Impact of Dietary Counseling on Nutritional requirements and Mitigating Noncompliance behavior in Hemodialysis Patients: A Pilot Study

Introduction Hemodialysis is the most sought-after treatment modality in patients with end-stage renal disease. The success of hemodialysis depends on the patient ’ s adherence to diet and ﬂ uid restrictions to a great extent. Nutritional health is a critical consideration, especially for hemodialysis patients. Nutritional education and counseling for renal disease patients signi ﬁ cantly preserve renal function and overall well-being. Methods Quantitative research approach with a quasi-experimental crossover design to determine the effectiveness of dietary counseling on the nutritional requirement and noncompliance behavior of patients undergoing hemodialysis conducted at Mangala Kidney Hospital, Mangalore, Karnataka, India. Results The mean age among the participants was 46.07 þ 9.67 years. Nearly half of the subjects, 11 (39.29%), had undergone dialysis for 1 to 5 years. Twenty-six (96.3%) had noncompliance behavior toward diet and ﬂ uid. Based on biochemical parameters, 20 (74.07%) were classi ﬁ ed as low-risk noncompliance and 7 (25.92%) high-risk noncompliance behavior. A paired t -test showed that there is a signi ﬁ cant difference in knowledge of nutritional requirements, t (26) ¼ 6.30, p (cid:2) 0.001 at 5% level of signi ﬁ cance, and noncompliance among the participants before and after the dietary counseling program as t (26) ¼ – 5.41, p (cid:2) 0.001 at 5% level of signi ﬁ cance. Conclusion Implementing nurse-led counseling for hemodialysis patients can improve biochemical parameters and enhance understanding of dietary and ﬂ uid restrictions, positively impacting laboratory indicators


Introduction
Nutritional health is one of the most critical considerations among patients with chronic kidney disease, especially those undergoing hemodialysis.Nutritional education and counseling for renal disease patients significantly preserve renal function and overall well-being.In preparation for renal replacement therapy, a consultation with the renal nutritionist or a nurse to establish a diet consistent with the current diagnosis may increase the likelihood of reducing cardiovascular risk factors, preventing malnutrition anemia, and slowing the progression of renal disease, all of which can contribute to positive patient outcomes.Nutrition tips are another effective way of providing a practical nutrition education message in a simple format. 1 Nursing intervention has been progressively identified as increasingly important in improving patients' compliance with dialysis.Such interventions, including education, training, and behavioral introduction, help patients learn about dialysis and develop healthy life habits, further improving their compliance with this treatment.The most commonly reported indicators for assessing compliance include serum phosphorus level and interdialytic weight gain (IDWG).In contrast, in some studies, compliance has been directly evaluated, and the compliance rate has been reported.Nephrology nurses can lead the way to implement numerous proactive interventions before, during, and after hospitalization of patients on hemodialysis.Nurses often have more contact with patients than other clinical personnel and are in an ideal position to optimize assessment, management, and monitoring of clinical issues likely to affect patients on dialysis, including malnutrition status.Nurses are encouraged to apply the principles of successful nursing models to develop site-specific practices and processes to improve the quality of care before, during, and after hospitalization of patients on dialysis.Moreover, the role of nurses in the nutritional screening and counseling of these patients has been shown to have positive impacts.

Study Design and Participants
The investigator adopted a quantitative research approach with a quasi-experimental crossover design to determine the effect of dietary counseling on the noncompliance behavior of patients undergoing hemodialysis at a private hospital specialized in kidney diseases at Mangalore, Karnataka, India.Twenty-seven participants between 18 and 60 years who fulfilled the inclusion criteria participated in the study.Patients with multiple organ failure, critically ill patients, unconscious patients, patients not interested in the counseling program, patients with human immunodeficiency virus or hepatitis, and patients preparing for kidney transplantation were excluded from the study.

Data Collection Instruments
Data was collected using the sociodemographic pro forma.Self-reported checklist on assessing noncompliance behavior among dialysis patients and self-reported checklist on nutrition status (24-hour recall) was administered.The selfreported checklist on the assessing compliance behavior scale was used to allow the samples into two study groups: compliance and noncompliance.Based on biological parameters, the noncompliance group is subdivided into control and experimental groups based on criteria prepared by the clinician and reviews.The checklist consisted of four items related to drug, diet, treatment, and fluid.It included biochemical parameters like hemoglobin, serum potassium, serum phosphorus, and IDWG.

