Chronic Kidney Disease (CKD) is a global threat to health in general and for developing countries in particular, because therapy is expensive and life-long. Dietary and fluid regimen for CKD patients is complicated and identifying characteristics and reasons of those most likely to experience difficulty in adhering to dietary restrictions is important. Objective: The objective of this study was to describe the fluid and dietary restriction behavior among admitted patients with chronic kidney disease. Methods: The descriptive study design was conducted among 100 admitted patients from NIKDU, Dhaka, by using purposive sampling technique. Data was collected by self-administered questionnaires. (1) Demographic Data Assessment Questionnaire, (2) Fluid restricted and (3) Diet Restriction Related Questionnaire. Pearson’s correlation (r), T-Test (t) and ANOVA was used for data analysis. Results: The mean score of fluid restriction behavior is 2.04±0.32 and diet restriction behavior is 2.28(±0.41). A significant relationship between fluid restriction behavior with age (p = 0.018) and Nutritional education (p = 0.01). There is also another significant relationship between diet restriction behavior and nutritional education (p = 0.006). Conclusion: Patients with Chronic Kidney Disease who have behavior with age and nutritional education, showed significantly higher fluid and diet restrictions behavior. Hospital can consider those characteristics to guide Patients with Chronic Kidney Disease by nurses.
Background and Significance of the Study
Chronic Kidney Disease (CKD) is a slow, progressive irreversible deterioration in renal function and the prevalence is estimated at 8-16% around in the world (Vivekanand, Guillermo, Kunoichi, Zou & Saarlander). In the United States of America, 30 million people suffering from chronic kidney disease. Kidney disease is the ninth leading cause of death in the United States. Approximately 19 million United States adults have chronic kidney disease and an estimated 80,000 persons have chronic kidney failure diagnosed annually is a global threat to health in general and for developing countries in particular, because therapy is expensive and life-long. [1]. In India 90%, patients cannot afford the cost. Over 1 million people worldwide are alive on dialysis or with a functioning graft.
Chronic kidney disease is rapidly growing disease in Bangladesh. Results of this study also demonstrated that most of the CKD patients had type 1 diabetes (39.02%) and type 2 diabetes (41.46%) mellitus. Only 5% of the CKD patients had undergone nephro -surgery. Around 24.30% of the CKD patients had hypertension [2].
Preventing progression from earlier stages of chronic kidney disease (CKD) to end-stage kidney disease and minimizing the risk for cardiovascular events and other complications is central to the management of CKD. Patients’ active participation in their own care is critical, but may be limited by their lack of awareness and understanding of CKD [3].
Dietary counseling and nutritional interventions are quintessential components in the management of chronic kidney disease (CKD) patients, including those who receive maintenance dialysis therapy. To that end, in the United States it is a regulatory requirement for an outpatient dialysis clinic to have an on-site registered dietitian to provide dietary monitoring and counseling to all dialysis patients [4]. Poor diet can have serious consequences for patients, including impaired physical abilities, depression, acute pulmonary edema, congestive heart failure and death. A poor dietary habit is associated with low quality of life and morbidity and mortality of patients on dialysis.
Further, malnutrition and inflammation increase cardiovascular risk and mortality in patients on hemodialysis. Both dietitians and nephrologists often impose a number of dietary restrictions on their patients related to dietary phosphorus, potassium, sodium, fluid intake and macronutrients including carbohydrate and fat. Dietitians also emphasize the importance of high dietary protein intake in dialysis patients, while they may also recommend weight loss efforts in patients with morbid obesity [5].
Fluid restriction is considered the most difficult to accomplish and this remains a major clinical problem in individuals with CKD [6]. Contributing to severe complications include intradialytic cramping and hypotensive episodes, treatment related fatigue and dizziness, lower extremity oedema, ascites, left ventricular hypertrophy and congestive heart failure, hypertension, shortness of breath and pulmonary vascular congestion or acute pulmonary oedema [6,7].
CKD impairs the proper function of kidney for removal of waste substances from the food and from the body. Due to CKD a person's diet must be changed to the maximum of the remaining normal kidney function [8]. In the early stage of kidney disease for normal functioning of the kidneys restriction of dietary protein, sodium, phosphate, potassium and fluid can help. Dietary and fluid management like as restriction of sodium intake is important to reduce kidney disease, more sodium in the diet can cause kidney disease more quickly [8]. In the early stage of the disease dietary protein restriction is not required and could even result in a decline in the patient´s nutritional status and overall fitness, but can be implemented in later stages of the disease. In the progression of the kidney disease and kidney declines function and the nutritional status typically deteriorates [8].
