Knowledge, attitude, and practices of renal diets among hemodialysis patients

Saumiya Kanagarajah; Supriya Velraja; Hemamalini Janardhanan Arambakkam

doi:10.4103/bbrj.bbrj_200_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 6 | Issue : 1 | Page : 86-92

Knowledge, attitude, and practices of renal diets among hemodialysis patients

Saumiya Kanagarajah, Supriya Velraja, Hemamalini Janardhanan Arambakkam
Department of Clinical Nutrition, Sri Ramachandra Faculty of Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research (Deemed to be university), Chennai, India

Date of Submission	25-Aug-2021
Date of Acceptance	01-Nov-2021
Date of Web Publication	11-Mar-2022

Correspondence Address:
Supriya Velraja
Assistant Professor, Department of Clinical Nutrition, Sri Ramachandra Faculty of Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai-116, Tamilnadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_200_21

Abstract

Background: Malnutrition and mineral disparities has become increasingly common in patients with the end-stage renal disease treated with hemodialysis (HD). Lack of nutritional knowledge is one of the most significant reasons for nutritional problems leading to improper practice and causing several complications. The objectives of the study were to asses the nutrition knowledge, attitude, and practice of HD patients regarding renal diet, to counsel the patients on HD dietary guidelines and to determine the association of factors such as income and education level on nutrition management of HD Patients. To assess the nutrition knowledge, attitude, and practice of HD patients regarding renal diet. To counsel the patients on HD dietary guidelines. To determine the association of factors such as income and education level on nutrition management of HD patients. Methods: A total of 120 patients undergoing HD were assessed for the level of nutrition knowledge, attitude, and practice, regarding HD dietary guidelines, using a validated questionnaire. Results: About 60.3% of HD patients had excellent knowledge, 60% had excellent attitude, and 40% had excellent practices. There is a significant positive correlation between knowledge and attitude, as well as knowledge and practice (r < 0.01) of the patients undergoing HD regarding renal diet. There is also a significant association between the knowledge, attitude, and practice scores with the selected demographical variables (education level and income) of patients at the significance level of P < 0.001. Conclusion: Although majority of the patients have excellent knowledge, attitude, and practice, a notable number of patients are unaware about their dietary guidelines and do not adhere to the dietary regime that needs to be followed. Diet counseling by a renal dietitian using a nutrition education module can effectively upgrade the nutrition knowledge, attitude, and practice of HD dietary guidelines by the patients.

Keywords: Attitude, diet counseling, education, hemodialysis, income, knowledge, practice, renal dietitian

How to cite this article:
Kanagarajah S, Velraja S, Arambakkam HJ. Knowledge, attitude, and practices of renal diets among hemodialysis patients. Biomed Biotechnol Res J 2022;6:86-92

How to cite this URL:
Kanagarajah S, Velraja S, Arambakkam HJ. Knowledge, attitude, and practices of renal diets among hemodialysis patients. Biomed Biotechnol Res J [serial online] 2022 [cited 2023 Jun 9];6:86-92. Available from: https://www.bmbtrj.org/text.asp?2022/6/1/86/339364

Introduction

Chronic kidney disease (CKD) is a global health burden in both developed and developing countries. In India, the number of deaths caused by CKD was 3.78 million in 1990 (40.4% of all deaths) and is expected to rise to 7.63 million in 2020 (66.7% of all deaths). The prevalence of CKD is 800 per million population (pmp), and the incidence of end-stage renal disease (ESRD) IS 150–200 pmp.^[1] The Global Burden of Disease (GBD) study of 2015, ranks CKD as 17^th owing to the most common cause of deaths globally, whereas in India, GBD 2015 ranks CKD as the 8^th most leading cause of death. Contributing to the world's one-sixth of the world's population and the ongoing demographic transitions, data from India are important to understand the world health dynamics.^[2]

The lack of regional data describing the statistics of prevalence of CKD and the awareness among the patients regarding their health status needs to be focused on without further ado.

