COUNSELING SKILLS

FOR THE RENAL DIETITIANS

INTERVENTIONS TO PROMOTE ADHERENCE TO THE RENAL DIET

Rana G. Rizk, PhD, MPH, LD

Maastricht University, The Netherlands

October, 2017
Acknowledgements
• Dr. Mirey Karavetian

• Dr. Hafez El Zein

• Pr. Nanne de Vries

• Dr. Mickael Hiligsmann

• Pr. Silvia Evers

 Learning objectives
• Define nutrition counseling

• Identify unique challenges & opportunities of nutrition counseling in renal care

• Learn strategies to improve renal nutrition counseling skills

• Capture the clinical & cost-effectiveness of nutrition counseling on

hyperphosphatemia management through a review of the NEMO trial
 Who is the dietitian
who serves renal patients?

If this question hits home … YOU ARE NOT ALONE

 Renal dietitian or renal counselor?
• 97% of renal dietitians were aware of the KDOQI guidelines
• 42.1% of them were unable to provide nutrition counseling
“I want the counseling tools
•Dietitians are often comfortable
but I don’tin the role
know how of
ornutrition
when educator
to use
•BUT NOT in the role of nutrition them…”
counselor

•Disparities in clinical practice

Byham-Gray et al., Nutrition in Kidney Disease. 2014

 Nutrition counseling: What is it?
Supportive process

Set priorities Establish goals Create individualized action plans

Promote Patient as primary
Self-care
adherence decision maker
Does not begin Collaborative effort Active listening
with transfer of between 2-way conversations
information caregiver & patient Offering choices
AND EAL, 2012; NCM, 2014
Stubborn gap between evidence-based recommendations
& implementation of recommendations in renal patients
Dietary Energy Intake

Dietary Protein Intake

Recommended 30–75% Recommended
nonadherence
30-35 kcal/kg/d
74.6-92% 1.2 g/kg/d
32.3-81%
non- with diet and/or non-
22.7±8.3 kcal/kg/d 0.88±0.57 g/kg/d
adherence fluid restrictions
26.8±11.9 kcal/kg/d
adherence
1.02±0.4 g/kg/d
Actual Actual

Therrien et al., J Ren Nutr. 2015; 25:329-38; Kugler et al., J Nephrol. 2011;24:366
 CKD: Unique challenges
Patient
related Unique challenges to
factors
Disease Socio- dietary adherence
related economic
factors factors Complex dietary regimens
Adherence
in CKD Physical detriments
Therapy Psycho-
related logical Psychosocial detriments
factors Health factors
care Burdens on patient’s circle
related
factors
Chironda et al., 2016; Tsay et al., 2005; Krespi et al., 2004; King et al., 2002; St-Jules et al., 2015
Nutrition counseling: Renal specific guidelines?
Education-based, EXPERT-centered guidance
vs. PATIENT-CENTERED COUNSELING
Informational + Cognitive/behavioral components

• Currently, there are no specific evidence-based guidelines in

nutrition counseling for CKD patients
• Counseling theories & strategies in CKD are similar to other
chronic disease conditions
Mason et al., Am J Kidney Dis. 2008;51:933-51
 Counseling theory:
Transtheoretical model
 Motivation
Making
Movement the
Commitment to
change
from
to→
Regression
Prevent
Notchange relapse
considering →
→
onechange
stage →→to
Reinforce
Build coping
change → self-
Complications
Simple instruction
another involvesof
efficacy
Reinforce & social
goal-
Set Relationship
goals,diet
disease, buildrole
self-&
self-efficacy
buildingsupport
setting,
&
management
self- &
minimal
&
expected
Each stage benefits
represents a
Emphasize
management
decisional
emphasis
efficacylearning
on &
Establish timeline
different level of motivation
from relapse
monitoring
balance
dietary changes
+ reinforcement
for change

Dynamic
process
Byham-Gray et al., Nutrition
in Kidney Disease. 2014
 Counseling strategy:
Motivational interviewing

Byham-Gray et al., Nutrition in Kidney Disease. 2014

 OUR EXPERIENCE…

STAGE-BASED EDUCATION BY DEDICATED

DIETITIANS IN THE HEMODIALYSIS UNIT

NUTRITIONAL EDUCATION FOR

MANAGEMENT OF OSTEODYSTROPHY
(NEMO) TRIAL, LEBANON
 Problem
Elevated prevalence of hyperphosphatemia: 41%
Patients