The dietary restriction is also vital to maintain optimal health for the CRF patients, because certain substances present in the foods and drinks, when taken in excess, damaged kidney may not be able to remove the waste, which are harmful to the body. So the foods and drinks containing those substances, which are harmful to the body, must be regulated. Dietary protein restriction represents an important new development in treatment of chronic renal disease for the last 10 years [9]. Dietary restrictions also prevent other opportunistic diseases such as hyperkalemia and hyperphosphatemia that are common in patients with chronic kidney disease. The key factors of maintaining quality of life weight management along with increased physical activity are key factors [8].
However, CKD is a progressive disease that cannot be reversed and can lead to kidney failure or end-stage renal disease (ESRD) if it is not detected and treated early [10]. Because of its chronic nature and potentially serious complications, individuals suffering from CKD experience poor quality of life, financial burden and significant life changes affect their families [11], CKD require dialysis or transplant at younger ages than any other group. These disparities in incidence and prevalence have been proven to be a function of high levels of CKD risk factors in African Americans, including diabetes, hypertension and obesity [9]. CKD patients face a complex treatment regimen and many of them have difficulty to manage fluid and diet restrictions, which is associated with high risk of mortality and the increase of health care budgets. Nephrology nurses help patients with CKD to manage their treatment, advising them about self-care measures related to changes in their health. To understand how patients, deal with treatment and what are the most effective self-care measures to manage fluid and diet restrictions in renal patients under HD, can contribute to a better nursing advice. This study aims to identify the level of the fluid and dietary restriction behavior among admitted patients in Bangladesh.
General Objective
To describe the fluid and dietary restriction behavior among admitted patients with chronic kidney disease.
Specific Objectives of the Study
To describe socio-demographic characteristics among patients with chronic kidney disease
To assess fluid and dietary restriction behavior among patients with chronic kidney disease
To examine the relationship between socio-demographic characteristics of fluid and dietary restriction behavior among patients with chronic kidney disease
Literature Review
The study aimed to assess the perception regarding Dietary and Fluid Restriction among the CKD patients who are admitted in National Institute of Kidney Diseases and Urology Hospital, Dhaka, Bangladesh. To gain understanding the variable of this study, this chapter presents literature review on the following topics:
Incidence of CKD
Self-management behavior of CKD patients
Fluid and dietary restriction of patients with CKD
Overview of Chronic Kidney Disease
Chronic kidney disease is defined as abnormalities of kidney structure or function present for 43 months with implications for health. The definition of CKD remains intact, but there is clarified the classification and risk stratification as indicated below. The addition of ‘with implications for health’ is intended to reflect the notion that a variety of abnormalities of kidney structure or function, but not all have implications for health of individuals and therefore need to be contextualized (Kidney Disease Statistics for the United States [1]. Kidney damage refers to a broad range of abnormalities observed during clinical assessment with insensitive and non-specific for the cause of disease but may precede reduction in kidney function. The excretory, endocrine and metabolic functions decline together in most chronic kidney diseases. GFR (Glomeruler Filtration Rate) is generally accepted as the best overall index of kidney function. It refers to a GFR o60 ml/min/ 1.73 m2 as decreased GFR and a GFR o15 ml/min/ 1.73 m2 as kidney failure. AKI may occur in patients with CKD and hasten the progression to kidney failure. Complications include drug toxicity, metabolic and endocrine complications, increased risk for CVD and a variety of other recently recognized complications, including infections, frailty and cognitive impairment. Complications may occur at any stage, often leading to death without progression to kidney failure. Complications may also arise from adverse effects of interventions to prevent or treat the disease and associated comorbidity (Kidney Disease Statistics for the United States [1].
The Incidence of CKD
According to Centers for Disease Control and Prevention (CDC) in USA 16.8% people are affected by CKD in the age of 20 years or above during 1999 to 2004. And in Canada, 1.9 to 2.3 million people have CKD. In Great Britain and Northern Ireland 8.8% people are affected by symptomatic CKD [2].
Incidence of chronic kidney disease has doubled in the last 15 years. Major causes of kidney failure are diabetic mellitus, chronic hypertension and glomerulonephritis, which account for approximately 60% of new cases [12]. Chronic kidney disease is rapidly growing disease in Bangladesh. Results of this study also demonstrated that most of the CKD patients had type 1diabetes (39.02%) and type 2 diabetes (41.46%) mellitus. Only 5% of the CKD patients had undergone nephro -surgery. Around 24.30% of the CKD patients had hypertension [2].