Many serious problems are associated with kidney failure and it arises from the patients' lack of awareness regarding their nutritional requirements as well as poor adherence to the knowledge due to a negative attitude toward practising the modified lifestyle. The major problems faced by the patients' are their limited capacity to achieve a balance between the intake and excretion of water and minerals and the accumulation of metabolic by-products. This causes serious complications of renal failures, such as hyponatremia, hyperkalemia, hyperphosphatemia, pulmonary edema, acidosis, anorexia, nausea, vomiting, infections, sepsis, undernutrition, and other uremic symptoms.^[3] The last stage of CKD is the progression of kidney toward ESRD (renal failure). Patients with ESRD requires a demanding medical nutrition therapy throughout the condition. But they often fail to follow prescribed diet regimen which undermines effectiveness of care and leads to unpredictable progression of disease and greater livelihood of complications. It is very essential for the patients to be aware about the right nutrition requirements, such as low sodium, low potassium, low phosphorous, low fluid, and high protein diet-to avoid diet-related complications.^[4] The patients should also have the right attitude toward the dietary guidelines and practice it without any discrepancies to attain an adequate nutritional status. Continuous nutrition education must be given, especially to the patients who are on long-term hemodialysis (HD). Similarly, continuous assessments on their knowledge about the nutrition management that is specific for the patient's condition, attitude toward the dietary guidelines that they are entitled to follow and practice of the patient's nutrition knowledge are very essential. Such assessments will be utilized to identify the aspects of nutrition that need to be repeatedly educated to the patients and also to improve the quality of nutrition education to obtain better results. The purpose of the study is to examine the dietary knowledge of patients on hemodialysis, with respect to protein, potassium, phosphorus, sodium, and fluid restrictions. This will help in educating patients and motivating dietary changes and compliance.^[5]

As there are only few data with respect to specific regions regarding the patients' nutrition knowledge, attitude, and practice of renal diet-this study were conducted to identify the prevalence of ignorance about nutrition that is necessary to be followed during HD and the possible factors that may play an important role in the knowledge, attitudes, and practices (KAP) of the patients such as education, income, and profession. therefore, it is essential to find the possible significant association between such factors and the nutrition knowledge, attitude, and practice among HD patients.^[6],[7]

Methods

Study area, design, and period

The study was conducted at the HD units of Sri Ramachandra Hospital, located at Porur, Chennai. There are two HD units in the premises of Sri Ramachandra Institute of Higher Education and Research, one being in the Private block and the other being in the General block. This prospective observational study was conducted from June 2018 to November 2018.

Target population

The target population is the patients undergoing HD treatment in the HD units and the sample was chosen based on the inclusion and exclusion criteria. The inclusion criteria required patients undergoing HD within the age group of 20–60 years with the willingness to participate in the study. Patients who were undergoing HD for not more than 3 months were excluded from this study.

Sample and sampling procedure

Simple random sampling was recruited to obtain the desired sample size of 120 subjects. Hence, for convenience, 60 patients from the Private HD unit and 60 patients from the General HD unit were chosen for the study.

Ethical considerations

Ethical approval for this study was obtained from the Students' Ethics Committee of Sri Ramachandra Institute of Higher Education and Research before data collection. Permission was taken from the head of the Department of Nephrology. Written consent was obtained from all the subjects in the form of a signature or thumbprint after explaining the purpose of the study and reassuring that the data obtained would be kept confidential.

Ethical clearance

The present study has been approved by the Institutional Ethical Committee (IEC) and the reference number is CSP/17/ OCT/34/170.

Study instrument

A structured, self-administered questionnaire was used to collect data for this study. The instrument was developed following an extensive literature review guided by the objectives of the study and validated by subject experts. The questionnaire was pretested to determine its reliability and validity before using it in the actual study.

Questionnaire

The questionnaire consists of 48 items excluding 6 questions targeting to elicit demographic characteristics of the subjects; the questionnaire is divided into three sections – knowledge, attitude, and practice with 16 questions under each category. The knowledge section deals with obtaining information on awareness of nutrition requirements during HD. Questions regarding attitudes and practices were also involving the same. Correct answers were scored as per the scoring guidelines where each correct response was given a score of 1. A score of 13–16 was marked as excellent, 9–12 = good, 5–8 = average, and 0–4 = poor under each category of the questionnaire, respectively.

Data analysis

SPSS (IBM Statistics Software for windows Version.23.0 (Armok NY: IBM COV P))was used for data analysis. Descriptive and inferential statistics were analyzed. Chi-square was used to test the relationship between categorical variables. A P < 0.05 was considered statistically significant.

Results

Sociodemographic data

A questionnaire was given to each of the 120 subjects, who completed the survey with a response rate of 100%. There were 74 (62%) males, and 46 (38%) female participants in the study. Most Among the subjects chosen, majority of the samples, 54 (45%) belonged to the age group of 51–60 years. The family income per month of the subjects show that 51 (42.5%) of the samples belonged to the age group of 41–50 years, whereas the least number of samples belonged to the age group of up to 41 years were 15 (12.5%). Of the total subjects, 65 (54.2%), belonged to the high-income group (less than Rs. 6254); 52 (43.3%) of the samples belonged to the middle-income group (Rs. 3127–6253) and 3 (2.5%) of the samples belonged to the low-income group, according to BG Prasad's socioeconomic status scale. The educational qualification of the subjects shows 50 (41.6%) were high school certificates. 40 (33.3%) of the samples were primary school certificates, 14 (12%) of the samples were graduates or post graduates and 16 (13%) of the samples were illiterates. 95 (79.2%) of the samples had received dietary counseling by a dietitian. 25 (20.8%) of the samples did not receive dietary counseling by a dietitian.

