It can be burdensome for dialysis patients to record their nutrient intake; PDAs may help.

Protein malnutrition occurs frequently in patients on hemodialysis. When patient assessment indicates protein malnutrition, increased protein intake is recommended.

Even if protein intake appears to be adequate, inadequate intake of foods providing energy (fats and carbohydrates) can lead to protein malnutrition because protein will be metabolized to provide energy. So both adequate protein and energy intake are necessary.

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Although dietary instruction is given by a dietitian, improvement in nutritional status requires knowledge of food composition relative to the needed nutrients and some way of monitoring food and nutrient intake. Like so many other aspects of health care, self-monitoring of diet is an essential aspect of successful treatment. A patient can only improve intake by continually recording food and comparing actual intake with clinical goals.

Most people eat up to 100 different foods during a given month, however, and each food has a different nutrient composition. Patients often limit their intake to the few foods they are familiar with, which they identify as acceptable to their therapy. In this situation, food boredom sets in and intake drops to the detriment of nutritional status. The alternative of eating a wider variety of items, looking up their nutrient content, and then recording the findings is too burdensome for most patients. The benefit of written dietary records, however, is that patients are made aware of the foods they eat simply by the act of keeping a journal.

Dietary recalls

Another alternative for determining nutrient intake is multiple dietary recalls. Patients can usually remember what foods they ate in the preceding 24 hours, with more difficulty in recalling the size of portions eaten. For hemodialysis patients, there appears to be lesser food intake on days of dialysis compared with non-dialysis days (J Renal Nutr. 2007;17:88). This variability is in addition to differences due to other changes in activity, with differences between workdays and non-workdays being especially marked for those who are employed.

Analysis of multiple dietary recalls is burdensome for the dietary staff, as foods and amounts must be entered into a diet analysis computer program to generate nutrients that can be compared with pa-tient needs and goals. The time between recording a food intake and getting feedback on the appropriateness of that intake to dietary goals interferes with applying that new knowledge.


A new tool that has the potential to greatly improve patient dietary compliance and reduce staff time is the personalized digital assistant (PDA) loaded with dietary analysis software. Two pilot studies recently reported on their effectiveness with hemodialysis patients. In a study published in the Nephrology Nursing Journal (2006;33:271-277), Shannon A. Dowel, MSN, RN, and Janet L. Welch, DNS, RN, recruited four adult hemodialysis patients from a hospital outpatient clinic. After training in PDA use, the subjects were asked to keep records for three months.

One patient withdrew, saying too much time was required for the record-keeping. For the three patients who completed the study, weekly averages of the six focus nutrients varied quite widely. Inspection of the graphed intake data shows that protein and energy intake never meet requirements of these nutrients. This occurred in spite of a weekly meeting with clinical staff to review the dietary information generated. Overall, the patients were fairly adherent to sodium, potassium, and phosphorus goals. Future studies need to determine whether adherence to restriction of some nutrients, in this case these three minerals, affected the intake of foods higher in protein and energy.

Serum albumin improvements

In a similar study, Sevick et al (J Renal Nutr. 2005;15:304) had five long-term dialysis patients monitor their diet using PDAs for four months. After initial training, the patients reviewed their dietary intakes weekly with a renal dietitian during a dialysis treatment. The investigators extensively used self-efficacy-based interventions in their counseling sessions.

These were well-documented in the published paper. Monthly serum albumin improved in four of the five patients and was stable in the fifth. Serum phosphorus decreased in a patient with an elevated level and was stable in the other four. Al-though energy intake increased, patients apparently chose foods relatively lower in sodium because interdialytic weight gain was either stable or decreased.

Two other studies of dietary self-monitoring using PDAs have been reported. Glanz et al (Am J Health Promot. 2006;20:165-170) showed that 33 female participants in the Women’s Health Initiative reported improved compliance with study diet goals. Over 90% said they would continue to use the PDA if it were available. Ma et al (Eur J Clin Nutr. 2006;60:1235-1243) reported that 15 adult patients with poorly controlled diabetes type 2 reduced their average HbA1c, body weight, and BP over the six-month study period using PDAs programmed with information about glycemic index.

Similar larger studies with more hemodialysis patients are needed to determine which patients would benefit from PDA self-monitoring and how to most effectively use PDAs to improve outcomes.