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Effects of Non-Compliance with Dietary Restrictions on

Hemodialysis Patients Health Outcomes

Christiana N. Ikome

Coppin State University

A Non-Thesis Paper Submitted to the Faculty of the School of Graduate Studies of

Coppin State University in Partial Fulfillment of the Requirements for the
Degree of Master of Science in Nursing





Area Dean:________________________________________


Dean, Graduate Studies:______________________________


Format used: Publication Manual of the American Psychological Association, 6th edition


Special thanks to my family for their support throughout this academic journey,
especially my little princess, Fayth-Stevanna, who stayed up most of the nights while I studied.
Additionally, I would like to express my gratitude to Dr. Leo Eyombo for his continuous
encouragement and for editing my paper. My sincere gratitude also goes to the faculty,
especially Dr. Dorsey, Dr. Obiako, and Dr. Hinds.


The topic of this clinical project is the effects of non-compliance with dietary restrictions on
hemodialysis patients health outcomes. The purpose of this clinical project is to educate health
care providers as well as patients and their families, the effect of non-compliance with dietary
restrictions on hemodialysis patients health outcome. In order to achieve the purpose of this
clinical project, an educational presentation was completed to the targeted audience at Future
Care Irvington, a long term care nursing facility located in Baltimore City. This facility cares for
a large population of patients undergoing hemodialysis. This clinical project is important
because hemodialysis patients do not have the ability to eliminate excess water and waste
products from their system, therefore what they choose to eat and drink has a direct effect on
how they feel. A qualitative descriptive design was utilized for the implementation of this
clinical project, the conceptual framework used was the Health Belief Model (HBM). The HBM
was deemed appropriate for this clinical project because it emphasizes that individual beliefs and
attitudes influence health behavior. Implementation of the clinical project was accomplished
through oral presentation, poster board, and handouts. In order to assess whether teaching was
effective, a question and answer session followed the oral presentation. Information presented
was in accordance with current research and national guidelines.


Table of Contents

Chapter One: The Problem......6
Significance of the Clinical Project.........7
Statement of the Problem.....9
Purpose of the Clinical Project......10
Clinical Project Question.......10
Theoretical Definitions......11
Operational Definitions.....11
Chapter Two: Literature Review...13
Causes Associated with Dietary non-compliance..13
Effects of Dietary non-compliance on HD patients health outcomes......17
Interventions to support dietary adherence19
Articles which present more than one view point .....22
Conceptual Framework......24
Chapter Three: Methodology.....27


Design of the Clinical Project....27
Sample and Setting....28
Inclusion Criteria...29
Exclusion Criteria..................................................................29
Limitations of the Clinical Project.....29
Protection of Human Subjects...30
Procedure for the Clinical Project..30
Instruments.. ......31
Appendix A: Kidney-Friendly Diet and Foods .............37
Appendix B: Sample questions used to evaluate learning.. ......49
Appendix C: SUPPH-29 Scale...........51
Appendix D:

BDCS (HD-Version).....52

Appendix E: Power Point Presentation...53


Chapter One: The Problem

According to the United States Renal Data System (USRDS), about 23million U.S. adult
have chronic kidney disease, and approximately 857 thousand are undergoing hemodialysis
(USRDS, 2013). Approximately one in three American adults is currently at risk for developing
kidney disease, and the risk increases to one in two over the course of a lifetime (National
Kidney Foundation, 2014). Approximately one in nine American adults has kidney disease, and
most don't know it because kidney failure is mostly due to high blood pressure, which is often
not felt or noticed until late or when organ damage has occurred (National Kidney Foundation,
2014). Kidney disease kills over 90 thousand Americans every year, more than breast and
prostate cancer combined. Black are three times more likely to experience kidney disease
compared to the general population. Once a persons kidneys fail, dialysis or a kidney transplant
is required for survival (National Kidney Foundation, 2014; USRDS, 2013).
In addition to high blood pressure, diabetes, race, and family history of kidney failure,
being age 60 or older, having a health history of kidney stones, smoking, obesity, and
cardiovascular diseases have also been implicated as causes of kidney failure (National Kidney
Foundation, 2014; USRDS, 2013). Chronic kidney disease (CKD), end stage renal disease
(ESRD) and hemodialysis (HD) patients are required to adhere to a specifically complex renal
dietary requirement and manage medications for co-morbidities such as diabetes, hypertension,
anemia, and cardiovascular diseases, resulting in patients having to adhere to multiple dietary
restrictions and manage multiple medications (Mok Wen, Hui Ang, & Christensen, 2011). Nonadherence with dietary requirement is therefore a rampant problem among patients undergoing
dialysis and can impact multiple aspects of the patients care including medications and


treatment regimens, as well as dietary and fluid restrictions (Kammerer, Garry, Hartigan, Carter,
& Erlich, 2013). It is estimated that about 50%-75% of patients on hemodialysis do not adhere
their dialysis regimen, be it medication, diet, treatment or treatment time (Kara, Caglar, & Kilic,
The need of daily dietary compliance CKD, ESRD and HD patients is well known to heath care
professionals providing care to these patients (Denhaerynck, Manhaeve, Dobbels, Garzoni,
Nolte, & De Geest, 2009). The possible reason for uncontrolled cardiovascular
disease, diabetes and hypertension in CKD, ESRD, and HD patients is not due
to lack of knowledge of medications, but may be related to the lack of
dietary non-compliance and lack of self-care behaviors (Agarwal, Nissenson,
Batille, Coyne, Trout, & Warnock, 2011).
Knowledge of the prevalent causes and effects of dietary non-compliance in patients at
risk shall enable patients, as well as their families and the health care providers to have an
increased understanding of the factors causing dietary non-adherence, and may improve how
care is provided. This change in care can eventually improve health outcomes of CKD, ESRD,
and HD patients. Adherence with dietary restrictions is associated with greater perceived
benefits such as improved blood pressure, improved blood glucose, improved anemia, decreased
depressive symptoms, decreased stress level, and improved perceived social support (Walsh,
Walsh, & Lehane, 2011, p. 3).
Significance of the Clinical Project
The predicted increase in prevalence of hypertension and diabetes has greatly increased
the cost of treating or managing patients with end stage renal disease. Approximately, $35


billion dollars is spent yearly to treat people with ends stage renal disease by way of dialysis,
including hemodialysis, peritoneal dialysis, and electrophoresis (USRDS, 2013). Despite the
financial commitment to the treatment of ESRD, hemodialysis patients experience significant
mortality and morbidity due to non-compliance with dietary restrictions (USRDS, 2013). The
effects of dietary non-compliance are made worse in the presence of other co-morbidities such as
diabetes, hypertension, and cardiovascular diseases (USRDS, 2013). Dietary compliance is an
issue which needs attention and plays a role in the outcome of patients with ESRD, those on HD,
and those with other co-morbidities as stated above. For instance, in the United States,
cardiovascular diseases account for almost 50% of deaths in patients with renal disease (USRDS,
2013). Diabetes, hypertension, and cardiovascular diseases are three major significant causes of
mortality and morbidity of most hemodialysis patients (USRDS, 2013).
The National Kidney Foundation Task Force on cardiovascular disease in chronic kidney
disease suggests that the possible reason for uncontrolled cardiovascular diseases, hypertension,
and diabetes in ESRD -HD patients is not due to non-availability of pharmacological agents, nor
lack of knowledge thereof, but emphasizes that dietary non-compliance, has a major impact in
the health outcome of ESRD-HD patients, especially those with other co-morbidities such as
diabetes, hypertension, and cardiovascular diseases (National Kidney Foundation, 2014).
Dietary non-compliance in ESRD-HD patients can significantly influence health
outcomes of patients with ESRD- HD and those ESRD- HD patent who comply with dietary
recommendations, as well as comply with medication and dialysis treatment sessions as
instructed by health care providers, have better health outcomes compared with those patients
who are non-compliant with dietary, medication, or treatment recommendations (Denhaerynck et
al., 2009, p. 3).