Excessive fluid overload contributes to an increased morbidity and high mortality [6]. In CKD patients. Similarly, dietary restriction in CKD forms part of the management of the condition and its goal is to minimize uremic and anemia symptoms, reduce the incidence of fluid, electrolyte and acid base imbalances, decrease patient’s vulnerability to infections and limit catabolism [13]. Again, documented poor adherence to dietary restriction has been documented to be in the ranges of 2% to 81% [14], among CKD patients. In this regard, fluid and diet engagement plays a pivotal role in the effective management of CKD as it lowers morbidity, improve rehabilitation, survival and clinical outcomes [15].
There is an exponential growth worldwide of patients with End-Stage Renal Disease (ESRD). Prevalence, outcomes and underlying causes of ESRD are relatively well documented through different organizations. It is, however, clear that a large part of the bad outcome of ESRD patients is due to deficient follow-up during the earlier Chronic Kidney Disease (CKD) stages. According to data on CKD, prevalence of the different stages and the evolution to ESRD are rather scant and available data are conflictive. This is at least partly due to the lack of an international standard for measurement of renal function. In addition, there is compiling evidence that presence of proteinuria, even with abnormal renal function, predisposes to ESRD. Most authors now prefer the term “kidney injury” rather than “kidney failure” to indicate people at risk for evolution to ESRD or for complications of CKD. Detection of these patients at risk is important to implement measures to slow down progression of CKD and avoid secondary complications. As it is clear that most of these CKD patients die before they reach ESRD, it might be that by taking the necessary preventive measures, the number of ESRD patients might still further increase exponentially [16].
Self-Management behavior of chronic kidney disease patients: A study was conducted 2006 about self-care Management in adults undergoing hemodialysis. The study shows that clients with end stage renal disease require continual care. Daily self-care includes managing a complex treatment regimen of dietary restrictions, fluid limitations, medications and vascular access care.
A study was conducted to assess the effectiveness of a self-monitoring tool on perceptions of self-efficacy, health beliefs and adherence in patients receiving hemodialysis. Both the treatment and control groups were randomly selected and received surveys to assess health beliefs, perceptions of self-efficacy for performing specific healthful behaviors and renal diet knowledge at baseline, before intervention and 6 months later. The treatment group also received monthly feedback of monthly phosphorus levels and inter-dialytic weight gains. Analysis of variance tests of repeated measures were used to examine relationships between adherence with phosphorus and fluid restrictions to health beliefs and perceptions of self-efficacy after training in self-monitoring. Overall, there were no significant improvements in adherence with phosphorus and fluid restrictions between the two groups, although a comparison within the groups revealed the treatment group had a statistically significant decrease in mean phosphorus levels of 7.14 to 6.22 mg/dl (P = 0.005) from baseline to month. No significant differences existed between the two groups for health beliefs and perceptions of self-efficacy. Knowledge scores in the treatment group, however, improved significantly as compared to the control group (P = 0.008) and was a significant increase from baseline (P = 0.002). They concluded that benefits of patient self-monitoring and behavioral contracting upon adherence in patients on hemodialysis are inconclusive, as serum phosphorus and inter dialytic weight gains did not differ between the two groups.
A retrospective study was conducted on positive effect of protein restriction in patients with chronic kidney disease in which 122 renal patients were participated, among them 61 patients were treated with low protein diet there was less mean weight loss in the low protein diet group the year before dialysis(0.14kg/month control group 0.36kg/month p,0.05).The mean rate of progression during the 6months before dialysis was lower in the low protein group(4.1 ml/min/year) than in the control group (13.4 ml/min/year o<0.001).The low protein diet group had fewer days of hospitalization at the start of dialysis than the control group(8.2 vs 15.4 days p<0.01).The findings of the study shows that low protein diet can reduce patient morbidity, preserve renal function, relieve uremic symptom and improve nutritional status.
A prospective study was conducted to assess the utility of Leventhal's Self-Regulatory Model (SRM) to predict self-care behavior with regard to dietary, medication and fluid regimes in end-stage renal disease (ESRD) patients. In this study, ESRD patients treated via hospital-based hemodialysis (N = 73) were screened for cognitive deficits and completed questionnaires that enquired about illness perceptions, coping strategies, knowledge of kidney disease and psychological distress at Time 1. Physiological proxy measures of self-care behaviors regarding diet, fluid intake and medication regimes were collected 3 weeks later at Time 2. They concluded that the SRM has predictive utility. Psychological interventions should focus on alleviating disease-specific distress and challenging erroneous timeline perceptions in order to increase adherence to dietary and medication regimes in ESRD patients. A more specific measure of coping for ESRD is required to clarify the role of coping strategies in this population. Younger, male patients should be targeted for extra support with fluid restrictions.
