EFFECT OF NUTRITION EDUCATION PROGRAM ON HEALTH STATUS OF HEMODIALYSIS PATIENTS IN MAKKAH AREA

Doaa R. Negm 1 , Enad A. Al-Qurashi 2 , Muhammad A. Alghamdi 2 , Musaab A. Ali 2 , Mohammed M. Alshareef 2 , Faris T. Alsaedi 2 , Ghadeer S. Dairi 1 and Shahd A. Alhelaly 1 . 1. Clinical Nutrition department, Faculty of Applied Medical Sciences, Umm al Qura University, Makkah, Saudi Arabia. 2. Faculty of Medicine and Surgery, Umm Al QuraUniversity, Makkah. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 4 (12), 2277-2283 2278 involves being connected to a dialysis machine for about four hours at a time, three times per week. Dialysis is accompanied by demanding dietary and fluid intake restrictions, fatigue, and other symptoms that may limit one's activities (2) .
The incidence and prevalence of ESKD has been rapidly increasing among the Saudi population in the last three decades (3) . There is a growing prevalence of ESKD in all regions of Saudi Arabia, yetthe prevalence is higher in the Western region of Saudi Arabia when compared to the other regions (4,5,6) . It is well known that the Western region of Saudi Arabia is a multicultural area with various ethnicities (because of pilgrims to Mecca) who have settled there (7,8) . Since ethnic and genetic factors are responsible for certain renal diseases.These factors may play a role in the increased prevalence of ESKD in the Western region of Saudi Arabia (9,10) .
In ESRD patients, the diet adherence can influence the serum levels of calcium and phosphorus thus affecting the morbidity and mortality risk in these patients causing ESRD bone disorders (11,12) . Thus it should be a priority for the physician to keep the levels of these minerals under control. Physicians use calcium-based phosphorus binders to treat both low calcium and high phosphorus levels to keep the phosphate and calcium levels intact along with Dietary restriction, which is considered an underrated measure of controlling mineral serum levels such as phosphate blood levels (13) . Despite all these efforts, controlling the serum levels of these minerals is not an easy task and more often than not, the dietary knowledge and compliance plays a key role in controlling them. For example, it has been found that hyperkalemia is found in 41.2% pre-dialysis, 6.5% post-dialysis and 66.9% before the next session of dialysis (14) .

Subjects and methods:-
Subjects:-Study was conducted on 80 patient of King Faisal Hospitaland Al Noor Specialist hospital in Makkah. All cases had clinical and laboratory evidence of chronic renal disease.

Methods:-Study design:
This study was divided into two phases; pre and post-nutrition education program. In pre-nutrition education phase structured questionnaire was introduced to identify the nutrition status of hemodialysis patient and thus clarify priorities of the education program. The post-education phase involved the introduction of education program to assess its effect on renal disease and anthropometric measurement as well as behavior of hemodialysis patients.
Data collection:-Preeducation program: -The data were collected during the period of dialysis by direct interview. The questionnaire was completed by the researchers.
Education method: -Interview, brochures and posters.
The Post -education program: -The same questionnaire was administered two month after the education took place.
The study questionnaire: -The questionnaire covering three sections as follows: Section one: Socio-demographic data include: -sex, age, education level, and medical information.
Section two: Biochemical assessment: -Creatinine, Ca, K, ph, Na and PTH collected from the patient file.
Section three nutrition assessment:-Anthropometric measurement: In this study height, weight and body mass index (BMI) were measured for the patients. Dietary assessment: It is a major part of nutritional assessment and plays an essential role in any efficient health care system. The researchers applied the following methods to assess the type and quantity of food intake of sample.
Food record: -The patient recorded their food intakes during 3 consecutive days. The patients were asked to give a detailed description of the food eaten, if possible to give brand name and to estimate the amount using natural measures (e.g. pieces, slices, etc.) orhousehold measure (e.g. spoon, cup, etc.) (15) .
Food analysis: -Daily nutrient intake was obtained for three different days and nutritional values of consumed food were calculated using the computer program software for United States Department of Agriculture USDA (16) .
Statistical analysis: -All results were tabled with SPSS software 20 th edition using T test and frequency. Results were reported as mean ±SD.