The significance of this clinical project is to bring more awareness by way of teaching
patients, and their families as well as health care providers the effects of non-compliance with
dietary and fluid restrictions on HD patients. Although hemodialysis eliminates toxins and
waste products in HD patients, diet and fluid restriction has a direct effect on how HD patients
feel, and how certain co-morbidities such as cardiovascular diseases, hypertension and diabetes,
my affect the patients overall health. Understanding the effects of non-compliance with fluid
and dietary restrictions on the health outcomes of HD patients shall therefore enable patients,
their families as well as health care providers to make better and informed decisions in order to a
achieve better health outcomes (Denhaerynck et al., 2009).
Statement of the Problem
Hemodialysis patients are required to adhere to a specifically prescribed renal diet
consisting of low potassium, low sodium/fluid, low phosphorus, and high protein because
malfunctioning kidneys are unable to regulate protein, fluid, sodium, potassium, and phosphorus
levels (Sabate, 2010; USRDS, 2013, Wells, 2011). Non-compliance with dietary and fluid
restrictions is a problem for HD patients, as health care providers usually provide these
patients with lists of foods to avoid, alternative cooking strategies, or suggestion on how to
improve food flavor, but the daily implementation of such complex dietary requirement remains
the challenging responsibility of HD patients who are expected to make several other lifestyle
modifications and manage other co-morbidities (Agarwal et al., 2011). Noncompliance with dietary restrictions has a direct negative effect on the
health outcomes of HD patients (Denhaerynck, et al., 2009, p. 8).



Purpose of the Clinical Project

The purpose of this clinical project is to ascertain current knowledge,
identify gaps, and determine the factors contributing to dietary noncompliance in HD patients, and to examine what can be done to assist HD
patients improve adherence with dietary restrictions. Knowledge of what is
known about the factors which cause patients not to adhere with dietary and
fluid restrictions will enable health care providers, families, and the patients
to best address those particular issues in order to achieve optimal health
outcomes (USRDS, 2013). Reducing non-adherence factors will therefore
enhance dietary and fluid compliance and in turn, significantly reduce
mortality and morbidity caused by worsening cardiovascular diseases and
diabetes- related complications (USRDS, 2013).
Clinical Project Question
What are the effects of non-compliance with dietary restrictions in HD patients health
Literature related to non-compliance with dietary restrictions in HD patients and the effects on
health outcomes, in relation to hypertension, diabetes, and control of cardiovascular diseases,
was reviewed, and concepts from these research articles led to the following assumptions: All
HD patients who are compliant with dietary and fluid restrictions would have better health
outcomes and proper control of hypertension, diabetes, and cardiovascular related disease
compared with those who are non-compliant with dietary and fluid restrictions. Another
assumption is that supportive and educative interventions about dietary requirement for HD



patients will improve self-care ability and help promote dietary compliance in hemodialysis
patients. Another assumption is that blood pressure, diabetes, and cardiovascular diseases caused
by poor dietary adherence will improve if self-care actions improve.
Variables with Theoretical and Operational Definitions:
The following variables are identified:
1. Compliance
2. Self-care management
3. Social support
Operational Definitions of Variables:
Compliance: Compliance shall be determined by inter-dialytic weight gain and serum
electrolytes (Wells, & Walker, 2012).
Self-Care Management: Self-care management shall be measured by Strategies Used by
People to Promote Health (SUPPH) scale (American Kidney Foundation, 2014).
Social Support: Refers to resources provided by other people, including a wide variety of social
networks and relationships, emotional, physical, and moral support and perception that one is
cared for by others, and that one has assistance available from others to support them in times of
perceived needs, thus creating a sense of belonging and acceptance.
Theoretical Definitions of variables:
Compliance: Compliance is the extent to which a persons behavior such as taking medications,
following a prescribed diet, and or executing lifestyle changes corresponds with
recommendations from a health care provider (Sabate, et al., 2010)
Self-Care Management: Self-Care Management is the process of maintaining health with
health- promoting practices within the context of the management required of a chronic illness.
The key concepts include self-care maintenance, self-care monitoring, and self-care



management. Factors influencing self-care include experience, skill, motivation, culture,

confidence, habits, function, cognition, support from others, and access to care (Sabate et al.,
In summary, hemodialysis removes waste products from the body; however, dietary and
fluid restriction are major components of requirements when patients are on hemodialysis
(USRDS, 2013). The question for this clinical project is to find out what effects non-compliance
with dietary restriction would have on the health outcomes of hemodialysis patients. The purpose
of this clinical project is to educate health care providers as well as patients and their families, on
effect of non-compliance with dietary restrictions in hemodialysis patients heath outcome. In
order to achieve the purpose of this clinical project, an educational presentation was completed
to the targeted audience at Future Care Irvington, a long term care nursing facility located in
Baltimore City. This facility cares for a large population of patients undergoing hemodialysis.
This clinical project is important because hemodialysis patients do not have the ability to
eliminate excess water and waste products from their system, therefore what they eat and drink
has a direct effect on how they feel and what their health outcomes might be. Low potassium,
low phosphorus, low fluid and high protein intake are key factors determining the quality of life
for individuals on hemodialysis (USRDS, 2013).



Chapter Two: Literature Review

Unfortunately, dietary non-compliance is a widespread problem in health care that carries
with it substantial medical, social, and economic consequences, particularly among patients with
CKD and ESRD and those who are on HD (Baraz, Parvardeh, Mohammadi, & Broumand, 2010).
Literature review shall discuss causes associated with dietary non-compliance; the effects of
dietary non-compliance on HD, patients health outcomes. Interventions to support dietary
adherence; furthermore, articles which present more than one view point regarding dietary noncompliance, and relevant information on dietary and fluid non-compliance based on national
agencies such as USRDS, and the National Kidney Foundation (NKF) shall be examined.
Cause Associated with Dietary Non-Compliance
Lack of self-care management skills: Lack of self-management skills has been
identified as one of the major causes of dietary non-compliance in CKD, ESRD, HD patients
(Mok et al., 2011). Self-care management skills are those behaviors employed by an individual
in managing and implementing the treatment regimen within the individuals lifestyle routine and
it recognizes an individuals central role in managing chronic diseases (Mok et al., 2011). Selfcare management has been used successfully in a variety of chronically ill populations including
hypertension, diabetes mellitus, obesity, and asthma. Using a sample of 410 adult patients with
CKD, ESRD and on HD (mean age =53 years) from multicenter outpatients units, a six months
prospective randomized controlled trial to investigate effectiveness of sodium restriction and its
effect on blood pressure, fluid, and weight gain between hemodialysis treatments revealed that
blood pressure was significantly reduced in mean systolic BP by 7.5mmHg and by 5.5mmHg, in



mean diastolic BP, and that fluid and weight gain between dialysis treatment was significantly
low by 1.2kg, compared to the control group.
Lack of self-motivation: Individuals with CKD, ESRD, and HD are likely to experience
emotional burdens such as fear, denial, anger, depression, social isolation, and anxiety about the
treatment process and the uncertain prognosis (Mok et al., 2011). These individuals may also
experience physical constraints such as overwhelming fatigue, peripheral edema, sleeplessness,
and back pain, urinary frequency which affects work, lifestyle, and limits participation in social
activities as well as self-care activities (Mok et al., 2011).
Depression: Depressive symptoms has been associated with fluid and dietary noncompliance which could lead to poorer outcomes (Khalil, Frazier, Lennie, & Sawaya, 2011).
Using a sample of about 810 ESRD-HD patients, a study to determine the relationship between
dietary non-compliance and depressive symptoms was conducted. The mean age of the sample
was 43.4 year; 90% of the patients reported that either they were depressed or they were having
depressive symptoms and that these symptoms contributed to non-adherence to fluid and dietary
restrictions (Khalil et al., 2011). Hopelessness, cognitive distortions, and fatigue produced
negative expectations of the future that affected the individuals expectations of the future and
therefore influenced the ability or inability to carry out prescribed therapies, including diet and
fluid adherence (Khalil et al., 2011).
Co-morbidities: Co-morbidities such as diabetes, hypertension, anemia, and
cardiovascular diseases result in HD patients having to adhere to multiple medications and
dietary restrictions (Kammerer et al., 2013). More than half of patients on HD have comorbidities which have been attributed to some of the reasons for non-compliance (Kammerer et
al., 2013). In order to address most of these problems, patients may be required to adhere to



strict dietary restrictions, and take phosphate binders, vitamin D preparations, calcimimetic
agents, antihypertensive medications, hypoglycemic medications, erythropoietin, iron
supplements and a variety of other medications (Kammerer et al., 2013).

