AbstractBackground: The dietary self-management of chronic kidney disease (CKD) is complex. People with CKD are advised to follow dietary recommendations that restrict individual nutrients, however these interventions have been described by people as confusing and an intense burden to follow. Emerging evidence suggests that improving the overall dietary pattern may attenuate cardiovascular risk, morbidity and mortality in people with CKD. Changing dietary patterns is a complex intervention, which may be facilitated utilising telehealth. Telehealth interventions may overcome patient-centred barriers to face-to-face programs and provide a feasible, ubiquitous and accessible solution. However, a telehealth-delivered dietary pattern intervention has not been tested in the CKD population.
Aim: The aim of this thesis was to develop and test the feasibility and acceptability of a patient-centred telehealth program for the dietary management of CKD.
Methods: Several different methods were utilised to address the aim of this thesis. In the first study, a narrative review of the literature is described, exploring potential dietary interventions in CKD that go beyond the common single nutrient restrictions. Two systematic reviews and meta-analyses were then conducted. The first systematic review explores the association between healthy dietary patterns and all-cause mortality or progression to end-stage kidney disease, by aggregating all existing CKD cohort studies and performing a meta-analysis. The second systematic review investigates the effectiveness of telehealth-delivered dietary interventions in chronic disease evaluated in randomised controlled trials. The fourth study is a qualitative investigation utilising focus groups to explore the experiences of people with CKD with dietary recommendations and the potential to use telehealth for dietary self-management. These projects were used to inform the development of a telehealth-delivered dietary intervention for people with CKD (titled ENTICE-CKD). The ENTICE-CKD study was a six-month pilot randomised controlled trial to explore the feasibility, acceptability, safety, and potential effectiveness of improving dietary quality and clinical parameters utilising a telehealth-delivered dietary program in people with stage 3-4 CKD. The intervention group received fortnightly phone calls for three months and weekly tailored text messages for six months to assist with the implementation of a diet consistent with the Australian Dietary Guidelines. The control group received usual care for three months followed by a non-tailored education-only text message intervention for three months.
Results: The narrative review highlighted the potential for a healthy dietary pattern to improve renal outcomes. This dietary approach may be attractive for several reasons, including the potential to be more comprehendible to people with CKD.
The systematic review of healthy dietary patterns identified six existing CKD cohort studies (n=15,285 participants). A meta-analysis found a healthy dietary pattern was associated with reduced risk of all-cause mortality (relative risk 0.73, 95% confidence interval [CI] 0.63 to 0.83), but no consistent association with end-stage kidney disease was found. There was no standardised dietary pattern, however, diets were generally higher in fruit and vegetables, fish, legumes, cereals, whole grains, and fibre and lower in red meat, salt, and refined sugars compared to reference diets.
The systematic review of telehealth-delivered dietary interventions identified a total of 25 studies (n=7,384 participants) eligible for inclusion, with study duration ranging from eight weeks to eight years. Telehealth interventions were effective in chronic disease dietary management, specifically for improving diet quality (Standardised Mean Difference [SMD] 0.22, 95%CI 0.09 to 0.34]), fruit and vegetable intake (Mean Difference [MD] 1.04 servings/day, 95%CI 0.46 to 1.62), and dietary sodium intake (SMD -0.39, 95%CI -0.58 to, -0.20). Half (52%; n=13) of the included studies were conducted utilising the telephone, and 16% (n=4) using mobile phone text messaging. Other forms of telehealth were less commonly utilised for chronic disease dietary management. No randomised controlled trials conducted in CKD populations were identified.
The qualitative study comprised five focus groups involving 21 people with CKD (and 3 carers; n=24 participants). Key findings were that people with CKD experience an array of barriers and facilitators to achieving their dietary recommendations, and these were reported across five primary themes: 1) Exasperating stagnancy (where people feel patronised by redundant advice, confused and unprepared for dietary change, feel there is an inevitability of failure, and many barriers to accessing dietetic services); 2) Supporting and sustaining change (where people prefer receiving regular feedback, getting incremental and comprehendible dietary modification, practical guidance on food, receive services with flexibility in monitoring schedule, and valuing peer advice); 3) Fostering ownership (seeking kidney diet information, enacting behaviour change, making reminders, and tracking progress against targets); 4) Motivators and positive learning instruction (relying on reassurance, positive reinforcement, wanting clinicians to focus on allowable foods, and involving their family); 5)Threats and ambiguities of risk (where people view sugar as the culprit in their diet, experience ubiquity of salt, difficulty with illegible food labelling, wanting to avoid processed foods, and questioning credibility of sources where appropriate). Participants were open to using telehealth to support their dietary recommendations, with each of the five themes having important sub-themes related to using telehealth for dietary self-management.
The collective results of the narrative review, two systematic reviews, as well as the qualitative study were used to inform the development of a telehealth-delivered dietary intervention specific for people with CKD. The telephone and mobile phone were identified as the best delivery methods, as participants in the qualitative study were most comfortable using these telehealth modalities. The delivery schedule was decided to be fortnightly with weekly text messages to ensure contact and feedback was regular, and the diet advice was not restriction focused, but was comprehensive and delivered in steps across each phone call.
Eighty participants were recruited for the ENTICE-CKD pilot trial. The intervention was shown to be feasible and acceptable by participants. The trial had good retention with 93% and 98% remaining in the intervention and control groups for the six-month study duration, respectively. The intervention was successfully delivered to protocol, and 96% of all planned intervention calls were completed. All (100%) participants in the intervention group viewed the tailored text messages as acceptable in supporting their dietary change, compared to 27 participants (69%) in the non-tailored education-only text messages (control) group. At three months, participants in the intervention group improved the proportion of calories from the core (non-discretionary) food groups (5.2%, 95% CI 0.6 to 9.9) that they consumed, increased vegetable intake (1.4 serves, 95% CI 0.6 to 2.1] per day), increased dietary fibre intake (5.5 grams, 95% CI 2.7 to 8.2] per day), and reduced body weight (-1.7kg, 95% CI -3.1 to -0.3]) compared to the control group. At six months, only the proportion of calories from core (non-discretionary) foods consumed by participants remained significant (4.3%, 95% CI 0.3 to 8.2]) compared to the control group. No adverse events related to the intervention were reported throughout the study.
Conclusion: The research conducted as part of this thesis shows that a telehealth-delivered intervention to improve diet quality may be feasible, acceptable, safe and effective for stage 3-4 CKD dietary self-management. This research addresses important gaps in the literature, can be used to inform public policy about the use of telehealth in chronic disease management. A large-scale randomised controlled trial to determine the effectiveness of the ENTICE-CKD program on patient-centred quality of life, and renal and cardiovascular outcomes is now needed.
|Date of Award||13 Oct 2018|
|Supervisor||Katrina Campbell (Supervisor), Dianne Reidlinger (Supervisor) & Tammy Hoffmann (Supervisor)|