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Table 5 presents some of the common methods to assess dietary intake and the advantages and disadvantages of each. There are three major types of dietary assessment tools that are useful in CKD. First, there are tools that help the clinician assess intakes of specific nutrients and energy. Examples include 24-h recalls and food records. Next are tools that help one to assess dietary patterns that may vary greatly from day to day (e.g. between sick and well days, or between dialysis and non-dialysis days). Examples include 2-day assisted food records and diet history. Finally, tools that assess eating-related QOL in kidney

Table 3

Major Challenges and Nutritional Status at Various Stages of Chronic Kidney Disease (26,27,33—36)

Table 3

Major Challenges and Nutritional Status at Various Stages of Chronic Kidney Disease (26,27,33—36)

CKD stagea GFR (rnl/m in/ 1.73m2)

Protein-energy malnutrition

Body composition (lean body mass, fat mass deficit)

Micronutrient deficiencies

Dietary intake

Anemia

Bone disease

Fluid retention

1 GFR>90

2 GFR 60-89

?

?

3 GFR 30-59

t

t

t

;

t

t

4 GFR 15-29

tt

tt

tt

44

tt

tt

t

5 GFR <15 (or

ttt

ttt

ttt

444-

ttt

ttt

tt

dialysis)

"Adapted from ref. (25). CKD, chronic kidney disease; GFR, glomerular filtration rate; f = increase; |= decrease; ? = not certain.

"Adapted from ref. (25). CKD, chronic kidney disease; GFR, glomerular filtration rate; f = increase; |= decrease; ? = not certain.

Table 4

Key Nutrients for Dietary Assessment in Chronic Kidney Disease (26,80,74)

CKD stage

Energy

Protein

Calcium

Phosphorus

Iron Vitamin D Potassium

Other vitamins and minerals

Fluid

2 GFR 60-89

3 GFR 30-59

4 GFR 15-29

5 GFR <15 (or dialysis) KDOQI standards for stage 4 and 5

Maintenance dialysis (HD, PD)

Age > 60 years 30-35 Age < 60 years 35 Age > 60 years 30-35 Age < 60 years 35

1.5 gm/day <2.0-2.5 gm/day including binder load <2.0-2.5 gm/day including binder load

10-12 mg/gm protein or 10 mg/kg/day

10-12 yitmg/gm protein or <900 mg/day

Indivi- Individualized dualized

Indivi- Individualized dualized

Usually unrestricted unless high

2-3 gm/day adjusted for the serum levels

DRI: B-complex Maintain balance

C: 60-100 mg B6: 2mg Folate: 1 mg B12: 3 /xg Other vitamins: DRI E: 151U Zn: 15 mg

Maintain Balance

DRI, Dietary Reference Intake; GFR, glomerular filtration rate; KDOQI, Kidney Disease Outcomes Quality Initiative; HBV, high biological value; HD, hemodialysis; PD, peritoneal dialysis; +, Need modification; ++, more intense modification; +++, most intense modification.

Table 5

Dietary Intake Assessment Tools for Chronic Kidney Disease (CKD) patients

Dietary Intake Methods

Assessment method nutrient intake

Description

Strengths

Weakness

24-h recall

Food record

Clinician assists the patient to recall food intake of previous 24 h. Using food models or pictures can help the patient to identify portion size (46-52,85)

Food records provide information on intakes of food and beverages (and dietary supplements) over specific periods. The most common food record includes 3 days which include 2 weekdays and 1 weekend day (46,53,57,61,64,65,85)

Good tool to use for large population studies and in the clinic. Useful for international comparisons of nutrient intake in both healthy and chronically ill patients. Inexpensive and easy to collect intake data for all populations, especially for illiterate patients. Random days can help to get valid estimates of usual intakes Useful to assess actual or usual food intakes. This method is widely used for dietary intake studies, especially macro- and micro-nutrient analysis

Single recall does not represent the patient's usual intake and foods consumed infrequently may not be recorded. Elderly patients may not provide adequate information due to memory problems. Underreporting is common

Accuracy is dependent on the number of days. Patients may change their usual diet pattern and under report intake. Patient should be literate. Underreporting is common

(Continued)

Table 5 (Continued)

Dietary Intake Methods

Assessment

method nutrient

intake

Description

Strengths

Weakness

2-day diet diary

Dietitian assists the food intake

Food intake varies between

It often does not include weekend

dialysis day and

data specific for hemodialysis

non-dialysis day and dialysis day

days during the data collection;

non-dialysis day

patients. Specific food models

due to the dialysis schedule.

therefore, patients can change

and pictures help patients to

Useful for comparing the dietary

his/her eating pattern on the

report better intake records (30).

intake data for these days. Can also be used in CKD patients who are not in stage 5.

weekend

Semi-quantitative

Used to identify the food intake of

Useful in epidemiological studies

Not very useful in CKD patients

food frequency

specific foods over period of

and analysis includes a broad

due to dietary restrictions. Making

questionnaire

time (i.e., dairy products use in a

range of food intakes. Provide

food lists and lists of dietary

day, week, month, or year).

good comparison of specific

supplements inappropriate.

Data collection is usually

foods, food components and

Accuracy of data collection is

self-administered and portion

nutrients with the prevalence or

lower

sizes are included in the

mortality of specific disease.

questionnaire (46,66-85)

Identify food patterns associated with inadequate intakes or specific nutrients. Better data collection from the study participant with faster analysis than other methods

This consists of 24-h recalls of food intake, information of usual intake, and other information such as food allergies, aversions, and preference. The clinician can plan intervention and improve patient's intake using this technique (46,52,57,58,85)

Useful to describe food and nutrient intake of patients for a long period of time and estimate the prevalence of inadequate intakes. Useful tool for food policy and food fortification planning

Labor intensive and time-consuming. The results vary with the interviewers' skill of data collection disease are available. These different tools provide the clinician with a view of what the patient experiences subjectively and how he/she feels about eating and how it is affected by the disease process from day to day. One example is the Food Enjoyment in Dialysis (FED) tool which will be discussed later (45).

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