CKD: Nutrition Assessment: Dietary Intake (2020)
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
CKD: Considerations when Assessing Dietary Intake
In adults with CKD 3-5D or posttransplantation, it is reasonable to assess factors beyond dietary intake (e.g. medication use, knowledge, beliefs, attitudes, behavior and access to food, depression, cognitive function etc.) to effectively plan nutrition interventions. (OPINION).
CKD: 3-Day Food Records to Assess Dietary Intake
In adults with CKD 3-5D, we suggest the use of a 3-day food record, conducted during both dialysis and non-dialysis treatment days (when applicable), as a preferred method to assess dietary intake (2C).
CKD: Alternative Methods of Assessing Dietary Intake in CKD 3-5
In adults with CKD 3-5 (OPINION), 24-hour food recalls, food frequency questionnaires and normalized protein catabolic rate (nPCR) may be considered as alternative methods of assessing dietary energy and protein intake.
CKD: Alternative Methods of Assessing Dietary Intake in CKD 5D
In adults with CKD 5D (2D), 24-hour food recalls, food frequency questionnaires and normalized protein catabolic rate (nPCR) may be considered as alternative methods of assessing dietary energy and protein intake (2D).
Risks/Harms of Implementing This Recommendation
There are no potential risks or harms associated with these recommendation statements.
Conditions of Application
Despite the food record/diary being the most reliable and valid measure of dietary intake among patients diagnosed with CKD, it does rely on accurate reporting inclusive of portion sizes. The food record may be seen as cumbersome to complete for several days and is limited to individuals that are able to read and record intake reliably. With the generation of smartphone applications, there has been a burgeoning interest in recording dietary intake using technology, with limited success in its adoption among certain subgroups (e.g., elderly). Dietary intake methods may need to be simplified, modified, or be combined with a few strategies in order to obtain reliable dietary intake data, with emphasis on them being culturally appropriate.
- Routine dietary assessment among adults diagnosed with CKD stages 1-5D should occur to allow for the identification and treatment of nutritional concerns related to nutrient intake.
- Assessing dietary intake using multiple, complementary methods, such as FFQ and 24-hr uring collection to measure urine urea nitrogen, sodium and potassium, may be useful to confirm accuracy of dietary intake estimates.
- Dietary assessment should be conducted at the initial visit and completed whenever there is a change in health status or as per institutional or regulatory policies.
Monitoring and Evaluation
A thorough assessment of dietary intake will guide the nutrition intervention prescribed. The clinician should monitor key nutrition care outcomes based on the treatment plan and re-assess and change the plan accordingly to achieve the goals established.
Potential Costs Associated with Application
There are no costs assocaited with implementation of these recommendation statements.
Poor nutritional intake and obesity are prevalent among patients diagnosed with CKD and therefore, it is important to monitor dietary intake that provides information on total energy, macro- and micro-nutrients as well as overall food/liquid servings and eating patterns. In this context, it is important to identify reliable methods for estimating dietary intake in diverse care settings. Under- and over-reporting of intake are a concern in this population.
A total of seven studies reported on use of methods to assess protein and energy intake in CKD subjects (Griffiths et al 1999, Kloppenburg et al 2001, Laxton et al 1991, Avesani et al 2005, Bazanelli et al 2010, Kai et al 2016, Shapiro et al 2015).
Based on the findings of included studies, food records/diary for assessing dietary intake of protein and calories were reliable and correlated with reference standards. Food records can provide accurate information if patients are instructed and trained, and food intake is recorded for at least 7 days (Griffiths et al 1999, Kloppenburg et al 2001, Kai et al 2016). Two studies used food diary/3-day food records to determine underreporting of energy intake in non-dialyzed and PD patients (Avesani et al 2005, Bazanelli et al 2010). Underreporting was noticed in 72.5% of non-dialyzed CKD patients and 52.5% PD patients. Both the studies indicated that underreporting was more pronounced in overweight patients. Shapiro et al 2015 compared energy intake measured by 3-day food record (dietitian interview-assisted) and REE measured by indirect calorimetry. Energy intake reported by interview-assisted food records were lower than measured REE (Shapiro et al 2015).