Results:-
Demographic, social and economic data of the 80 th hemodialysis patient are listed in table (1). The number of female received hemodialysis was higher than male. The number of secondary education was the lowest followed by university education level. Concerning to income level, the patients have ≤ 3000 SR/month and >5000 SR/month were nearly equal. Effect of nutrition education program on weight and BMI of hemodialysis patients was illustrated in table (2). It is clearly noticed that weight and BMI showed no significant changes after nutrition education program but slightly increased than before Table 2:-Effect of nutrition education program on anthropometric measurements of hemodialysis patients (mean ± S.D).
NS non-significant. NS non-significant **P 0.01 As shown in table (4) the mean value of serum creatinine after nutrition education program was significantly (P<0.05) decreased than before nutrition education program represented (7.09 ± 3.01 mg/dl vs. 9.03 ±3.40 mg/dl). Whereas serum uric acid shows insignificantly change after nutrition education program. It is clearly noticed that serum ALB and T.protein shows insignificantly different after and before nutrition education program.   NS non-significant.
Table (7) illustrates the effect of nutrition education program on the consumption of CHO, protein (from animal and plant sources) and fat (from animal and plant sources) of hemodialysis patients. According to food analysis, the mean values of CHO, fat animal and fat plant intake after nutrition education program were (366.70 ±22.69gm/day), (35.58 ± 7.03 gm/day) and (30.54 ±7.51gm/day) respectively, which were insignificantly different than the same values before education. Concerning protein intake from plantsource the mean value after nutrition education program was significantly (P <0.05) lower than protein intake from plant source before nutrition education program represented (33.42 ±5.75gm/day vs. 38.38 ± 8.12gm/day), whereas the protein intake from animal source was significantly (P<0.05) increased after nutrition education program than before represented (36.62±7.27gm/day vs. 32±6.57gm/day).

Discussion:-
Our results revealed that, hemodialysis patients were in a desirable weight as a categories of BMI and changes in weight and BMI after nutrition education program were insignificant, these results agree with Bossola et al., ( 2006) (17) and Carreroet al.,( 2008 ) (18) they found that (4%) HD patients presented BMI values below 18.5 kg/m 2 , twenty-four (48%) presented normal values for BMI, (38%) were overweight and (10%) were obese. Anthropometric measurements are regarded as important indicators of an individual's nutritional status. Anthropometry is a convenient and reliable technique whereby changes in the status of nutrition can be evaluated easily (19) .

Parameter
Before education After education T. calculate T.  (20) reported that high serum potassium level, may cause severe and fatal complications such as cardiac arrest. National Kidney Disease Education Program, ( 2009 ) (21) reported that one of the most important steps for patients with CKD is to control blood pressure by reducing sodium intake blood pressure control reduces the level of protein urea and lowers the risk of developing cardiovascular disease.
The level of serum creatinine was higher than normal individual while serum ALB was lower than normal individual these results agree with Rambodet al., (2008) (22) .
Levels of serum PTH and Ph were slightly decreased after nutrition education program and there is a positive relationship between them as reported by Melamedet al., (2008) (23) they found that chronic kidney disease (CKD) patients may develop secondary hyperparathyroidism with rising PTH levels, when the glomerular filtration rate (GFR) falls below 60 mL/min/1.73 m 2 (CKD stage 3) , mechanistically triggered by the accumulation of phosphate, and involving a feedback loop between PTH and fibroblast growth factor (FGF) (23) .
Blood RBC and HBG of hemodialysis patients were significantly increased after nutrition education program these results similar with that found by Luciana et al., (2012) (24) .
Hemodialysis patients should regard their intake of minerals and make efforts to reduce Na, K and Ph intake. The obtained data shows that the consumption of Na, Ph and K were significantly (P <0.01) decreased after nutrition education program.Blumenkrantz, (1994) (20) reported that hemodialysis patients usually must restrict their daily potassium intake to 50-75 mEq/day (2-3 g/day) and phosphorus intake needs to be restricted to 0.6-1.2 g/day .The reduction on Na, Ph and K consumption after nutrition education program due to help patients to improve adherence to suitable diet and food items, these results agree with Coplan et al., ( 2008 ) (25) they reported that the dietetic regime is restrictive (low in salt, phosphorus, potassium and fluid) .

Conclusion:-
The present study suggested that intervention using nutrition education program improving knowledge and skills of the HD patients toward their disease and dietary management to improve their nutritional status.

Recommendations:-
 Using motivational interviewing techniques that tailor advice based on patients' status and laboratory results.  Nutritional monitoring and intervention improves creatinen, phosphor, PTH, sodium and potassium on HD patient.  Make other study emphasis on physical activity to reduce weakness, stiffness, muscle wasting, and negative nitrogen balance on HD patient.

Limitations:-
The limitation in this study may be related to the small sample size.