Management of these

health issues, together with management of diet places multiple, complicated and unavoidable
demands on a patients lifestyle (Kammerer et al., 2013).

Non-adherence is therefore a rampant

problem among patients undergoing hemodialysis and can impact multiple aspects of the
patients care including medications, treatment regimens as well as dietary and fluid restrictions
(Kammerer, 2013). About 50%-75% of patients on hemodialysis do not adhere to at least part of
their dialysis regimen, be it medication, dietary restriction, hemodialysis treatment or treatment
time (Kara, Caglar, & Kilic, 2009).
Financial, economic and social constraints: Financial, economic, and social problems
such as lack of a steady financial income, knowledge deficit, alcohol and other illicit drugs
usage, and polypharmacy have been highlighted as some of the causes of dietary non-compliance
(Mok et al., 2011).
Lack of self-care ability: Lack of self-care ability has also been attributed as one of the
reasons for non-compliance with dietary and fluid restrictions in HD patients (Wells, et al.,
2012). Self-care is a learned behavior and therefore being able to learn to take care of ones self
is a valuable factor which contributes to adherence or non-adherence with dietary restrictions
(Wells, et al., 2012). For instance if patients are educated to understand the rationale for their
medical regiments, and the causes and consequences of their choices in terms of what they eat
and drink, they are able to make informed decisions about whether or not to adhere to
recommendations. Therefore, it seems that a lack of information is the most important factor



contributing to non-compliance with therapeutic regimens, especially diet and fluid restrictions,
which in turn may lead to exacerbation of illness and complications (Wells, et al., 2012).
Educational level and age: Patients level of education and age are factors which affect
compliance (Wells et al., 2012). Younger and more educated patients were noted to be more
compliant with dietary and fluid restrictions compared with older and less educated patients
(Well et al., 2012).
Other factors: Patient variables such as knowledge deficit, hectic lifestyle, lack of
decision-making in own dietary choices, and dissatisfaction with the prescribed renal diet are
some other reasons thought to be contributing to dietary and fluid non-compliance in HD patients
(Mok et al., 2011). HD patients sometimes lack the knowledge and resources and may have few
ideas on the types of food choices which meet the nutritional recommendations. They may even
have the knowledge but may lack the money or the resources to meet the nutritional
recommendation and therefore may not know how to make necessary adjustments in their eating
habits to fit the prescribed renal diet regimen (Mok et al., 2011). Hectic lifestyles for instance
may prevent a patient from adhering to the prescribed nutritional regime, leading to patient
eating from fast food restaurants or foods prepared at hawker centers and food courts which tend
to have higher ratios of saturated fats and salts than home-cooked food (Mok Wen, Q., Hui Ang,
J., & Christensen, M., 2011).
Another reason why HD patients are non-compliant with dietary restrictions is the
unpalatable taste of the renal diet making it challenging, especially for new HD patients to
change from their usual eating patterns to specifically restricted renal diet. Patients are more
likely to comply with dietary recommendations if they have higher satisfaction towards the



prescribed diet and are more likely to adhere to the dietary regimen than those dissatisfied with
the diet (Mok et al., 2011).
Relationship variables including inconsistencies in the advice provided by health care
professionals, and the ineffective interaction between health care providers and have been
attributed to some of the reasons for non-compliance with dietary restriction. This ineffective
relationship may lead to confusion in terms of dietary recommendations and may also be seen as
relinquishing patient control over the condition in favor of health care advice (Mok et al., 2011).
The ineffectiveness of communication and interaction between the patient and health care
provider may result in inadequacy of dietary instruction and supervision to ensure adherence
(Mok et al., 2011).
The inconvenience of the dietary regimen being prescribed by health care providers
without taking into consideration the patients lifestyle, culture, and religious beliefs has also
been attributed to contribute to non-compliance with dietary and fluid restriction (Mok et al.,
Effects of dietary non-compliance on HD, patients health outcomes
Most of the literature reviewed revealed that nutritional therapy is a complex but
essential component in managing HD patients because HD patients are not able to eliminate the
waste products and excess water from their blood stream and therefore what HD patients eat and
how much they drink has a direct effect on how the patient feels (USRDS 2013; NKF, 2014).
HD patients kidneys lack the ability to maintain homeostasis in the body, as they are no longer
able to regulate fluid, release hormones, or excrete waste products of metabolism such as urea
and creatinine or excess minerals such as sodium, potassium and phosphate (Mok et al., 2011).
In failed or non-functioning kidneys for instance, phosphorus will accumulate in the blood



stream, causing the person to have hypocalcemia and hyperparathyroidism resulting as a

compensatory mechanism for low calcium, and eventually causing bone pain, osteoporosis
resulting in fracture, and cardiac muscle contractility issues which may precipitate congestive
heart failure (Mok et al., 2011).
Like phosphorus, salt intake is of great concern in HD patients since high sodium intake is
likely to cause or worsen hypertension in response to an expansion of the extracellular space
through fluid retention exacerbated by the kidneys and the thirst center, thus increasing cardiac
contractility, a normal compensatory mechanism in response to fluid overload which may
possibly lead to cardiomegaly and congestive heart failure over time (Eskridge, 2010; Mok et al.,
Urea and creatinine are the prime metabolites needed to be removed from the body. Urea
has a very finite excretion factor through the kidneys, that is to say, in the normal, functioning
kidney; the nephrons will filter 100% of the urea presented to them. Creatinine is also 100%
excreted in normal functioning kidneys, however; in HD patients, the inability of the remaining
glomeruli to filter urea and creatinine is greatly decreased, causing urea and creatinine levels to
rise quickly and accumulate, leading to neurologic disorders affecting the central nervous system
and the peripheral nervous system. These complications may include diffuse encephalopathy,
seizures, stoke, movement disorders, sleep alterations, and polyneuropathy (Seeley, VanPutte,
Regan, & Russo, 2011).
Non-compliance with dietary and fluid restrictions may lead to or worsen hypertension,
diabetes, cardiovascular diseases, uremia, mental status change, shortness of breath,
hyperkalemia, hypernatrimia, hyperphospotemia, and osteodystrophy in HD patients
(Denhaerynck et al., 2009). In a sample of 710 HD patients, it was found that non-compliance