Nutrition knowledge

Of the total participants, 73 (60.3%) had excellent knowledge. The mean knowledge score obtained by the patients undergoing HD was 13.10 (standard deviation 2.8) and the score for knowledge was in the range of 6–16.

There is no association between knowledge and age (P = 0.636) and sex (P = 2.006) of the subjects. There is significant association between knowledge and educational qualification (P = 0.000) and family income per month of the subjects (P = 0.000). There was also significant association between the nutrition knowledge of the subjects and their exposure to diet counseling. This shows that age and sex of the patients did not have any impact on their knowledge regarding renal diet guidelines to be followed while undergoing HD. However, with increased educational qualification and socioeconomic status, the subjects tend to have a better nutritional knowledge regarding the renal diet. It was also observed that patients who had received diet counseling from a dietitian previously also had a better nutritional knowledge than those who did not receive the counseling.

Hemodialysis related nutrition knowledge

The results of the current study indicated that majority of the subjects undergoing HD are aware of topics related to nutrition management during HD, increased protein requirements, restriction of sodium, potassium, and fluid intake. Patients also have a good knowledge regarding management of nutrition on an everyday basis.

Attitude and practice

About 60% of the subjects had an excellent attitude and only 40% had an excellent practice of nutrition management during HD. Although a majority of the subjects had an excellent knowledge regarding renal diet, these patients lacked a healthy attitude toward the same, which can be evidenced with the mismatch between the percentages of excellent knowledge with attitude toward nutrition management. Similarly, there is a severe decline in the percentage of patients who had an excellent practice of nutrition management. Patients with a good knowledge about specific nutrition aspects, tend to not practice it on a daily basis.

[Table 1] shows the calculated scores to find the association between KAP and the age and sex of the patients-the KAP of the subjects were independent of the age and sex of the patients. Age does not have a significant association with the knowledge of patients on dietary guidelines for undergoing HD.^[8] Similarly, there was no significant difference between the knowledge, attitude, and practice scores between men and women.^[9]

Table 1: Percentage distribution of subjects according to age and sex (n=120)

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[Table 2] shows the calculated scores to find the association between KAP and the educational qualification and family income per month of the patients – KAP of the patient has a significant association with educational qualification and family income per month of the patient. Subjects who had a high educational background and socio– economic status seemed to have an improved KAP compared to the other subjects.^[10]

Table 2: Percentage distribution of subjects according to their educational qualification and family income per month (n=120)

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[Table 3] shows the calculated scores to find the association between KAP and dietary counseling received by the patient – which shows that there is a significant association between KAP and the exposure of the patients to diet counseling. Patients with CKD are charged with assimilating complex treatment regimes, maintaining physical activity, changing eating patterns, adhering to complicated medication regimes, and avoiding nephrotoxins. To implement these activities and participate in care decisions and planning, patients must have knowledge of their condition and self-management support. Patient understanding of CKD and its requirements improves outcomes.^[11] As CKD progresses, people often lose their appetites because they find that foods do not taste the same. As a result, they consume fewer calories - important units of energy in food - and may lose too much weight. Renal dietitians can help people with advanced CKD find healthy ways to add calories to their diet if they are losing too much weight.^[12]

Table 3: Percentage distribution of subjects based on their exposure to diet counseling

Click here to view

Inferential statistics

There is a positive correlation between knowledge and attitude (r < 0.01) as well as knowledge and practice (r < 0.01) of the patients undergoing HD regarding renal diet. There was a significant association between the level of knowledge regarding renal diet, and the educational qualification of the patients at P < 0.001 level. A significant association between the knowledge and attitude regarding renal diet, with the patients' family income per month at P < 0.001 level. There was a significant association between the level of knowledge, attitude, and practice regarding renal diet with the exposure of the patients' to diet counseling (P < 0.001). Nonsignificant association was observed between knowledge, attitude, and practice regarding renal diet with the patients' age and sex (P > 0.05).

Correlation between knowledge, attitude, and practice among patients undergoing hemodialysis regarding renal diet

The correlation coefficient of the attitude of patients undergoing HD (r = 0.820) was highly significant (P < 0.01) and positively correlated with knowledge. The correlation coefficient of practice with knowledge of patients undergoing HD (r = 0.318), was highly significant (P < 0.01).

