1. Polly Peru Rachelle Sebastian DFM 451 – Community Nutrition Assessment Sarah Josef MA, RD San Francisco State University

2. Overview Introduction Mission, Goals, and Objectives Literature Review Materials and Methods Results Discussion Summary Primary Grant Funders Reference List

3. Introduction One in nine American adults is currently suffering from chronic kidney disease. Chronic kidney disease is the eighth leading cause of death in America and 485,000 Americans have advanced to end stage renal disease (ESRD). Treatments are limited to hemodialysis, peritoneal dialysis and kidney transplantation. The kidneys perform many vital functions in the body which include: filtering toxins out of the body, regulating blood pressure, maintaining acid-base balance, and stimulates the bone marrow to make red blood cells by producing the hormone erythropoietin.

4. Mission, Goals, and Objectives Our mission is to design a hemodialysis nutrition education program- focused on imparting sodium and protein nutrition education for hemodialysis patients at the Pleasanton DaVita Dialysis Clinic in Pleasanton, California.  The first goal is to educate hemodialysis patients about sodium content in foods and to recommend comparable alternatives.  Objective: To instill the ability to decipher food labels to empower patients to identify and determine low-sodium foods and alternatives.  The second goal is to educate hemodialysis patients on the importance of consuming adequate protein and to provide them with healthy protein options.  Objective: To instill the ability to recognize high-quality protein options and portions to avoid protein energy malnutrition (PEM).

5. Literature Review Two major challenges for hemodialysis patients are the restriction of sodium and meeting their individualized protein recommendations. 1. The dietary sodium guideline for dialysis patients is 2000 – 3000 milligrams per day and is individualized based on the patient’s medical history and interdialytic weight gains.  Damaged kidneys cannot eliminate excess sodium and fluid form the body and can result in fluid buildup in extracellular tissues and the bloodstream.  The extra fluid can cause dangerous complications such as increased blood pressure, edema, shortness of breath, and heart failure. 2. The Kidney Disease Outcomes Quality Initiative Clinical Practices Guidelines recommends 1.2 - 1.3 g/Kg body weight per day for hemodialysis patients.  Dialysis treatments remove protein waste and some amino acids from the blood resulting in higher needs of high quality protein.  Protein energy malnutrition (PEM) in dialysis patients is associated with increased morbidity and mortality

6. Materials and Methods Sodium Workshop During the month of March 2014 our team conducted two sodium workshops in the lobby of the Pleasanton DaVita Dialysis Clinic.  A colorful display table of high sodium foods and provided low sodium alternatives.  We provided low and sodium free recipes and offered samples of renal safe low sodium snacks to the patients.

7. Materials and Methods Sodium Workshop Spaghetti sauce

8. Materials and Methods Protein Education Workshop During the month of April 2014 our team conducted two protein education workshops.

9. Materials and Methods Protein Bars Display  We prepared handouts providing ideas of high quality protein choices.  We offered samples of dialysis approved protein bars.

10. Results Based on our pre and post sodium FFQ our team was disappointed to observe that there was less than a 10% difference between the pre and post FFQ data.  Sodium compliance is a continual issue that Renal Dietitians contend with.  The socioeconomic class of the majority of the patients that attend the Pleasanton DaVita Dialysis Clinic range from upper middle class to wealthy.  A large number of the patients do dine out five to six times a week. Ranked In Order of Patient Preference 1. Crunchy Rice Rollers 1 roll=5 milligrams of Sodium 2. Food Should Taste Good Multigrain tortilla chips 1oz (about 10 chips) = 80 milligrams of Sodium, 65 milligrams of Potassium 3. Barefruit Fuji Red Apple Chips 1oz (about ½ cup)=10 milligrams of Sodium 4. Skinny Pop popcorn 28 g (about 4 cups)=50 milligrams of Sodium (1)(2) (4)(3)

11. Results Each month DaVita Dialysis Clinics collect and analyze albumin levels for individual patients and the average for the overall clinic.  Due to time constraints we were unable to collect the overall albumin levels for May 2014 Our poll of the patients indicates that they prefer fruit flavored bars over the chocolate bars. Ranked In Order of Patient Preference 1. Luna Bar – Lemon Zest 9 grams of Protein 2. Zone Bar – Strawberry Yogurt 14 grams of Protein 3. Atkins Bar – Cranberry Almond 14 grams of Protein 4. Atkins Bar – Chocolate Peanut Butter Bar 17 grams of Protein 5. Balance Bar – Chocolate Mint Cookie Crunch 14 grams of Protein (1) (2) (3) (4) (5)

12. Discussion Most of the patients at Pleasanton DaVita Dialysis Clinic were eager to participate, ask questions and sample the low sodium snacks and protein bars. Our team found that the majority of the patients appeared to have a clear understanding of the renal diet, but do not comply with the guidelines of the diet.  A common theme we encountered was that many of the patients justified their non-compliance with the renal diet as compensation for having to endure dialysis three times a week or that the dialysis machine would remove the bad effects of what they consumed. It is very important for the technicians and nurses to have knowledge of the renal diet to help guide their patients in attaining and maintaining their health while on hemodialysis.

13. Summary The need for science based quality hemodialysis nutrition education is evident based on the high prevalence of chronic kidney disease in the United States.  Maintaining the proper balance of nutrients, electrolytes, and other chemicals is crucial for individuals suffering from chronic kidney disease.  Non-compliance to the renal diet guidelines is a major obstacle to maintaining an individual’s quality life while on hemodialysis.  Overcoming this obstacle is not an easy task and requires patience, understanding and a non-judgmental attitude on the part of the nutrition educator. It was our intention to provide nutrition education strategies to the hemodialysis patients of the Pleasanton DaVita Dialysis Clinic that would allow them to maintain their health status while on dialysis by successfully implementing our programs goals and objectives by utilizing our project design and methods as described.

14. DaVita Healthcare and the American Kidney Fund Based on our mission statement and goals, DaVita Healthcare and the American Kidney Fund would be optimal grand funders for our program.  Both organizations are dedicated to improving the lives of individuals diagnosed with kidney disease and living on dialysis.

15. Reference List