in terms of shortening treatments ranged from 7% - 32%, while skipping dialysis sessions ranged
from 0.1% - 35%; non-adherence with medications was 10% - 35%, while non-adherence with
dietary and fluid restrictions ranged from 20% - 88% of the sample (Denhaerynck et al., 2009).
Denhaeryncks findings support other researchers by way of confirming that elevated dietary
potassium may lead to hyperkalemia and probably cause or worsen cardiac arrhythmias. Like
potassium, phosphorus is an important mineral which works closely with calcium to build bones
and keep nerves and muscles working properly. In a normally functioning kidney, excess
dietary phosphorus is excreted; however, in kidney disease, this process of elimination does not
work efficiently, thus causing a high phosphorus levels in the blood to rise and cause calcium and
phosphorus imbalance. Over time, bones may become weak and brittle and can be broken more
easily. Symptoms of high phosphorus include itching and joint or bone pain. High phosphorus
levels can also cause hard deposits to form in the patients blood vessels and soft tissues.
Excessive intake of foods containing high amount of sodium causes thirst which increases fluid
intake, thereby resulting in the detrimental cardiovascular consequences associated with
excessive fluid intake (Denhaerynck 2009; USRDS, 2013; NKF, 2014).
Interventions to support dietary adherence
Some strategies to support the renal dietary requirement for HD patients are complicated
and necessitate multiple, integrated interventions and approaches to support adherence (Mok et
al., 2011). Patient education, behavioral modification and organizational changes are strategies
used to support or promote nutritional adherence in HD patients (Mok et al., 2011). Living with
kidney disease is not always easy; however it is possible to enjoy a productive and satisfying life
with knowledge and good support system from family and the health care system (Baraz,
Parvardeh, Mohammadi, & Broumand, 2010). Nutritional education is a necessary initial step to



achieve dietary changes, as education seeks to increase patients knowledge and changes any
potential undesirable attitudes (Baraz et al., 2010). Nurses, nutritionists, social workers, doctors,
and other health care providers, should teach patients nutritional values of food types and
ingredients such as salt, sugar, fat and potassium and provide guidelines for diet modification in
accordance with renal diet prescription, in consideration of the patients identified nutritional,
religious, and cultural values and needs (Wells, et al., 2012).
While it is easy to provide education, it is imperative that health care staff assess patients
self-care ability, motivation to learn, and religious and cultural preferences in order to address
individualized dietary needs. Additionally, it is essential those health care providers follow-up
with patients and their families to ensure that patients are utilizing the knowledge, and are
seeking for clarifications as needed (Wells, et al., 2012). Furthermore, in instances where the
patients diet is determined by someone else such as caregiver, education should then be targeted
at the person involved in preparing the patients diet (Wells, et al., 2012).
Behavior modification strategies focusing on individual patients beliefs towards health
and wellness should also be taken into consideration in an effort to influence specific adherence
behavior (Baraz et al., 2010). Techniques such as reminders, self-monitoring, and positive
reinforcement are suggestions that health care providers can use in order to promote adherence
(Wells et al., 2012). Reminders can improve non-adherence as a result of cognitive decline and
forgetfulness (Wells et al., 2010). Various aids such as charts and menus serve to remind patients
to limit minerals like potassium, and sodium (Wells, 2012; Mok 2011).
Self-monitoring is another strategy that can encourage patients nutritional adherence, as it
encourages patients to be proactive in observing and recording their dietary intake (Mok et al.,
2011). One form of self-monitoring is record-keeping, where patients are expected to record the



nutritional contents of all food they eaten on an individualized patient log. This log helps
patients to assume a more active role in nutritional choices and adherence. Health care providers
can also act as facilitators by instructing on the proper way to self-monitor, checking patients
records for accuracy and providing useful feedback (Cicolini, Palma, Simonetta, & Di Nicola,
Strategies involving organizational changes can also improve quality of interaction
between patients and healthcare providers so as to enhance dietary adherence (Gunney, I., et al.,
2011). To reduce complexities of nutritional regimen, health care providers can work in
collaboration with dieticians and the patient in an attempt to make the renal diet less complex by
prioritizing the regimen and breaking the dietary plan into sequential implementable stages
(Gunney, I., et al., 2011). Furthermore, health care providers can directly involve the patient in
the development of nutritional plans; this can help to minimize inconveniences by tailoring the
diet regimen to the patients cultural and religious lifestyle as closely as possible and therefore
promoting dietary adherence. Health care providers can act as advocates and translate the
recommended nutrient levels by the dietician into an individualized meal pattern for the patient.
One method of creating individualized meal plans is to provide a food choice list with greater
variety in the diet and enhance its palatability while preserving the consistency of daily nutrients
level (Mok et al., 2011).
In addition, healthcare providers should collaborate with other health care team members
including dieticians and social workers, in order to assist patients with resources that may
facilitate acquisition of recommended and favorite food items (Mok et al., 2011). Assessment of
patient satisfaction can be made before dietary modifications are prescribed as there is a positive
correlation between satisfaction of prescribed diet and dietary adherence (Mok et al., 2011).



Articles which present more than one viewpoint regarding dietary non compliance
Current available research related to dietary non-compliance of HD patients reveal that,
although much research has been targeted towards understanding factors causing noncompliance and the effects of non-compliance with dietary restrictions on HD patients health
outcomes, there is generally no single or any particular patient demographic or psychological
characteristics that are consistent predictors of dietary compliance (Kammerer et al., 2010). In
addition to factors such as knowledge deficit, educational level, individual motivation, which
influenced dietary compliance, factors such as cultural heritage and cultural beliefs are
significant considerations in HD patients dietary compliance (Kammerer et al., 2010). In
support of Kammerers 2010 findings, Hanson et al. (2014) suggest that, in addition to education,
behavioral modification, factors such as age, gender were significantly correlated dietary
(Hanson et al., 2014). Younger patients were significantly more likely to demonstrate fluid nonadherence as well as a low level of family support was also significantly associated with fluid
and dietary non-compliance (Hanson, L., et al, 2014).
According to findings from the USRDS (2013); Kammerer (2013); and the NKF (2011),
better health outcomes of HD patients are directly related to compliance, including dietary
restrictions, medication regimens and fluid restriction. However, factors such as availability of
resources also play a significant role in dietary non-adherence. For example, the USRDS
suggests that African Americans have a four times higher risk than whites in having CKD,
ESRD, and HD because African Americans have been disproportionately affected by health
disparities, leading to CKD, ESRD, and HD (USRDS, 2014). Wells (2012) argues that factors
influencing health care disparities include interactions between the socioeconomic environment,
genetics, and health care delivery system. Wells (2012) attributes the disparity to a form of



institionalized racism, where structures, policies, practices, and norms resulting in differential
access to the goods, services, and opportunities of society are distributed by race (Wells et al.,
Low serum 25-hydroxy vitamin D (25OHD) predicts higher cardiovascular risks in the
general population, and because patients with CKD, ESRD, and HD are more likely to have low
serum 25OHD, mortality is common in this group (Mehrotra et al., 2009). A cohort study with
3011 subjects was carried out, and in the cohort, 1123 died over a mean follow-up period of 9.0
0.2 years (Mehrotra, et al., (2009). Individuals with serum 25OHD levels 15ng/ml had a
significantly higher risk for death in 15 of the 23 subgroups examined compared with those with
levels 30ng/ml (Mehrotra et al., 2009).
Current reviewed literature reveals that evidence supporting impact of the factors that
affect adherence is somehow unclear, as most studies agree that to improve a patients ability to
adhere with dietary, fluid, medication, and treatment regimens, all potential barriers to adherence
need to be considered. Healthcare professionals should take into account factors under the
patients control as well as interactions between the patients resources and the patients
motivation to adhere to treatment or dietary protocol. Individuals with chronic illnesses who
experience a diminished sense of control often seek alternative methods to re-establish control.
These behaviors may manifest in positive or negative ways. Many theories suggest that a
perceived lack of control over the disease process and or the dialysis procedure may help to
explain non-adherence (Kim & Evangelista 2010).