A study was conducted to assess the impact of nurse-led clinic on self-care ability, disease specific knowledge and home dialysis modality to enhance patients' disease-related knowledge, involvement and self-care ability. Comparison of patient outcomes with the nurse-led clinic to the previous model of care was seen. The participants in the nurse-led clinic chose and started dialysis in a self-care alternative and also had a functioning, permanent dialysis access to a greater extent than the patients in the comparison group. Those choosing home-hemodialysis rated their self-care ability higher. The participants rated self-care and effects of treatment options on family and everyday life as the most important disease-related areas of knowledge.
An evaluative research study was conducted in Vijaya dialysis unit to find out the effectiveness of information booklet provided to care givers of patients undergoing hemodialysis on knowledge of home care management. A pre-experimental one group pre-test post-test design was used to achieve the objectives of the study, the sample size of 30, selected through Non-probability convenient sampling technique. The major finding of the study showed that the overall knowledge score obtained by the care givers in the pretest was 50.35 and 86.26 in the post test. The overall improvement in the mean score was 35-89 with ‘t’ value 13.4 which was highly significant.
Fluid and Dietary Restriction Behavior of Patients with CKD
Patient perception refers to a patient’s knowledge, ability and willingness to manage his or her own health care, paired with interventions which promote positive adherent behavior [15]. In this context, perception is conceptualized as ability, willingness and active participation of CKD patients with their dietary and fluid restriction to promote highest levels of adherent behaviors. Carman et al. further highlighted that patient perception is required for successful treatment of CKD as involvement has been shown to promote less frequent and shorter hospital stays, lower morbidity, improve survival and clinical outcomes [15]. Consistent findings reported that perception is strongly associated with improved adherence with treatment (Skolasky, Mackenzie, Wegener & Riley ,2008). Therefore, perception with fluid and dietary restriction is of importance to improve documented poor adherence to these management modalities [14], among CKD patients. Removal and control of excess fluid is the cornerstone of volume management in CKD patients. Furthermore, low rates of adherence to fluid restriction have been evident from previous studies [17], as they range from9.7% to 72%. Self-care behavior includes adherence to prescribed medications, caring for vascular access and as importantly, dietary recommendations that include selecting food items low in sodium, potassium and phosphorus, maintaining adequate protein intake and limiting daily fluid intake. Lack of compliance to these dietary recommendations may lead to accumulation of metabolic by products and excess fluid in the circulatory system, leading to increased morbidity and mortality for renal failure patients.
Summary of the Literature Review: Optimal management of patients with chronic kidney disease (CKD) requires appropriate interpretation and use of the markers and stages of CKD, early disease recognition and collaboration between primary care physicians and nephrologists. Because multiple terms have been applied to chronic kidney disease (CKD), eg, chronic renal insufficiency, chronic renal disease and chronic renal failure, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQ) has defined the all-encompassing term, CKD. Using kidney rather than renal improves understanding by patients, families, healthcare workers and the lay public. This term includes the continuum of kidney dysfunction from mild kidney damage to kidney failure and it also includes the term, end-stage renal disease (ESRD). However, from the literature review, there is no any study about family member’s perception regarding chronic renal disease patients in Bangladesh.
This chapter describes the research methodology of the study which were covered by the following areas: study design, study participants, data collection instruments and data collection methods and data analysis.
Study Design
An exploratory study design was used to examine the socio-demographic characteristics and perception on fluid and dietary restriction among CKD patients in Bangladesh.
Study Participants
The target population in this study was patients with CKD who visited the in-patient department at the National Institute of Kidney Diseases and Urology Hospital (NIKDU), Dhaka, Bangladesh. The NIKDU is the only one specialized tertiary care hospital in Bangladesh for treatment of all types of kidney patients. The hospital was established in 2001. The hospital has two parts: academic and clinical services. On the clinical part there are treated and managed all Acute and chronic kidney diseases, Renal stone diseases, Obstructive uropathy and genito-urinary malignancies are the major diseases and all forms of renal replacement therapy including kidney transplantation. The NIKDU has 150 beds for inpatient department and also OPD treatment facilities. A large number of patients came to the hospital to the OPD and dialysis center. On the academic part it provides postgraduate courses like MD (Nephrology), MS (Urology) and conducting a number of community based research works for early detection and prevention of kidney diseases. In the year 2017, a total of 5636 CKD patients were admitted at this hospital.
Sample Size
Sample size was estimated by using G Power analysis. The estimated sample size calculated for an acceptable medium level of significant (α) 0.05 and acceptable power of 0.90 (1-β) and effect size 0.3 (Y). The sample size was 106 with 20% attrition rate. Due to missing data 6 data was cleaned. Finally, the sample size was 100.
