“to eat” or “not to eat” at treatment

Debbie Benner, MA, RDN, CSR

“To EAT” or “NOT to EAT”

At Treatment

June 2016

2

Illinois Connection

• Ginny Pletzke

• Karen Graham

EAT Co-authors:

• Brandon Kistler

• Kenneth Wilund

Univ of Illinois, Champaign

3

Objectives

Participants will be able to:

describe the range of practice with EAT (eating at treatment)

state 3 common concerns

state 3 potential benefits

discuss methods to proactively address common concerns

describe how eating at treatment relates to integrated

kidney care

4

EAT and ONS

1980’s Dialysis and EAT

2010 - DANSE (DaVita Assessment Nutritional

Supplement Evaluation)– Albumin not significantly

improved

2014 – analysis demonstrated ONS provided per tx

is associated with markedly and significantly better

survival and missed treatment rates

These data argue persuasively for administration of

ONS to hypo-albuminemic dialysis patients

5

Publications: Positive Impact of ONS

Caglar K, Fedje L, Dimmitt R, Hakim RM, Shyr Y, Ikizler TA: Therapeutic effects

of oral nutritional supplementation during hemodialysis. Kidney Int 62: 1054-

1059, 2002

Tomayko EJ, Kistler BM, Fitschen PJ, Wilund KR: Intradialytic Protein

Supplementation Reduces Inflammation and Improves Physical Function in

Maintenance Hemodialysis Patients. J Ren Nutr 25: 276-283, 2015

Scott MK, Shah NA, Vilay AM, Thomas J, Kraus MA, Mueller BA: Effects of

Peridialytic Oral Supplements on Nutritional Status and Quality of Life in Chronic

Hemodialysis Patients. J Ren Nutr, 19: 145-152, 2009

Weiner DE, Tighiouart H, Ladik V, Meyer KB, Zager PG, Johnson DS: Oral

Intradialytic Nutritional Supplement Use and Mortality in Hemodialysis Patients.

Am J Kidney Dis 63: 276-285, 2014.

Lacson E, Jr., Wang W, Zebrowski B, Wingard R, Hakim RM: Outcomes

associated with intradialytic oral nutritional supplements in patients undergoing

maintenance hemodialysis: a quality improvement report. Am J Kidney Dis, 60:

591-600, 2012

6

ONS during tx has shown to positively impact

mortality and morbidity

Yet, EAT (eating at treatment) remains a

controversial topic

Question to consider: Does the more restrictive

practices in US contribute to poorer nutritional

status and elevated mortality compared with some

other parts of the world?

Little published related to in–center food practices

2016

7

DOPPS data

8

2011 and 2014

We sought to understand the variation of practice

within our own company

There is no corporate policy

Facility Governing Body determines what is

allowed, not allowed, educated on and ignored…

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Methods

In 2011, we surveyed RD’s regarding clinic

practices and clinician (RD, FA, & MD) opinions

related to in–center food consumption within our

LDO

After the initial survey, we provided clinicians with

educational materials about EAT (eating at

treatment)

In 2014, we performed a follow-up survey and

analyzed differences in practices and opinions

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Results

2011

28% (343 of 1199 clinics) did not allow eating

during tx

18% (222 clinics) did not allow drinking during tx

2% (19 clinics) did not allow eating at the facility

before or after tx

2014

22.6% (321 of 1422 clinics) did not allow eating

during tx

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Not allowed and does not occurNot allowed but does occurNo policyAllowed but not encouragedAllowed and encouraged

Pe

rcen

t

0

10

20

30

40

50

60

2011

2014

Comparison of 2011 vs 2014 clinic practices

for eating at treatment

Not allowed

and does

not occur

Not allowed

but does

occur

No

policy

Allowed but

not

encouraged

Allowed and

encouraged

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Why the shift?

Of the 178 (6.8%) clinics reporting eating was

“more allowed” in 2014, the main reason given was

an increased focus on nutritional status

Among clinicians, a higher percent encouraged

eating during treatment (53.1% vs 37.4%; P,0.05),

and FA and MD’s were less concerned about the

seven reasons commonly cited for restricting eating

at tx in 2014 versus 2011 (P,0.05 for all).

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Clinicians Opinions on EAT

Position Year N

Strongly

Discourage

N (%)

Discourage

N (%)

No Opinion

N (%)

Encourage

N (%)

Strongly

Encourage

N (%)

RD’s

2011 1,192275

(23.1)

264

(22.1)

95

(8.0)

446

(37.4)

112

(9.4)

2014 1,408163

(11.6)

204

(14.5)

97

(6.9)

607

(43.1)

337

(23.9)

FA’s

2011 1,003316

(31.5)

238

(23.7)

131

(13.1)

250

(24.9)

68

(6.8)

2014 1,238312

(25.2)

238

(19.2)

126

(10.2)

409

(33.0)

153

(12.4)

MD’s

2011 828255

(30.8)

159

(19.2)

158

(19.1)

209

(25.2)

47

(5.7)

2014 978235

(24.0)

156

(16.0)

169

(17.3)

293

(30.0)

125

(12.8)

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Reasons Given for Non-Support of EAT

Position Year N

Facility

Policy

N (%)

Infection

Control

N (%)

Hypotension

N (%)

Choking

N (%)

GI

Distress

N (%)

Reduce

d Kt/V

N (%)

Spills/

Pests

N (%)

RD’s

2011 539174

(32.3)

383

(71.1)

363

(67.3)

436

(80.1)

402

(74.6)

55

(10.2)

339

(62.9)

2014 367114

(31.1)

268

(73.0)

253

(68.9)

275

(74.9)