Conceptual Framework or Theory

The theoretical framework used for this clinical project is the Health Belief Model
(HBM). The HBM was developed in the 1950s as a technique to explain shy medical screening
programs offered by the U.S. Government were not successful (Walsh & Lehane, 2011). The
HBM is one of the most commonly used theories in education and health promotion (Walsh et
al., 2011). The underlying concept of the HBM is that the behavior is determined by personal
beliefs or perceptions about a disease and the strategies available to decrease the occurrence of
the disease impact (Walsh et al., 2011). The concept within the HBM are perceived severity,
perceived susceptibility, perceived benefits, perceived barriers, cues to action, and self-efficacy
(Walsh et al., 2011).
Perceived seriousness and severity is the extent to which an individual recognizes a
health threat to be severe and determines the extent to which he/she will utilize resources to
protect themselves from the threat (John, 2012, p. 6). In most instances, the perception of
seriousness is often based on medical information. However, this perception may also be as a
result of an individuals health beliefs about the difficulties or burden a disease would create in
his/her life (John, 2012, p. 6).
Perceived susceptibility is the degree to which an individual believes he/she is vulnerable
to a particular health threat (White, Jaffey, & Magner, 2010). The greater the individuals
perception of susceptibility, the more likely the individual is to participate in behaviors that
reduce the risk of developing the disease or health condition (White et al., 2010). The HBM
emphasizes that when people believe they are at risk for a disease, they are more likely to take
actions to prevent the disease (White et al., 2010).



Perceived benefits refer to the extent an individual feels a specific course of action will
successfully manage a problem or be favorable to his/her overall well-being (White et al., 2010).
This perception predicts the likelihood of engaging in the health behavior because people tend to
implement healthy behaviors when they believe the new behavior will decrease their chances of
developing a disease (White et al., 2010).
Perceived barriers constitute factors that inhibit or disrupt the individuals ability or
desire to implement a specific heal behavior (White et al., 2010). Of all of the constructs of the
HBM, a perceived barrier is the most significant for determining behavior change (White et al.,
2010). In order for a new behavior to be adopted, the individual must believe that the new
behavior outweighs the consequences of the old behavior (White et al., 2010).
In addition to the four constructs as mentioned above, the HBM suggests that behavior is
also determined by cues to action, and self-efficacy (White et al., 2010). Cue to action which
refers to the strategies used to activate ones readiness to perform a specific health behavior, and
self-efficacy is the degree to which an individual believes he/she is capable of accomplishing a
specific health behavior (White et al., 2010). This model was chosen to guide this clinical project
because it is assistive in examining health behaviors. The HBM suggests that beliefs and
attitudes of individuals can influence health behavior (Walsh et al., 2011). The HBM has
demonstrated that components such as perceived benefits, perceived barriers, cue to action and
self-efficacy, have high predictive positive health behavior (Walsh et al., 2011). The HBM was
applicable to this clinical project because it specifically focuses on an individuals behavioral !be
accurate in predicting individual factors associated with adherence in HD population and patients
at risk for other chronic diseases such as hypertension, diabetes, obesity, and other cardiovascular
diseases (Walsh et al., 2011). The model emphasizes that to understand and/or modify individual



behavior in patients who are deemed non-adherent, the HBM constructs of perceived benefits
and perceived barriers offer researchers predictive factors associated with adherence in health
information (Walsh et al., 2011). The HBM is best suited for this clinical project since the major
focus of this clinical project is to disseminate health information and disease prevention
Several research has shown that CKD, ESRD, and HD is a complex condition that
requires many lifestyle changes for survival and that factors such as nutritional adherence, selfcare, social support from both health care providers and family members can contribute to
improved control of hypertension, diabetes mellitus, cardiovascular diseases, edema, uremia,
osteodistrophy, and ultimately better overall health outcomes for CKD, ESRD, and HD patients
(Walsh et al., 2011). Self-monitoring of fluid and dietary restrictions in combination with other
behavioral, educational and cognitive behavior interventions have been found to improve
interdialytic weight gains as well as considerably reduced blood pressure (Yokoyama et al,
2009). A supportive, educative interaction between the patient at risk for CKD, ESRD, and HD
and the health care provider has been shown to improve dietary compliance, improve blood
pressure, and control of diabetes and other co-morbidities which are prevalent in this population.
Further investigation on factors that may affect adherence abilities and self-care behaviors are
needed to help guide nurses and other health-care providers to better care for HD patients.



Chapter 3: Methodology
This chapter describes the clinical project, design, methods, sample, and a description of
how and where the subjects were obtained, it will discuss the limitations, restrictions resulting
from the sample selection or data collection procedure, it will discuss how information was
disseminated, as well as discuss protection of human subjects, confidentiality, anonymity for
clinical project participants, instruments used for evaluation of the clinical research project and a
description of the instruments, reliability and validity of the instrument.
The purpose of this clinical project is to determine factors contributing
to dietary non-compliance in HD patients and to exam the effects of such
non -compliance behavior on the health outcome of HD patients.
Knowledge of what is known about the factors which cause patients not to
adhere to dietary and fluid restrictions will enable health care providers,
families and the patients to best address those particular issues in order to
achieve optimal health outcomes for HD patients (USRDS, 2013). Since HD
patients lack the ability to eliminate fluid and waste products from their system; they rely mostly
on HD treatment and diet to prevent waste product build up in the blood stream (Fine, Martz, &
Stablein, 2010). Participants at the clinical project shall benefit from literature review on the
effects of dietary non-compliance and what health care providers and other interdisciplinary team
members can do to assist HD patients.
Design of the Clinical Project
A descriptive research design was utilized to implement the clinical project. Descriptive
research is appropriate for the research question because it is capable of providing information



about naturally occurring heath status, behavior, attitudes or other characteristics of a particular
group or phenomenon, as it attempts to explore and describe a phenomenon in real-life situation.
Descriptive research is one of the most used in nursing research for problem solving, making
decisions or to improve care in clinical settings (Burns & Grove, 2009).
In order to implement this clinical project, the target population and an appropriate site
was selected. The site was a long term care nursing facility located in Baltimore city. This
facility was appropriate because it cares for a large number of CKD, ESRD and HD patients.
The project implementation date was Friday, December 5, 2014, at 1100 hours through 1300
hours. The clinical question for this project was what the effects of non-compliance with dietary
restrictions have on HD patients health outcome. Following the presentation the participants
were able to demonstrate understanding through a question and answer session.
Sample and Setting
The type of sample appropriate for implementing the clinical research project is a
stratified random sampling. A stratified random sampling is appropriate in situations where the
researcher knows some of the variables in the population that are critical for achieving
representativeness (Burns & Grove, 2009). Variables commonly used include age, gender,
ethnicity, socioeconomic status, diagnosis, geographical region, type of institution, and type of
care (Burns et al., 2009). Stratified random sampling was selected because a certain category of
patients, in this case people who have CKD, ESRD and HD and those who provide care for this
group of patients including nursing staff, dietary staff, physical and occupational therapy staff,
activity staff, housekeeping staff as well as the social workers were the target population.
The setting was at Future Care Irvington, a long term care nursing facility located in
Baltimore City. The population and setting was ideal for the clinical research project because



most of the patients in this facility have CKD, ESRD, and on HD. The staff of this facility cares
for these patients and therefore it was perceived that information included in this clinical
research project shall be beneficial this population and the HD patients whom the staff cares for.
Inclusion Criteria
Participants were considered eligible for participation if they were: a) male or female
more than 18 years of age, caring for HD patients, b) providers including but not limited to
nursing staff, dieticians, social workers or family members of patients with CKD, ESRD, and
HD, c) individuals who are able to read and express themselves in the English language, d) live
either in Baltimore City or Baltimore County, either at home or in a long term care facility, and
e) be free of major psychiatric disorders or cerebrovascular diseases that may affect cognitive
Exclusion Criteria
Participants were excluded from participation if they were: a) male or female younger
than 18 years, b) determined or suspected to have psychiatric issues that might disrupt the
clinical project presentation, c) have language barriers that impedes participation, and d) those
visiting the facility of visiting their family members living in the long term care facility.
Some limitations observed in the course of implementation of this clinical project include:
1. This project was performed only in one demographic location, and therefore the project
cannot be generalized to other patients.
2. Patients who still produce large volume of urine must adhere to less stringent fluid
restrictions than patients who are totally anuric.
3. The small sample size may also be a limitation as this might prevent generalization.