Data Collection Instruments
The data collection instrument that was employed in this study was consisted of three self-administered questionnaires. Based on the literature review and getting ethical consideration, researcher-built questionnaire with:
Part I: Demographic Data Assessment Questionnaire (DDAQ)
Part II: Fluid restricted Related Questionnaire (FRRQ)
Part lll: Diet Restriction Related Questionnaire (DRRQ)
The researcher will be used existing instrument.
Part I: Demographic Data Assessment Questionnaire (DDAQ) -14(Fourteen) items (Age; Gender; Religion; Marital status; Educational Background; Employment status; Number of Family member; Monthly family income; BMI; Years of treatment for CKD in Months; Smoking history; Co-morbidity history and Nutritional education
Part ll: had 31 questions related to fluid restriction
Part III: Had 19 questions related to Dietary Restriction related questionnaire
The frequency measures were assessed using a 5-points Likert scale with scores from 1(almost never/0 days per week) to 5 (almost always/ 7days a week).
Data Collection Methods
Data was collected after obtaining approval from the Institutional Review Board (IRB) of National Institute of Advanced Nursing Education and Research (NIANER), Mugda, Dhaka, the Institutional Review Board (IRB) of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh and permission was received from the Director and Nursing Superintendent of selected specialized hospital in Bangladesh. The researcher highly considered about the human rights of the participants of this study. The researcher explains the purpose of the study, the procedure, the possible benefits and risks of the study to the participants. The researcher informed the participants that they had right to choose whether they were willing to participate or not and that they can withdraw from the research at any time after consenting to participate in the study. The researcher explained all the instruments in Bangla language. If the agreement to participate was approved verbally, they have further asked to sign the informed consent form and return it to the researcher. Subjects’ autonomy and confidentiality was strictly maintained and participation was voluntary. The anonymity of participants was strictly maintained.
The researcher read the questionnaire to subjects, explain details repeatedly until the subject understood and ensured time that was appropriate for each subject to answer the questionnaire. Then the researcher checked the questionnaires to ensure that it was completed properly.
Data Analysis
The collected data was entered using a data analysis program and the editing and cleaning of data was performed. Data was analyzed as per objectives of the study and additional analysis was completed to support the research findings. The collected data were processed using SPSS 23 version for analysis including descriptive statistics and inferential statistics. Descriptive statistics consisting of frequency, percentage, range, mean and standard deviation were to used analyze the subjects’ Socio-demographic characteristic, fluid and dietary restrictions. Inferential statistics was used to find out the relationship between socio-demographic and fluid restriction & dietary restriction among CKD patients. Data were analyzed by using independent t test (t), correlation (r) and ANOVA (F) a significance level of p<0.05 was considered as a statistically significance.
Table 1 Showed the distribution of Socio-demographic characteristics of the participants. The average age was 44.20 ±13.04 years with an age range from 20-60 years.61.0% were male, 95.0% were Islam among the participants 88% were married. For the educational background of the participant, 38.0% were illiterate and only 1% was post-graduate. Among participants,54% of participants were unemployed and 74% of participants who had family member 5 or more. An annual income of family ranges from 12000-35000 taka and mean was 22710 takas. Maximum participants were normal BMI (59%) with the mean of 24 and pattern of treatment range were 36% in month. More than 50% of participants were smoker. Whereas more than participants’ comorbidity history was absent. Only 11% of respondents had received nutritional education.
Table 1: Distributions Socio-Demographic Characteristics Among CKD Patients (N = 100)
| Variables | n (%) | M (SD) | |
| Age | 44.20±13.04 | ||
| Gender | Male | 61(61) | |
| Female | 39(39) | ||
| Religion | Islam | 95(95) | |
| Hindu | 05(05) | ||
| Marital status | Single | 12 (12) | |
| Married | 88 (88) | ||
| Educational Background | Illiterate | 38(38) | |
| High School | 34(34) | ||
| Under Graduate | 27(27) | ||
| Post Graduate | 01(01) | ||
| Employment status | Un-employed | 54(54) | |
| Employed | 46(46) | ||
| Number of Family member | ≤4 | 26(26) | |
| ≥5 | 74(74) | ||
| Monthly family income | ≤23000 | 50(50) | 22710 ±5494 |
| ≥ 250000 | 50(50) | ||
| BMI | 24 ±13.00 | ||
| BMI | Under Weight | 03(03) | |
| Normal | 59(59) | ||
| Over Weight | 38(38) | ||
| Years of treatment for CKD in Months | ≤9 | 31(31) | 13 ±5.02 |
| 10-14 | 36(36) | ||
| ≥15 | 33(33) | ||
| Smoking history | Smoker | 51(51) | |
| Non-Smoker | 49(49) | ||
| Co-morbidity history | Absent | 59(59) | |
| Hypertension | 39(39) | ||
| DM | 02(02) | ||
| Nutritional education | Yes | 11(11) | |
| No | 89(89) | ||
Table 2 shows the mean scores to measures management of fluid restriction related characteristics. The mean score of the management of fluid restriction related characteristics was 2.04. The most common management of fluid restriction related characteristics actions were: drinking warm water (3.32); use unsalted butter or margarine (3.25) and rinse the mouth with warm water (3.16). Among the frequent measures we found: avoid eating spicy food (1.29); record the amount of daily fluid intake (1.24) and check the amount of salt on product labels (1.23).