263

(71.1)

48

(13.1)

206

(56.1)

FA’s

2011 554209

(37.7)

398

(71.8)

390

(70.4)

415

(74.9)

338

(61.0)

107

(19.3)

343

(61.9)

2014 550149

(27.1)

368

(66.9)

358

(65.1)

382

(69.5)

300

(54.5)

77

(15.4)

290

(52.7)

MD’s

2011 414162

(39.1)

259

(62.6)

305

(73.7)

302

(72.9)

246

(59.4)

81

(19.6)

212

(51.2)

2014 391

95

(24.3)

180

(46.0)

243

(62.1)

220

(66.3)

171

(43.7)

48

(12.3)

134

(34.3)

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Reasons Given by RD’s that Support EAT

Position Year nMeeting Caloric

Needs

N (%)

Blood

Glucose

N (%)

Difficulty

Enforcing Policy

N (%)

Teaching

Opportunity

N (%)

RD’s

2011 554423

(76.4)

489

(88.3)

226

(40.8)

410

(74.0)

2014 944784

(83.1)

756

(80.1)

323

(34.2)

668

(70.8)

Top Reasons:

• Meeting caloric needs

• Blood Glucose

• Teaching Opportunity

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Survey Conclusions

Practices and clinician opinions are shifting toward

allowing patients to eat.

We found that 28.6% (2011) and 22.6% (2014) of

clinics within the US restricted eating during

treatment, a rate more than double that found in an

international cohort.

What are practices internationally?

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2014 Germany….

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Internationally

• We developed an 11-item survey

• Surveys were distributed to attendees during the

2014 International Society of Renal Nutrition and

Metabolism Conference in Wurzburg, Germany

• Data were analyzed and partial responses were

included in the analysis

19

0

5

10

15

20

25

30

35

40

45

Africa Asia Australia Europe NorthAmerica

SouthAmerica

Distribution of 73 Respondents by Continent

Continent Number (%)

Africa 3 (4.1)

Asia 7 (9.6)

Australia 5 (6.8)

Europe 39 (53.4)

North America 9 (12.3)

South America 10 (13.7)

Position Number (%)

Dietitian 52 (71.2)

Nephrologist 19 (26.0)

Other

(Researcher)

2 (2.7)

Practice Type Number (%)

Hospital 46 (63.0)

Outpatient 33 (45.2)

Research 12 (16.4)

73

Survey Respondents

21

05

101520253035404550

Policies regarding eating during

hemodialysis

22

Does your facility provide

food?

0

10

20

30

40

50

60

Yes No

Does your facility

provide supplements?

0

10

20

30

40

50

60

Yes No

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Reasons Given to Allow/Provide EAT

Yes No

Additional Energy 55 (88.7%) 7 (11.3%)

Blood Glucose

Control20 (32.3%) 42 (67.7%)

Teaching

Opportunities29 (46.8%) 33 (53.2%)

Difficulty

Enforcing No

Eating Policy

10 (16.1%) 52 (83.9%)

Never Rarely Sometimes Often

Postprandial Hypotension (n=53) 18 (34.0%) 15 (28.3%) 18 (34.0%) 2 (3.8%)

Gastrointestinal Symptoms (n=52) 14 (26.9%) 23 (44.2%) 15 (28.8%) 0 (0.0%)

Treatment Efficiency

(n=45)42 (93.3%) 2 (4.4%) 1 (2.2%) 0 (0.0%)

Spills or Pests

(n=46)31 (67.4%) 7 (15.2%) 5 (10.9%) 3 (6.5%)

Choking

(n=46)39 (84.8%) 6 (13.0%) 1 (2.2%) 0 (0.0%)

Infection Control Issues (n=46) 42 (91.3%) 2 (4.3%) 2 (4.3%) 0 (0.0%)

Clinician Experience with Six Commonly Cited

Reasons to Not Allow Eating At Treatment

25

If facility allows eating…do you agree with this

policy

0

10

20

30

40

50

60

Yes No

26

Percent of clinics that provide food by continent

0

10

20

30

40

50

60

70

80

90

100

Africa Asia Australia Europe N.A. S.A.

27

Percent of clinics that provide supplements by

continent

0

10

20

30

40

50

60

70

80

90

100

Africa Asia Australia Europe N.A. S.A.

28

EAT Guidelines

Knowing Patients are Eating at Treatment we

developed and have available tips and guidelines

which include:

Teammate EAT Education Tips

Patient EAT Guidelines – Practical Aspects

Tips/ Suggested Snacks to Bring

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EAT – Eating At Treatment Guidelines

For practical reasons, you should bring food that

does not need to be heated at the center

does not have a strong odor or leave a mess

can be eaten with one hand / does not require help

to open or eat

will not make you thirsty

Remember to take your phosphate binders when you

eat during or after dialysis.

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Foods eaten during dialysis should be kidney-

friendly.

Potassium and phosphorus eaten at treatment will

not reach the bloodstream until after dialysis where

it builds up until the next treatment.

Patients who bring food to the clinic should only

bring food that is securely sealed or wrapped to

prevent leakage and does not require refrigeration

or heating at the facility.

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If you have any of these symptoms you can eat

after your treatment instead of during dialysis:

Low blood pressure

Coughing or choking

Diarrhea

Vomiting

Nausea

You should eat in an upright position to decrease

the chance of choking

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Integrated Kidney Care

Prevent Hospitalization

More holistic and preventative care

Food and Eating are Quality of Life Aspects

Well being and nutritional status contribute to better

quality of life and reduced mortality

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Stay Curious…….. My Friend!

“to eat” or “not to eat” at treatment

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