Protection of Human Rights:

Approval for participation was sought from the facility administrator; participants
confidentiality was assured by using an evaluation form with no information that would directly
or indirectly identify participants. No procedure or situation and or materials hazardous to
participants were used; no risks of injury or harm was anticipated, and participants were
informed that participation was voluntary and that anonymity shall be maintained, and there is no
anticipation that participants would experience any kind of anxiety or psychological stress.
Procedures for the Clinical Project:
The clinical project was targeted towards improving dietary and fluid compliance in HD
patients with components including teaching, guiding, supporting and providing therapeutic food
options. Phase one of the project was to teach participants about the importance of adhering to
recommended nutritional and fluid restrictions and to provide list of kidney friendly diet and
food items that are appropriate and those that are not appropriate for HD patients (see
Appendix A). Phase two was to evaluate understanding of the content by way of a question and
answer session (see Appendix B). The people to Promote Health (SUPPH) scale by the
American Kidney Foundation was also used to evaluate how well dietary rules were followed
after a patient has been on HD for at least three months (see Appendix C). During this second
phase of the clinical project, participants were provided with skills to establish appropriate goals
to help adjust behaviors to achieve specific goals. A belief about dietary compliance scale
(BDCS) (see Appendix D) was utilized to measure beliefs (perceived benefits and barriers)
related to following HD dietary restrictions. A power point presentation was utilized for
discussions and dissemination of the information to the participants (see Appendix E).



The People to Promote Health (SUPPH-29) scale was utilized during this clinical project.
The People to Promote Health (SUPPH-29) scale is a concise self-reporting scale with 29 short
questions used to evaluate how people use different ways to adapt to their illness. Information
provided during this clinical project implementation was based on current research and evidence
based literature, and the information was in accordance with the national guidelines for care of
HD patients. Although HD patients did not directly complete this tool, nursing staff were used to
assess how well they thought their patients would score on the scale. The tool was scored in
three categories: positive attitude towards illness, stress reduction, and making decisions. The
beliefs about Dietary Compliance Scale (BDCS) (HD version) was also used to measure beliefs
(perceived benefits and perceived barriers) related to following the HD dietary and fluid
restrictions. The BDCS was originally developed in 1997, and was modified subsequently to suit
HD population (Gutierrez and Wolf, 2010). The BDCS (HD version) is a 12-item scale: 7 items
address perceived benefits, and 5 items address perceived barriers. Both tools use a Likerttype scoring system where participants indicate their agreement with statements from 1 being
strongly disagree to 5 being strongly agree. The responses will be summed for each subcategory and results evaluated or validated. The BDCS (HD version) was found to have
moderately high internal consistency with Cronbachs s for the benefits and barriers subscales
ranging from 0.66 0.81 at three time point (Gutierrez & Wolf, 2010).



This section of the clinical research project discussed the design and methods, sample
selection and size, a description of the setting and how subjects were obtained. Discussions on
the limitations or biases resulting from the sample selection or data collection procedure were
also discussed. Protection of human subjects, confidentiality, and anonymity for clinical project
participants, instruments used for data collection including a description of the instruments,
reliability and validity of the instrument are also mentioned.



Agarwal, R., Nissenson, A., Batille, D., Coyne, D., Trout, J., & Warnock, D. (2011).
revalence, treatment and control of chronic hemodialysis patients in the United States.
American Journal of Medicine, 115(4), 291-297.
Baraz, S., Parvardeh, S., Mohammadi, E., & Broumand, B. (2010). Dietary and fluid
compliance: An educational intervention for patients having haemodialysis. Journal of
Advanced Nursing, 66(1), 60-68. doi:10.1111/j.1365-2648.2009.05142.x
Burns, N., Grove, S. (2009). The practice of nursing research: Appraisal, synthesis, and
generation of evidence (6th ed). Missouri: Saunders Elseveir.
Charra, B. (2010). Fluid balance, dry weight and blood pressure in dialysis. Hemodialysis
International, 11,(1) 21-31.
Cicolini, G., Palma, E., Simonetta, C., & Di Nicola, M. (2012). Influence of family carers on
haemodialyzed patients' adherence to dietary and fluid restrictions: An observational
study. Journal of Advanced Nursing, 68(11), 2410-2417. doi:10.1111/j.13652648.2011.05935.x
Denhaerynck, K., Manhaeve, D., Dobbels, F., Garzoni, D., Nolte, C., & De Geest, S. (2009).
Prevalence and consequences of non-adherence to hemodialysis regimens. American
Journal of Critical Care 16(3), 222235.
Eskridge, M. (2010). Hypertension and chronic kidney disease: The role of lifestyle modification
and medication management. Nephrology Nursing Journal, 37(1), 55-59



Fine, R., Martz, K., & Stablein, D. (2010). What have 20 years of data from the North American
Pediatric Renal Transplant Cooperative Study taught us about growth following renal
transplantation in infants, children, and adolescents with end-stage renal disease?
Pediatric Nephrology, 25(4), 739-746. doi:10.1007/s00467-009-1387Gunney. I., Atalay, H., Solak, Y., Altintepe, L., Tonbul, H.Z., Turk, S. (2012). Poor quality of
life is associated with increased mortality in maintenance hemodialysis patients: A
prospective cohort study. Soudi J Kidney Disease Transplant, 21(3) 493-499.
Gutirrez, O., & Wolf, M. (2010). Dietary phosphorus restriction in advanced chronic kidney
disease: Merits, challenges, and emerging strategies. Seminars In dialysis, 23(4), 401406. doi:10.1111/j.1525-139X.2010.00750.x
Hanson, L., Haynes, L. K., Turiano, L., Wesseling, C., Crowe, J., Hogstedt, C., & ... Wegman,
D. (2014). Chronic Kidney Disease in Central America: The big picture, 23(11), 401-405
Wesseling, C., Crow, J., Hagstedt, C., Jakobsson, K., Lucas, R., Wegman, D.H. (2012). The
epidemic of chronic kidney disease of unknown etiology in Mesoamerica: A call for
interdisciplinary research and action, American Journal of Public Health, 104(7), e9e10.oi:10.2105/AJPH.2014.301984
John, A. (2012). The relationship between self-efficacy and fluid and dietary compliance in
hemodialysis patients. Nephrology Nursing Journal, 36(4), 359-366.
Kammerer, J., Garry, G., Hartigan, M., Carter, B., & Erlich, L. (2013). Adherence in patients on
dialysis: Strategies for success. Nephrology Nursing Journal, 34(5), 479-487.
Kara, B., Caglar, K., & Kilic, S. (2009). Nonadherence with diet and fluid restrictions and
perceived social support in patients receiving hemodialysis. Journal of Nursing
Scholarship, 39(3), 243-248. doi:10.1111/j.1547-5069.2007.00175.x



Khalil, A., Frazier, S., Lennie, T., & Sawaya, B. (2011). Depressive symptoms and dietary
adherence in patients with end-stage renal disease. Journal of Renal Care, 37(1), 30-39.
Kim, Y., & Evangelista, L. (2010). Relationship between illness perceptions, treatment
adherence, and clinical outcomes in patients on maintenance hemodialysis. Nephrology
Nursing Journal, 37(3), 271-281.
Mehrotra, R., Kermah, D., Salusky, I., Wolf, M., Thadhani, R., Chiu, Y., Norris, K. (2009).
Chronic kidney disease, hypovitaminosis D, and mortality in the United States. Kidney
International, 76(9), 977-983.
Mok Wen, Q., Hui Ang, J., & Christensen, M. (2011). Meeting the nutrition
challenge of stage 3 kidney failure: considerations for nursing practice.
Singapore Nursing Journal, 38(4), 10-13.
National Kidney Foundation (NKF), 2014, http://www.national kidney
Rangarajan, D. D., Ramakrishnan, S. S., Patro, K. C., Vakrani, G. G., Badrinath, S. S. (2014).
A study of impact of cost-effective nutritional supplement in patients on maintenance
hemodialysis. Indian Journal Of Nephrology, 24(4), 222-225. doi:10.4103/09714065.132995.
Ramirez-Rubio, O., McClean, M. D., Amador, J., & Brooks, D. R. (2013). An epidemic of
chronic kidney disease in Central America: an overview. Journal of Epidemiology &
Community Health, 67(1), 1-3. doi:10.1136/jech-2012-201141
Sabate, E. (2010). World Health Organization. Adherence to long-term therapies:
Evidence for action. Retrieved from