Table 2: Distribution of Management Of Fluid Restriction Behavior Related Characteristics (N = 100)
| Variables | M(SD) |
| Avoid eating spicy food | 1.29 (±0.47) |
| Avoid foods with plenty of water | 1.49(±0.61) |
| Avoid to exceed the amount of liquid daily allowed | 2.77(±1.17) |
| Eat thick soup | 3.00(±0.69) |
| Reduce soup consumption | 2.75(±0.73) |
| Drinking only half a glass or cup half | 2.02(±0.79) |
| Drink cold liquids | 2.92(±0.63) |
| Drink only at meals | 1.85(±0.73) |
| Distributing the allowed volume of fluids day along | 1.64(±0.59) |
| Use small glass or cup to drink | 1.96(±0.76) |
| Gargle with water without swallowing | 2.74(±0.81) |
| Fill a bottle with the allowed liquid volume for the whole day | 1.59(±0.66) |
| Estimate the amount of fluid you can drink daily | 1.49(±0.55) |
| Eat a piece of fruit to reduce thirst | 2.68(±0.82) |
| Control the fluid amount by symptoms | 1.53(±0.61) |
| Sucking lemon slice | 2.80(±0.73) |
| Rinse the mouth with warm water | 3.16(±0.83) |
| Drinking warm water | 3.32(±0.82) |
| Adjust the amount of liquid according diuresis | 1.34(±0.06) |
| Record the amount of daily fluid intake | 1.24(±0.42) |
| Avoid instant food | 1.39(±0.54) |
| Avoid ketchup | 1.86(±0.69) |
| Avoid fast food | 2.11(±0.97) |
| Avoid pre-prepared sauces | 1.47(±0.57) |
| Avoid salt at the table | 1.37(±0.52) |
| Reduce salt when cooking | 1.41(±0.49) |
| Avoid sausage/smoked food | 1.68(±0.75) |
| Avoid using meat or fish broth to cook | 1.78(±0.91) |
| Use unsalted butter or margarine | 3.25(±1.08) |
| Check the amount of salt on product labels | 1.23(±0.56) |
| Total | 2.04(±0.32) |
Table 3 showed the relationship between demographic characteristic and management of fluid and dietary restriction related characteristics intake. Those who had age trend to have higher management of fluid restriction related characteristics compared to measures to control fluid intake (r = 0.23), they were statistically different (p = 0.03).
Table 3: Relationship Between Demographic Characteristic and Management of Fluid and Diet Restriction Behavior Related Characteristics (N = 100)
| Variables | Fluid restriction | Dietary restriction | |||
| M±SD | t/F/r(p) | M±SD | t/F/r(p) | ||
| Age | 0.23(0.018) | 0.13(0.18) | |||
| 20-40 | 1.96 ±0.33 | -2.17(0.03) | 2.23 ±0.41 | -0.928(0.35) | |
| 40-60 | 2.10 ±0.31 | 2.31 ±0.42 | |||
| Gender | Male | 2.05 ±0.34 | -0.167(0.86) | 2.26 (0.45) | -0.561 (0.57) |
| Female | 2.04 ±0.29 | 2.31 (0.36) | |||
| Religion | Islam | 2.05±0.31 | 0.587(0.58) | 2.28±0.41 | -0.152(0.88) |
| Hindu | 1.91±0.53 | 2.24±0.55 | |||
| Marital status | Single | 1.88±0.35 | 1.75(0.10) | 2.12±0.46 | .0125(0.23) |
| Married | 2.07±0.31 | 2.30±0.40 | |||
| Educational Background | Primary/ bellow | 2.11±0.05 | 0.94 (0.44) | 2.35±0.43 | 1.14(0.34) |
| Under Graduate | 2.03±0.07 | 2.29±0.38 | |||
| Post Graduate | 1.89± -- | ||||
| Employment status | Un-employed | 2.05±0.30 | 0.361(0.71) | 2.31±0.41 | 0.689(0.49) |
| Employed | 2.03±0.35 | 2.25±0.42 | |||
| Family member | 0.85(0.39) | 0.09(0.34) | |||
| ≤4 | 1.96±0.32 | -1.60(0.11) | 2.22±0.40 | 0.773(0.44) | |
| ≥5 | 2.07±0.32 | 2.30±0.42 | |||
| Income | 0.61(0.54) | 0.37(0.71) | |||
| ≤25000 | 2.04±0.31 | 0.256(0.80) | 2.28±0.38 | -0.201(0.84) | |
| ≥ 25000 | 2.06±0.38 | 2.25±0.52 | |||
| BMI | 0.11(0.27) | 0.00(0.95) | |||
| ≤23 | 2.08±0.32 | -0.132(0.18) | 2.26±0.41 | -0.314(0.75) | |
| ≥23 | 1.99±0.33 | 2.29±0.42 | |||
| Years of treatment for CKD in Months | ≤9 | 1.96±0.36 | 1.6(0.20) | 2.27±0.48 | 0.41(0.66) |
| 10-14 | 2.09±0.29 | 2.32±0.33 | |||
| ≥15 | 2.08±0.31 | 2.23±0.43 | |||
| Smoking history | Smoker | 2.02±0.35 | -0.648(0.51) | 2.24±0.48 | -1.03(0.30) |
| Non-Smoker | 2.07±0.29 | 2.32±0.33 | |||