Data Collection Procedure
Before the data collection, formal written permission was obtained from the concerned authorities.An informed written consent and participant information sheet were administered to the participants.
The study was conducted in three phases.
First phase: The treatment regimen was explored for each patient using a self-rating rating scale for compliance and noncompliance based on their noncompliance scores.Qualified participants were randomly categorized into control groups and experimental groups according to the criteria and biochemical parameters.
Second phase: Once the participants were allotted to the study group, their demographic pro forma and noncompliance behavior were collected.Twenty-four-hour dietary recall was assessed on the first selection day.After the preintervention assessment, the high-risk noncompliance participants were subjected to nurse-led dietary counseling for 20 to 30 minutes (form of video, demonstration, pamphlet on dietary guidelines, individualized dietary plan, and PowerPoint presentation) thrice a week for 1 week.Reinforcement sessions were provided if needed during their follow-up visits to the center.
Third phase: As it was a crossover design, the low-risk noncompliance participants were administered the nurse-led dietary counseling.The high-risk noncompliance group became the control group.The same intervention and assessments were performed for the low-risk noncompliance group.

Distribution of Sample Characteristics
The distribution of the subjects is based on their demographic variables.Most patients, 10 (35.71%), were in the age group of 51 to 60 years, and the mean age was 46.07 AE 9.67.Among the subjects, 16 (57.14%)were males, the majority of the samples 23 (82.14%) were married, 12 (42.86%) of them had high school education (10th standard), 5 (17.86%) were unemployed, and 11 (39.29%) had a monthly income of 5,001 to 10,000.Nearly half of the subjects, 11 (39.29%), had undergone dialysis for 1 to 5 years, and most of them 12 (42.86%)were diabetic.

Assessment of Noncompliance Behavior among Patients Undergoing Hemodialysis
The data were analyzed using frequency and percentage.The findings reveal that 27 (96.3%)exhibited noncompliant behavior, whereas only a minimal rate, 1 (3.7%), adhered to the compliance criteria.Based on biochemical parameters and according to predefined, clinician-reviewed criteria, the noncompliant group was further categorized into control (low-risk noncompliance) and experimental groups (highrisk noncompliance).Among dialysis patients, 20 (74.07%) were classified in the control group, while 7 (25.92%)were in the experimental group (►Table 1).
Journal of Health and Allied Sciences NU © 2024.The Author(s).

Impact of Dietary Counseling on Nutritional Requirements in Hemodialysis Patients Fernandes, Dsilva
The result shows that most participants are in good compliance (n ¼ 22, 81.5%) with the drugs and treatment (n ¼ 23, 85.2%).On the other hand, all the participants (n ¼ 27, 100%) showed noncompliance to fluid intake and 96.6% noncompliance to diet (►Table 2).
Among the participants, most demonstrated low-risk noncompliance (control group) for almost all biological parameters, including IDWG at 80%, serum phosphorous at 93%, and serum potassium at 100%, except hemoglobin levels.Specifically, 63% of the participants exhibited highrisk noncompliance (experiment group) in maintaining hemoglobin levels (►Table 3).

Effectiveness of Nurse-Led Dietary Counseling on Nutritional Status among Hemodialysis Patients
H 1 : There will be a significant difference between the nutritional status among hemodialysis patients before and after the dietary counseling program.
A paired t-test showed that there is a significant difference in nutritional status among the participants before and after the dietary counseling program as t (26) ¼ -6.30, p 0.001 at 5% level of significance.There was a notable (14.91%) improvement in the average caloric intake score (mean difference 5.22) following the nurse-led counseling.Hence, the research hypothesis (H 1 ) is accepted at 5% level of significance (►Table 4).The table depicts that Fisher's exact test was used to compute the association, and all the p-values of Fisher's exact for the demographic variables were > 0.05 except for the cause for kidney failure (p ¼ 0.003) and duration of the disease (p ¼ 0.046).It indicates a significant association between causes of disease and duration of illness at 5% significance level.Hence, the research hypothesis (H 3 ) is accepted for those two variables at 5% significance level (►Table 6).

Association of Noncompliance, Selected Demographic Variables
To conclude, ►Table 6 depicted that compliance behavior was significantly associated with selected demographic variables.Hence, the research hypothesis (H 3 ) is accepted for compliance behavior with demographic variables.The null hypothesis is accepted for the level of knowledge with demographic variables at a 5% level of significance.

H 3 :
Noncompliance will have a significant association with selected demographic variables.

Table 3
Level of noncompliance among hemodialysis patients based on biological parameters (n ¼ 27)

Table 1
Frequency and percentage distribution of noncompliance behavior among patients undergoing hemodialysis (n ¼ 28)

Table 4
Effectiveness of nurse-led dietary counseling on nutritional status among hemodialysis patients before and after the intervention (n ¼ 27) Impact of Dietary Counseling on Nutritional Requirements in Hemodialysis Patients Fernandes, Dsilva Abbreviations: MD, mean difference; SD, standard deviation.Ã refers to level of significance.Journal of Health and Allied Sciences NU © 2024.The Author(s).

Table 5
Effectiveness of nurse-led dietary counseling on noncompliance among hemodialysis patients (n ¼ 27)

Table 6
Association of noncompliance with selected demographic variables (n ¼ 28)