Seeley, R., VanPutte, C., Regan, J., & Russo, A. (2011). Seeleys Anatomy and physiology (9th
ed.). New York, NY: McGraw-Hill
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease
and End-Stage Renal Disease in the United States, National Institutes of Health, National
Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013. Walsh,
E., & Lehane, E. (2011). An exploration of the relationship between adherence with
dietary sodium restrictions and health beliefs regarding these restrictions in Irish patients
receiving haemodialysis for end-stage renal disease. Journal of Clinical Nursing,
20(3/4), 331-336.
Wells, J. R., & Walker, C. (2012). Factors Influencing Adherence in African Americans with
End Stage Renal Disease. Journal of Epidemiology & Community Health, 66(2), 31-36.
White, C., Jaffey, J., & Magner, P. (2010). Cost of applying the K/DOQI guidelines for bone
metabolism and disease to a cohort of chronic hemodialysis patients. Kidney
International, 71(4), 312-317.
Yokoyama, Y., Suzukamo, Y., Hotta, O., Yamazaki, S., Kawaguchi , T., Hasegawa, T.,
Fukuhara, S. (2009). Dialysis staff encouragement and fluid control adherence in patients
on hemodialysis. Nephrology Nursing Journal, 36(3), 289-298.



Appendix A
Kidney-Friendly Diet and Foods: Healthy Eating for People with Chronic Kidney Disease
and HD patients
You need to have a kidney-friendly meal plan when you have chronic kidney disease.
Watching what you eat and drink will help you stay healthier. This section of our website is for
people who have kidney disease but are not on dialysis. It describes a kidney-friendly diet and
why it is important.
Here, you will learn about:

The basics of a healthy meal plan

What makes a kidney-friendly meal plan different

Special steps for people with diabetes

Where to find more information

Keep this in mind

This is only general information. Nutrition needs vary from person to person depending on body
size, activity, the stage of kidney disease and other health concerns. Talk to a renal dietitian,
someone who specializes in the kidney-friendly diet, to find a meal plan that meets your needs.
Your doctor can suggest a dietitian, or you can find one through the American Dietetic
Association at or 1.800.87.1600. Medicare and many insurance plans will help



pay for sessions with a dietitian. Check with your insurance to see if it will cover Medical
Nutrition Therapy (MNT).
What you eat affects your health. Maintaining a healthy weight and following a balanced meal
plan that is low in salt can help you control your blood pressure. If you have diabetes, your meal
plan is also important in controlling your blood sugar. Controlling high blood pressure and
diabetes may also help slow down kidney disease. A kidney-friendly diet may also help. It limits
certain minerals in the foods you eat. This helps keep waste from building up in your blood and
may help prevent other health problems. Well start by reviewing the basics of a healthy meal
plan. Then, well take a look at the kidney-friendly meal plan and some helpful kidney-friendly
Healthy diet basics
All meal plans, including the kidney-friendly diet, need to take into account some of the same
things, like:





Nutrition Facts




In this section, well review each of these and how they relate to the kidneys. Well also take a
look at the nutrition facts label and explain how you can use this tool to help you have a healthy
Your body gets energy from the calories you eat and drink. Calories come from the protein,
carbohydrates and fat in your diet. How many calories you need depends on your age, sex, body
size and activity level. You may also need to adjust how many calories you eat based on your
weight goals. Some people will need to limit the calories they eat. Others may need to have more
calories. Your doctor or dietitian can help you figure out how many calories you should have
each day. Work with your dietitian to make a meal plan that helps you get the right amount of
calories, and keep in close contact for support and follow-up.
Protein is one of the building blocks of your body. Your body needs protein to grow, heal and
stay healthy. Having too little protein can cause your skin, hair and nails to be weak. But having
too much protein can also be a problem. To stay healthy and help you feel your best, you may
need to adjust how much protein you eat.
The amount of protein you should have depends on your body size, activity level and health
concerns. Some doctors recommend that people with kidney disease limit protein or change their
source of protein. This is because a diet very high in protein can make the kidneys work harder
and may cause more damage. Ask your doctor or dietitian how much protein you should have
and what the best sources of protein are for you.



Use the table below to learn which foods are low or high in protein. Keep in mind that just
because a food is low in protein, it is not healthy to eat unlimited amounts.

Lower-protein foods
Pasta and rice

Higher-protein foods

Carbohydrates (carbs) are the easiest kind of energy for your body to use. Healthy sources of
carbohydrates include fruits and vegetables. Unhealthy sources of carbohydrates include sugar,
honey, hard candies, soft drinks and other sugary drinks. Some carbohydrates are high in
potassium and phosphorus, which you may need to limit depending on your stage of kidney
disease. We'll talk about this in more detail a little later. You may also need to watch your
carbohydrates carefully if you have diabetes. Your dietitian can help you learn more about the
carbohydrates in your meal plan and how they affect your blood sugar.
You need some fat in your meal plan to stay healthy. Fat gives you energy and helps you use
some of the vitamins in your food. But too much fat can lead to weight gain and heart disease.
Try to limit fat in your meal plan, and choose healthier fats when you can.
Healthier fat or good fat is called unsaturated fat. Examples of unsaturated fat include:


Olive oil

Vegetable oils


Unsaturated fat can help reduce cholesterol. If you need to gain weight, try to eat more
unsaturated fat. If you need to lose weight, limit the unsaturated fat in your meal plan. As always,
moderation is the key. Too much good fat can also cause problems.
Saturated fat, also known as bad fat, can raise your cholesterol level and put you at risk for
heart disease. Examples of saturated fats include:





Limit these in your meal plan. Choose healthier, unsaturated fat instead. Trimming the fat from
meat and removing the skin from chicken or turkey can also help limit saturated fat.
Sodium (salt) is a mineral found in almost all foods. Too much sodium can make you thirsty,
which can lead to swelling and raise your blood pressure. This can damage your kidneys more
and make your heart work harder. One of the best things that you can do to stay healthy is to
limit how much sodium you eat. To limit sodium in your meal plan:



Do not add salt to your food when cooking or eating. Try cooking with fresh herbs, lemon
juice or other salt-free spices.

Choose fresh or frozen vegetables instead of canned vegetables. If you do use canned
vegetables, drain and rinse them to remove extra salt before cooking or eating them.

Avoid processed meats like ham, bacon, sausage and lunch meats.

Munch on fresh fruits and vegetables rather than crackers or other salty snacks.

Avoid canned soups and frozen dinners that are high in sodium.

Avoid pickled foods, like olives and pickled.

Limit high-sodium condiments like soy sauce, BBQ sauce and ketchup.

Important! Be careful with salt substitutes and "reduced sodium" foods. Many salt
substitutes are high in potassium. Too much potassium can be dangerous for someone with
kidney disease. Work with your dietitian to find low-sodium foods that are also low in
Nutrition Facts
Use the Nutrition Facts section on food labels to learn more about what is in the foods you eat.
The Nutrition Facts will tell you how much protein, carbohydrates, fat and sodium are in each
serving of a food. This can help you pick foods that are high in the nutrients you need and low in
the nutrients you should limit.


When you look at the Nutrition Facts, there are a few key areas that will give you the
information you need:

Choosing healthy foods is a great start, but eating too much of even healthy foods can be a
problem. The other part of a healthy diet is portion control, or watching how much you eat.
To help control your portions:




Eat slowly, and stop eating when you are not hungry any more. It takes about 20 minutes
for your stomach to tell your brain that you are full. If you eat too quickly, you may eat
more than you need.