| Co-morbidity history | Absent | 2.23±0.35 | 0.85(0.19) | 2.36±0.21 | 0.65(0.23) |
| Hypertension | 2.35±0.41 | 2.31±0.25 | |||
| DM | 2.21±0.52 | 2.38±0.35 | |||
| Nutritional education | Yes | 2.25±0.26 | 2.72(.01) | 2.49±0.21 | 3.04(0.006) |
| No | 2.02±0.32 | 2.25±0.26 | |||
Those who have received nutritional education trend to have significantly more measures to control fluid intake compared to those who did not receive (t = 2.72), but there was highly statistically significant (p = 0.004). Other variables had no significant relationship.
The aim of this study was to explore the pattern of the dietary and fluid restriction behavior among admitted patients with chronic kidney disease in Bangladesh. This study focused on describing the socio-demographic characteristics, dietary and fluid restrictions behavior among admitted patients with CKD in Bangladesh. The Fluid restriction behavior which were consisted of measures to manage the dietary restrictions to cover two areas; fluid intake and salt reduction. The Dietary restriction behavior which were consisted of self-care measures to manage fluid restriction to cover two areas; potassium restriction and over phosphorus restriction.
Socio-demographic characteristics of the participants participating in the study were presented in Table 1. A total of 100 participants recruited in the study. The average age was 44.20 ±13.04 years with an age range from 20-60 years.61.0% were male, 95.0% were Islam among the participants 88% were married. For the educational background of the participant, 38.0% were illiterate and only 1% was post-graduate. Among participants, 54% of participants were unemployed and 74% of participants who had family member 5 or more. An annual income of family ranges from 12000-35000 taka and mean was 22710 takas. Maximum participants were normal BMI (59%) with the mean of 24 and pattern of treatment range were 36% in month. More than 50% of participants were smoker and only1% of the respondents was consumed alcohol. Whereas more than participants’ comorbidity history was absent. Only 11% of respondents had received nutritional education.
Among the frequent measures we found: avoid eating spicy food; record the amount of daily fluid intake and check the amount of salt on product labels. Table 2 show that the measures most commonly used to control fluid intake are restrictive, revealing a strong adaptive effort of patients. Measures to the management of fluid restriction related characteristics a mean score of 2.04. Patients seem to be aware of the importance of avoiding spicy foods and candy, conditions that cause thirst. They also seem to respect the need to not exceed the daily amount of fluids allowed, attentive to use unsalted butter or margarine, rinse the mouth with warm water and to reduce soup consumption. Weight control, estimate the amount of fluid daily intake and adjust the fluid intake according to diuresis, they were less used measures, perhaps because they are complex and impractical actions. Sucking ice temporarily relieves thirst, but may increase the water intake if used very often [18].
Restrictive measures prevail among actions to reduce salt, stressing the limitations imposed by disease and by treatment. It is possible that patients are avoiding Asian food and fast food due to nutritional habits of Portuguese elderly people. High scores regarding avoid salt at table and when cooking and avoiding smoked and salty food, suggest that patients are aware and make some effort to prevent thirst. Patients may also rarely check the salt content on labels due to visual problems, due to poor food diversification, or because labels do not always provide clear information. These results suggest that subjects perceive the importance of salt restriction to reduce thirst [18-20].
