questions about the foods they eat, including how often and how much in the course of a week or more. Specifically, they complete a five-part analysis designed to evaluate possible barriers to dietary adherence, including assessment of health literacy and numeracy, a food frequency questionnaire, and a knowledge assessment of foods high in potassium and phosphorus. The researchers hypothesized a number of barriers to diet compliance would exist, including:

  • Limited health literacy and numeracy
  • Multiple prescribed modifications based on an individual’s clinical picture
  • Need for adjustment as the disease progresses
  • Limited self-management skills
  • Poor educational tools
  • Limited access to nutritionists

A telling and integral aspect of Dr. Rao’s study focuses on patient health literacy and numeracy. “What we found so far is that only 30 percent of the group has intact health literacy and numeracy,” she says. “Seventy percent of the cohort has either limited health literacy or limited numeracy – or both. We started to see how ineffective nutrition counseling can be and that technology could be extremely useful.”

Health Literacy and Numeracy Assessment

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Although these results were based on only 55 of the eventual 100 participants of this first preliminary study, it nonetheless points toward factors that may make it difficult for a person challenged by advanced kidney disease to take control of their very specific nutritional requirements.

Dr. Rao has been working with a healthcare technology company that has developed web-based dietary analysis software that provides the equivalent of 90 days of nutrition tracking in 20 minutes. This cloud-based, self-administered questionnaire collects data on an individual’s dietary behavior and food use patterns, estimates nutrient intake, and delivers detailed dietary analysis data and reports. From any computer or tablet, the patient can answer eating behavior questions about foods, frequencies, and portion sizes.

“The digital survey avoids any dependence on volume measurements,” says Dr. Rao. “The program interprets the nutritional values of a patient’s actual dietary intake. Our immediate goal is to create a tool that can be used in the office by a physician, a practitioner, or a nutritionist that gives patients very tailored recommendations and focuses on nutrients important in kidney disease, including sodium, potassium, and phosphorus content. The prescription will include reasonable food replacements to make the diet easier to follow.”

VioScreen Diet Assessment

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Patients with advanced kidney disease are generally seen every two or three months. “Repetitive use will allow us to provide patients with nutritional oversight with some frequency and to give feedback on any changes they’ve made to their diet,” she adds.

Dr. Rao envisions patients being able to fill out the questionnaire on their own in the waiting room prior to their appointment. “This is personalized medicine – it’s not about giving patients a generic diet that they can’t follow, but it’s figuring out what they’re eating, what they like to eat, and how we can work with them so that they can follow a prescribed diet. Providing them with a good quality of life, slowing down the disease progression, and lengthening the delay before dialysis are really our goals.”