There is always positive correlation of knowledge which is highly significant with attitude and practice regarding nutrition, and self-care activities among HD patients.^[13]

Knowledge, attitude, and practice are independent variables.^{[14],[15],[16],[17],[18]} This has been proved by the scores of the patient for each question. The frequency and percentage distribution of the patients' answers for the KAP can be utilized to understand the correlation between the three factors – knowledge, attitude, and practice of each question. [Table 4] shows the difference in percentage of knowledge, attitude, and practice levels of patients in few essential aspects of renal diet.

Table 4: The simplified form of questions asked with responses of the subjects in percentage

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Deliverance of nutritional education to patients undergoing hemodialysis

Following the completion of the self-administered questionnaire, the patients were educated on the HD dietary guidelines using an informative guide sheet. The guide sheet was formulated based on guidelines formed from several studies which is appropriate for the disease condition and their requirements. This form of nutrition intervention may prove to be useful for the patients undergoing HD to prevent malnutrition, noncompliance to fluid restriction, and inadequate consumption of macro and micronutrients. It is important for the people who are on dialysis to access nutrition counseling so they understand the importance of different foods and the types of nutrients they need to add in their diet and the food they should restrict. A structured teaching program and a dietary guide with continuous education will help to improve their knowledge, attitude, and practice of patients on dialysis regarding dietary management.^{[19],[20],[21]}

Discussion

The present study revealed that most of the subjects had excellent nutrition knowledge. Although a majority of the subjects excelled in their nutrition knowledge, there appeared to be a gap in their attitude and practice related to nutrition. The increase in nutrition knowledge was found to be in direct relation with their educational qualification, family income per month, and their exposure to diet counseling and was not in any relation with their age and sex.

Thus, despite the excellent knowledge and attitude acquired by a remarkable number of patients, the adherence and practice of the acquired knowledge is poor or unsatisfactory. The study also revealed that the knowledge regarding dietary management among HD patients was inadequate in a notable number of subjects. The result of the study implies that a structured teaching program by a renal dietitian will improve the knowledge of patients undergoing HD regarding dietary management in ESRD thereby preventing life-threatening complications and prolonging their life.^[15] It has been shown that nutrition can affect arise of infectious diseases (e.g. gastrointestinal infections), food poisoning, intestinal diseases, and systemic infectious diseases. Furthermore, the relationship between malnutrition and infectious diseases, nutrition in patients with severe joint immunodeficiency, and the relationship between overeating and infection are interrelated. Some factor can degrade the body's ability to fight against infection and its results in malnutrition.^[22] Findings of the study by c bhiwas et al. 2018 showed that Vitamin E via its antioxidant action and anti-inflammatory effects has protective effect on phosphine-induced toxicity in rats.^[23] Hence, it is concluded that a dietary guide formulated by a renal dietitian, keeping in mind, the individual needs of every patient, will help to improve not only the knowledge but also insist on an uncompromising attitude and a meticulous practice of the HD dietary guidelines.

Conclusion

The conclusion made based on the findings is that, Majority of the patients have excellent knowledge, attitude, and practice regarding renal diet. This is due to several factors which have an influential impact on the patients' KAP. Age and sex of the patients were found to be independent factors which did not have an impact on the KAP of the patients. However, factors such as educational qualification, family income per month, and their exposure to diet counseling had a direct influence on the KAP of the subjects. With improved education status and socioeconomic factors, the knowledge, attitude, and practice were found to be more. Similarly, the patient who had previously received diet counseling from a dietitian showed a better result in their nutrition KAP. Though a majority of the subjects had an excellent KAP, it has been observed that a notable number of patients are unaware about their dietary management; it was also evident that a remarkable number of patients do not adhere to the dietary guidelines that need to be followed while undergoing HD, i.e. the knowledge of the patients was remarkable, but the knowledge had poor execution and was not put into practice. It was also observed that the attitude of the patients was also unappreciable and needs more attention. Hence, diet counseling by a renal dietitian using a nutrition education module can effectively enhance the nutrition knowledge, attitude, and practice of HD dietary guidelines by the patients. Constant reinforcement and repetitive counseling and assessment of the KAP of patients is necessary to be done regularly.

Limitations of the study

The findings of the study cannot be generalized due to the selection of one area of study
The nutritional status of the subjects was not assessed in this study, which limits the determination of the prevalence of malnutrition and other long-term HD complications
KAP scores after nutrition education of patients for comparison were not taken in the study.

Future perspectives of the study

A similar study can be conducted for large sample size for a wider generalization
A follow-up study can be conducted to evaluate the efficiency of the informative guide sheet.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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