The measures to Management of Dietary Restriction Related characteristics a mean score of 2.58. The most common Management of Dietary Restriction Related characteristics actions were: Cook vegetables and potatoes twice; reduce the consumption of raw vegetables, avoid pulses and Reduce salt when cooking. Among the frequent measures we found: Avoid food with high containing potassium; avoid eating more than two piece of fruit per day and reducing the consumption of bread and toasts. In order to reduce potassium from diet, patients can avoid dried fruits so often because they are mainly consumed during festive seasons. Patients show their commitment to restrict potassium in the diet when implementing so often those restrictive measures. However, it seems they follow less often recommendations as vegetables and potatoes twice and reduce the consumption of raw vegetables. It is possible that those are impractical measures. Patients also can eat more bread and milk, because they are common and inexpensive food and being well tolerated by people. Eat less meat or fish meal may be due to the weak economic power of elderly people. Oilseeds consumption also can be less common because it is mainly consumed [18].
Dietary restriction in CKD forms part of the management of the condition and its goal is to minimize uremic and anemia symptoms, reduce the incidence of fluid, electrolyte and acid base imbalances, decrease patient’s vulnerability to infections and limit catabolism [13]. Yet diet plays a pivotal role in the effective management of CKD as it lowers morbidity, improve survival and clinical outcomes [15].
As mentioned by Fitzsimons, "The sensation of thirst is basic to our very existence. Its gratification is universally held to be one of the pleasures of life; it cannot be ignored and if water be lacking, the sensation comes to dominate our thoughts and behavior”. So, fighting against this vital instinct might be really arduous and stressful. In our sample, younger participants and the ones with higher BMI > 23 kg/m2 perceived even more difficult to control fluid intake. It was found that Dialysis Thirst Inventory score was directly correlated with BMI and inversely with age [21]. In this study, those who have 40 years or more, they can’t management of fluid restriction behavior compare to dietary restriction behavior. They require nutritional education as well.
The present study revealed that, most of participants had poor nutrition knowledge. Although only 11 % of the participants had basic nutrition education from different hospital setting and majority didn’t have. That’s why current study found gaps in their nutrition-related knowledge. The knowledge level of healthcare workers was found to be higher due to the nutrition education received and higher level of professionalism in the application of their knowledge.
The purpose objectives of an exploratory study design were to explore the pattern of the dietary and fluid restriction behavior among admitted patients with chronic kidney disease in Bangladesh.
For the relationship between demographic characteristic and management of fluid and dietary restriction behavior related characteristics intake among admitted patients with CKD who had age trend to have higher management of fluid restriction related characteristics compared to measures to control fluid intake(r = 0.23), they were statistically different (p = 0.03) and who have received nutritional education trend to have significantly more measures to control fluid intake compared to those who did not receive (t = 2.72), but there was highly statistically significant (p = 0.004). Other variables had no significant relationship.
For the Relationship between Demographic characteristic and total Fluid and Dietary Restriction Related behavior of participants who had age trend to have higher behavior (r = 0.19), they were statistically different (p = 0.05) and who have received nutritional education trend to have significantly more behavior about fluid and diet restriction (t = 2.27), but there was highly statistically significant (p = 0.03).
This study explored statistically significance between demographic characteristic and management of fluid and dietary restriction related characteristics intake among admitted patients with CKD who have had higher age and nutritional education, showed significantly higher fluid and diet restrictions behavior. Hospital can consider those characteristics to guide Patients with Chronic Kidney Disease.
Limitations of the Study
The study was conducted in only specialized hospital in Dhaka city which doesn’t represent the whole characteristics of patients with CKD in Bangladesh.
Recommendations
Based on the study findings, the researcher proposes the following recommendations:
Nurse and patients’ communication should improve for the development of treatment of CKD patient
Patient’ counselling should be developed in the indoor and outdoor settings
Dietician should be enrolled in every hospital especially specialized hospital
Further larger scale studies require to explore the pattern of the dietary and fluid restriction behavior among admitted patients with chronic kidney disease in Bangladesh from different settings to compare results of the current study.
Acknowledgment
All praises to almighty Allah, the compassionate and merciful who have given me the opportunity to complete this thesis. I am very much humble and grateful to him for providing me with enough energy and patience to carry out and complete this work. It is the enormous necessity to writing this page in an effort to acknowledge those who in all their possible ways have facilitated me in carrying out and completing this work, though this small return in a few words is only a fraction of what I was given by them.
I would like to express my heartiest gratefulness to family, friends and colleagues for their valuable suggestion, encouragement and wholehearted co-operation.
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