Food Frequency Questionnaires
Delgado et al conducted a validation study comparing Block Brief 2000 food frequency questionnaire (BFFQ) against 3-day food diary records (Delgado et al 2014) and found BFFQ under-estimated energy and macronutrient intake in patients on hemodialysis. However, the use of simple calibration equations can be used to obtain intake similar to 3-day food diary records.
Protein Catabolic Rate
Three studies examined the use of protein catabolic rate (PCR) to assess protein intake in CKD patients (Laxton et al 1991, Lorenzo et al 1995, Virga et al 1996), and found significant correlations with reference standards for measuring dietary intake (ex: food records). However, PCR overestimated protein intake when daily protein intake was <1 g/kg and when daily protein intake was >1 g/kg it was underestimated by PCR. In PD patients, PNA (PCR) normalized to desirable body weight was correlated better with BUN (r=0.702) and Kt/V (r=0.348) (Virga et al 1996).
Recommendation Strength Rationale
The evidence supporting these recommendations are based on Grade III/Grade C, D and Consensus/expert opinion.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Is there evidence to support the use of food records or 24-hr recall for assessing dietary protein or energy intake in adults with CKD 1-5D and post-transplant?
Is there evidence to support the use of FFQ for assessing protein or energy intake in adults with CKD 1-5D and post-transplant?
Is there evidence to support the use of PNA/PCR for assessing dietary protein intake in adults with CKD 1-5D and post-transplant?
Avesani C, Kamimura M, Draibe S, Cuppari L. Is energy intake underestimated in nondialyzed chronic kidney disease patients?. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2005; 15:159-65
Bazanelli A, Kamimura M, Vasselai P, Draibe S, Cuppari L. Underreporting of energy intake in peritoneal dialysis patients. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2010; 20:263-9
Griffiths A, Russell L, Breslin M, Russell G, Davies S. A comparison of two methods of dietary assessment in peritoneal dialysis patients. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 1999; 9:26-31
Kai H, Doi M, Okada M, Yamada K, Iwabe H, Sito C, Yamagata K. Evaluation of the validity of a novel CKD assessment checklist used in the frontier of renal outcome modifications in Japan study. Journal of Renal Nutrition 2016; 26:334-40
Kloppenburg W, Stegeman C, de Jong P, Huisman R. Anthropometry-based equations overestimate the urea distribution volume in hemodialysis patients. Kidney International 2001; 59:1165-74
Laxton J, Harrison S, Shaw A. Assessment of protein intake in early progressive renal disease. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 1991; 6:17-20
Shapiro B, Bross R, Morrison G, Kalantar-Zadeh K, Kopple J. Self-Reported Interview-Assisted Diet Records Underreport Energy Intake in Maintenance Hemodialysis Patients. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2015; 25:357-63
Delgado C, Ward P, Chertow G, Storer L, Dalrymple L, Block T, Kaysen G, Kornak J, Grimes B, Kutner N, Johansen K. Calibration of the brief food frequency questionnaire among patients on dialysis. Journal of Renal Nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2014; 24:151-156.e1
Lorenzo V, de Bonis E, Rufino M, Hernández D, Rebollo S, Rodríguez A, Torres A. Caloric rather than protein deficiency predominates in stable chronic haemodialysis patients. Nephrology, Dialysis, Transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 1995; 10:1885-9
Teo B, Toh Q, Chan X, Xu H, Li J, Lee E. Assessment of muscle mass and its association with protein intake in a multi-ethnic Asian population: relevance in chronic kidney disease. Asia Pacific Journal of Clinical Nutrition 2014; 23:619-25
Virga G, Viglino G, Gandolfo C, Aloi E, Cavalli P. Normalization of protein equivalent of nitrogen appearance and dialytic adequacy in CAPD. Peritoneal Dialysis International : Journal of the International Society for Peritoneal Dialysis 1996; 16:S185-9