Intro to counseling and nutritional priorities for CKD MNT

Why is CKD-MNT complicated? 1. Protein 2. Phosphorus 3. Sodium 4. Iron/Anemia 5. Gut Healing 6. Calcium 7. Diabetes/Carb Counting 8. Gout, Kidney Stones – Oxalates, etc… 9. Inflammation 10. No “ONE” diet – so many different variations depending on the person, stage of change, etc…

The Renal Diet “There is no standard renal diet. Instead, a progressive accumulation of dietary restrictions occurs as patients’ progress from CKD to ESKD.” Considerations: Sodium, Fluid, Potassium, Phosphorus, Protein, Vitamins, Minerals, Fiber 3.1.22: We recommend that individuals with CKD receive expert dietary advice and information in the context of an education program, tailored to severity of CKD and the need to intervene on salt, phosphate, potassium, and protein intake where indicated. (1B) - KDIGO 2012 Lambert K, Mullan K, Mansfield M. An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease.

How do we simplify and clarify nutrition for a person with CKD? 1. Know your priorities – All nutrition is important, but not all at once 2. Teach your clients basic principles 3. Take a lot of time really understanding what they eat and like to eat so you can direct your education based on their current diet 4. Get into the nitty gritty of actual products

Know Your Priorities: CKD MNT Prevent Complication Slow Progression Dispel Confusion Encourage

Info to Help Us Establish Priorities Labs Diet Medications Nutrition intake and history (current diet, cooking capacity, etc…) Patient’s biggest concern

Slow Progression Protein – hard to filter, acid-base balance * Type and quantity both matter Phosphate additives – cardiovascular disease Sodium – increased pressure to filter, causes proteinuria Diabetes – damages nerves Gut health – inflammation (1) Anemia (oxygenation to renal tissues) 1 https://academic.oup.com/ndt/article/31/5/737/1751657

Prevent Complication Phosphorus – Bone mineral disease, cardiac disease Potassium – Hyperkalemia/hospitalization Fluids – Fluid overload/hospitalization

Dispel Confusion What have they already read? What are valuable resources? Repetition – What do they need reassured of Actual Products (potassium BAD! Yikes no oranges, they will damage my kidneys!) Explain the physiology

What are patients looking for? 1. Real food ideas 2. Know what they really need to cut out – what they can still enjoy (though enjoyment isn’t as big of deal to many of them) 3. Practical answers 4. Guidance on supplements 5. Encouragement 6. Accountability “It is largely proven that nutritional therapy induces favorable metabolic changes, prevents signs and symptoms of renal insufficiency, and is able to delay the need for dialysis [3–5]. Currently, the main concern of the renal diets has turned from efficacy to the feasibility in the daily clinical practice [6].” -D’Alessandro C. Piccoli GB, etc.. “Dietaly”: practical issues for the nutritional management of CKD patients in Italy. BMV Nephrol. V 17;2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966713/

How do we make effective recommendations? 1. Empathy – THEIR concern first 2. Leadership – YOUR concern taught through 1 Helping them understand what is happening in their body 2 Helping them see what changes when they change 3 Being their cheerleader, hope, and encouragement Many, many models and tools of behavior change - Motivational Interviewing - 5A’s Organizational Construct for Clinical Counseling: Assess, Advise, Agree, Assist, Arrange (https://www.uspreventiveservicestaskforce.org/Page/Name/behavioral-counseling-interventions-an- evidence-based-approach#the-five-a39s-organizational-construct-for-clinical-counseling) - Do More, Do Less, Try

Individualize “Just like the renal diet is individualized, so should your approach be. Have a general guideline but then really think carefully about what that client will want!”

Summary 1. Establish Priorities – Patient and Clinician 2. Dispel Confusion 3. Support and Encourage 4. Individualize the diet and the approach for teaching

Questions?

Resources in Teachable 1. Patient Handout: Do More, Do Less, Try 2. “Behavioral Counseling Interventions 5A’s approach” 3. Motivational Interviewing: Today’s Dietitian Article