Employing novel health strategies, along with phosphate binder medication, may help hemodialysis patients reduce excess phosphorus, a small pilot study suggests.

Peter R. Reese, MD, of the University of Pennsylvania in Philadelphia and colleagues randomly assigned 36 hemodialysis patients to 3 groups—dietary and medication coaching, financial incentives, or usual care—for 10 weeks. Baseline serum phosphorus levels ranged from 5.6 to 7.6 mg/dl.

According to results published in the Journal of Renal Nutrition, patients’ monthly serum phosphorus levels declined in all groups: 0.32 mg/dl for patients receiving a monetary reward, 0.4 in coached patients, and 0.24 in usual care patients.

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“These findings suggest that a future trial might combine education (using a coach or a different delivery method) with financial incentives to give patients the knowledge and motivation to change nutritional and medication adherence habits,” the investigators explained.

Understanding and adopting the dietary restrictions necessary to limit phosphorus is challenging for patients, especially when labels fail to note phosphorus amounts. Patients also need to remember to take phosphate binders with every meal and phosphorus-rich snack. The renal dietitian bolstered patients’ knowledge about both diet and phosphate binder therapy. Individualized coaching 3 times a week included assessments, goal setting, and practical tips, such as a shopping lists and recipes.

Patients in the financial incentives group received only a cash reward ($1.50 per day) when they lowered their phosphorus levels to a reasonable target of 5.5 mg/dl or below or when their serum phosphorus levels declined by at least 0.5 mg/dl from the prior reading. Successful patients also were entered into a lottery to win $50.

Motivational techniques played a role in both interventions. The dietitian used motivational interviewing to promote readiness for behavior change in patients. Patients in the financial incentives group likewise received messages to reinforce goal attainment and offset inaction.

Larger and longer studies are needed to investigate the magnitude and durability of improvements in phosphorus levels with these interventions, the investigators stated. This study was not powered to detect clinical differences between groups, but it determined the feasibility of using novel strategies and corroborated findings from similar research on phosphorus education. Other studies have shown that self-management and financial interventions improve medication adherence, smoking cessation, substance abuse, glycemic control, and weight loss.

Roughly half of eligible patients in the current study agreed to participate in the program and no one dropped out. All expressed interest in receiving similar support in the future.


  1. Reese, PP; Mgbako, O; Mussell, A; et al. Journal of Renal Nutrition; doi: 10.1053/j.jrn.2015.06.001.