Dietitians

Karavetian et al., Patient Educ Couns. 2015;98:1116–22

 NEMO Trial: Design
Outcomes
Clinical: Serum phosphorus, SOC
Dedicated Existing Trained Hospital
Dietitian (DD) Practice (EP) Dietitian (THD) (adherence to low-phosphorus diet)
Cost-effectiveness

Karavetian et al., Nutr Res Pract. 2014;8:103-11

 Assessment tools
Serum phosphorus:
medical chart

SOC: low phosphorus

diet

Cost-effectiveness:
Trial based economic
evaluation
Karavetian et al., Nutr Res Pract. 2014;8:103-11
Delivery of nutrition counseling
2 hours/month: during HD sessions

3 sessions/month: SBNE
Counseling theory: TTM; Counseling strategy: MI

1 session/month: reinforcement

Self-management, Self-monitoring
& self-efficacy skills
Karavetian et al., Nutr Res Pract. 2014;8:103-11
 Educational material
Validated in Lebanese HD population
Arabic plain language, 5th grade literacy level, use of
illustrative photos
.

• Handouts
Simple, concise, clear, • Alternatives booklet
positive, realistic & actionable • Renal-friendly recipes
• Posters
written message
• Tracking Chart

Karavetian et al., Nutr Res Pract. 2014;8:103-11

Karavetian et al.,
Nutr Res Pract.
2014;8:103-11
 Educational material

Booklet of 3 recipe 7 breakfast 7 lunch 7 dinner

alternatives books menus menus menus

Karavetian et al., Nutr Res Pract. 2014;8:103-11

 Educational material
Tracking chart: Posters: high & low
serum phosphorus phosphorus food items

Karavetian et al.,
Nutr Res Pract.
2014;8:103-11
 Patient outcomes
Stage of Behavioral Change: Low Phosphorus Diet
DD EP THD

T0

T1

T2
Karavetian et al., Nutr Res
Pract. 2014;8:103-11
 Patient outcomes
Serum Phosphorus (mg/dL)
8.00

7.00

6.00

5.00

4.00

3.00
5.54 5.26 5.33 5.29 5.63
5.11 5.17 5.05 5.11
2.00

1.00

0.00
T0 T1 T2 T0 T1 T2 T0 T1 T2 Karavetian et al.,
DD (n=88) EP (n=96) THD (n=210) Nutr Res Pract.
2014;8:103-11
 Cost-effectiveness of nutrition education
 Inexpensive: 6-month cost: $74.5 (≈$1/session)
• Between t1 & t2
Mean Change in Societal Costs Mean Change in Resources Use
($) (%) Productivity
0 60% losses (hour)
DD EP THD Sevelamer (pill)
40%
-500
20% Emergency HD LOS (day)
-1000 (session)
0%
-1500
-20% DD

-2000 -40% EP

THD
-60%
-2500
Rizk et al., J Med Econ. 2017
 The formula for effective dietary education
to manage hyperphosphatemia
Interaction
• Patients-to-dietitian partnership; Involving relatives
Educational material
• Individualize education
• Attractive booklets, handouts & posters, games & puzzles , adapted recipes
Timing
• Before HD sessions; Duration: ≥ 6 months; Frequency: ≥ 1/month visits
Theory
• Use of behavioral theories & strategies Karavetian et al., Nutr Rev. 2014;72:471-82
 Take-home message
Dietary adherence is a key
Renal patients experience
component for successful
detriments that interfere with
treatment of CKD
readiness to make dietary &
lifestyle changes

SBNE & MI are promising in

promoting dietary adherence
Nutrition counseling should
Be matched to patient’s SOC; needs & interests; culture & community
Supportive, focusing on empowerment & ↑ self-efficacy
Relevant & timely; interesting & practical format; 1-on-1 face-to-face
 Take-home message
Check your knowledge of counseling theories & strategies

Check for opportunities Check your communication style

Check the integration of counseling Listen more, talk less
Help the patient: Ask more questions
Think about the change Avoid conversation blockers
See change Build confidence
Practice new habits Practice respect, empathy & genuineness
Problem-solve barriers
Change is a mystery
Counseling can support change,
but counseling cannot make it happen
 Closing the gap
between ideal & actual
is a shared responsibility

Thank you !