Check the Nutrition Facts on a food to learn the true serving size. Many packages have
more than one serving. For example, a 20-ounce bottle of soda is really two-and-a-half

Avoid eating while doing something else, like watching TV or driving. When you are
distracted you may not realize how much you have eaten.

Do not eat directly from the package the food came in. Instead, take out one serving of
food, and put the bag or box away.

Good portion control is an important part of any meal plan. It is even more important in a
kidney-friendly meal plan, because you may need to limit how much of certain things you eat
and drink. Keep reading to learn more!
How is a kidney-friendly diet different?
When your kidneys are not working as well as they should, waste and fluid buildup in your body.
Over time, the waste and extra fluid can cause heart, bone and other health problems. A kidneyfriendly meal plan limits how much of certain minerals and fluid you eat and drink. This can
help keep the waste and fluid from building up and causing problems. How strict your meal plan
should be depends on your stage of kidney disease. In the early stages of kidney disease, you



may have little or no limits on what you eat and drink. As your kidney disease gets worse, your
doctor may recommend that you limit:




Potassium is a mineral found in almost all foods. Your body needs some potassium to make your
muscles work, but too much potassium can be dangerous. When your kidneys are not working
well, your potassium level may be too high or too low. Having too much or too little potassium
can cause muscle cramps, irregular heartbeat and muscle weakness. Many people with kidney
disease will need to limit potassium. Ask your doctor or dietitian if you need to limit potassium.
Use the table below to learn which foods are low or high in potassium. Your dietitian can also
help you work in small amounts of your favorite foods that are high in potassium.
Eat this ... (lower-potassium foods)
Apples, cranberries, grapes, pineapples and

Rather than ... (higher-potassium foods)

Avocados, bananas, melons, oranges, prunes

Cauliflower, onions, peppers, radishes, summer

and raisins
Artichokes, kale, plantains, spinach, potatos

and zucchini squash, lettuce

Pita, tortillas and white breads

and tomatoes
Bran products and granola
Beans (baked, black, pinto, etc.), brown or wild

Beef and chicken, white rice




Phosphorus is a mineral found in many foods. It works with calcium and vitamin D to keep
bones healthy. Healthy kidneys keep the right balance of phosphorus in your body. When your
kidneys are not working well, phosphorus can build up in your blood. Too much phosphorus in
your blood can lead to weak bones that break easily.
Many people with kidney disease need to limit phosphorus. Ask your dietitian if you need to
limit phosphorus.
Depending on your stage of kidney disease, your doctor may also prescribe a medicine called a
phosphate binder. This helps to keep phosphorus from building up in your blood. A phosphate
binder can be helpful, but you will still need to watch how much phosphorus you eat. Ask your
doctor if a phosphate binder is right for you.
Eat this ... (lower-phosphorous foods)
Italian, French or sourdough bread
Corn or rice cereals and cream of wheat
Unsalted popcorn
Some light-colored sodas and lemonade

Rather than ... (higher-phosphorous foods)

Whole-grain bread
Bran cereals and oatmeal
Nuts and sunflower seeds
Dark-colored colas

You need water to live, but when you have kidney disease, you may not need as much. This is
because damaged kidneys do not get rid of extra fluid as well as they should. Too much fluid in
your body can be dangerous. It can cause high blood pressure, swelling and heart failure. Extra
fluid can also build up around your lungs and make it hard to breathe.



Depending on your stage of kidney disease and your treatment, your doctor may tell you to limit
fluid. If your doctor tells you this, you will need to cut back on how much you drink. You may
also need to cut back on some foods that contain a lot of water. Soups or foods that melt, like ice,
ice cream and gelatin, have a lot of water. Many fruits and vegetables are high in water, too.
Ask your doctor or dietitian if you need to limit fluids.
If you do need to limit fluids, measure your fluids and drink from small cups to help you keep
track of how much youve had to drink. Limit sodium to help cut down on thirst. At times, you
may still feel thirsty. To help quench your thirst, you might try to:

Chew gum

Rinse your mouth

Suck on a piece of ice, mints or hard candy (Remember to pick sugar-free candy if you
have diabetes.)

Other meal plan concerns

A kidney-friendly meal plan may make it hard to get all of the vitamins and minerals you need.
To help you get the right balance of vitamins and minerals, your dietitian may suggest a special
supplement made for people with kidney disease.
Your doctor or dietitian might also suggest a special kind of vitamin D, folic acid or iron pill, to
help avoid some common side effects of kidney disease, like bone disease and anemia.



Regular multi-vitamins may not be healthy for you if you have kidney disease. They may have
too much of some vitamins and not enough of others. Talk to your doctor or dietitian to find
vitamins that are right for you.
Important! Tell your doctor and dietitian about any vitamins, supplements or over-thecounter medicines you are taking. Some may be harmless, but others can damage your
kidneys more or cause other health problems.

What if I have diabetes?

Diabetes is the leading cause of kidney failure. Diabetes can also damage other parts of your
body, like your eyes and heart. If you have diabetes, you will need to watch your blood sugar and
diet to stay healthy. Work with your dietitian to make a kidney-friendly meal plan that helps you
keep your blood sugar in control and prevent other health problems.
A diabetes educator can also help you learn how to control your blood sugar. Ask your doctor to
refer you to a diabetes educator in your area. You can also get a list of diabetes educators from
the American Association of Diabetes Educators at or
1.800.338.3633. Medicare and many insurance companies may help pay for sessions with a
diabetes educator.
Learn how to manage diabetes here

A well-balanced meal plan is important for good health. It is even more important for people
with kidney disease, because it may help prevent further kidney damage. Work with your
dietitian to make a meal plan that helps you get the right amount of calories, protein,



carbohydrates, fat and sodium. Depending on your stage of kidney disease, you may also need to
limit your potassium, phosphorus and fluids. Your dietitian can help you with this as well.
Your doctor can refer you to a dietitian, or you can find one through the American Dietetic
Appendix B

Sample questions used to evaluate learning

1. The nurse is assisting a client on a low-potassium diet to select food items from
the menu. Which of the following food items, if selected by the client, would
indicate an understanding of this dietary restriction?
a) Cantaloupe
b) Spinach
c) Lima beans
d) Strawberries
2. The nurse teaches the client with chronic renal failure when to take the
aluminum hydroxide gel. Which of the following statements would indicate that
the client understands the teaching?
a) Ill take it every 4 hours around the clock.
b) Ill take it between meals and at bedtime.
c) Ill take it when I have a sour stomach.
d) Ill take it with meals and bedtime snacks.
3. Which of the following factors causes the nausea associated with renal failure?
a) Oliguria
b) Gastric ulcers
c) Electrolyte imbalances
d) Accumulation of waste products



4. The client with chronic renal failure is at risk of developing dementia related to
excessive absorption of aluminum. The nurse teaches that this is the reason that
the client is being prescribed which of the following phosphate binding agents?
a) Alu-cap (aluminum hydroxide)
b) Tums (calcium carbonate)
c) Amphojel (aluminum hydroxide)
d) Basaljel (aluminum hydroxide)



Appendix C:
SUPPH-29 scale



Appendix D
BDCS (HD-Version)

Eating a low-salt diet keeps me healthy
When I follow my low-salt diet, I feel better
Eating a low-salt diet keeps my heart healthy
Eating a low-salt diet reduces thirst
Salty food is not good for me
Eating a low-salt diet helps me breathe better
Eating a low-salt diet helps keep my blood pressure down
Following a low-salt diet takes too much time
Following a low-salt diet takes too much money
Following a low-salt diet is too hard to understand
Following a low-salt diet is hard to do when I go out to eat
Foods does not taste good on a low salt diet
Check the item number which best suits you in the table

Strongly agree








Strongly Disagree

Appendix E
Power Point Presentation