Design and Development of a Dialysis Food Frequency Questionnaire

doi:10.1053/j.jrn.2010.05.013

Journal of Renal Nutrition

Volume 21, Issue 3, May 2011, Pages 257-262

https://doi.org/10.1053/j.jrn.2010.05.013 Get rights and content

Objectives

Periodic assessment of dietary intake across a given dialysis population may help to improve the clinical outcomes related to nutrients such as dietary protein, phosphorus, or potassium. Although dietary recalls and food records are used to assess dietary intake at individual level and over shorter periods, food frequency questionnaires (FFQ) are used to rank subjects of a given population according to their nutrient intake over longer periods.

Design

To modify and refine the conventional Block FFQ to develop a specific FFQ for dialysis patients.

Setting

A total of 8 DaVita outpatient dialysis clinics in Los Angeles area, which participated in the “Nutrition and Inflammation in Dialysis Patients” study.

Patients

The study included 154 patients undergoing maintenance hemodialysis (MHD).

Main Outcome Measure

Dietary intake of participating MHD patients using a 3-day food record, supplemented by a person-to-person dietary interview, to capture food intake over the last hemodialysis treatment day of the week and the 2 subsequent nondialysis days.

Results

Analyses of the food records identified the key contributors to the daily nutrient intake in the 154 participating MHD patients. A “Dialysis-FFQ” was developed to include approximately 100 food items representing the total food intake of 90% of the patients of the “Nutrition and Inflammation in Dialysis Patients” study population. Distinctions were made in several food items on the basis of key nutritional issues, such as protein, phosphorus, and potassium, in dialysis patients.

Conclusions

We have developed a “Dialysis FFQ” to compare and rank dialysis patients according to their diverse nutrient intake. Although the Dialysis-FFQ may be a valuable tool to compare dialysis patients and to identify those who ingest higher or lower amounts of a given nutrient, studies are needed to examine the utility of the Dialysis-FFQ for nutritional assessment of dialysis patients.

Section snippets

Design and Development of the FFQ

One of the original goals of the NIED study⁷ was to design and develop a dialysis patient-specific FFQ in collaboration with Gladys Block, PhD, and the team in NutritionQuest, Berkeley, CA. The task started with developing the appropriate food list followed by the general steps used for all Block questionnaires or dietary screeners.8, 9 In general, detailed 24-hour recall or multiple-day record data are used to identify which foods are the key contributors to the nutrients of interest. For the

Patients

The original NIED Study patient cohort was derived over a period of 5 years from a pool of over 3,000 MHD outpatients in 8 DaVita chronic dialysis clinics in the South Bay Los Angeles area (see the NIED Study website at www.NIEDStudy.org for more details).7, 18, 19 The study included outpatients who were ≥18 years, undergoing MHD treatment for at least 8 weeks, and had signed the Institutional Review Board approved consent form. Participants with acute infections or an anticipated life

Dietary Data Recording and Analyses

The 154 patients undergoing hemodialysis in the NIED substudy provided a 3-day diet diary that included the last hemodialysis treatment day of the week (either Friday or Saturday) and 2 subsequent nondialysis days (Saturday, Sunday, and/or Monday) A trained dietitian from General Clinical Research Center reviewed the diet record data while in personal contact with the patients and conducted a supplementary dietary interview to fill in missing data. Collected dietary data, including oral

The Dialysis-FFQ

The resulting “Dialysis FFQ” is approximately 100 items long, and takes approximately 30 to 40 minutes to complete. Portion size is requested for each food item. Unitary items are requested for their numbers (“How many”).A portion size graphic aids the respondent in portion size assessment for nonunitary items. Portion size is considered important in those undergoing dialysis patients, in relation to controlling liquids, sodium, phosphorus, and potassium intake, as well as for assessing

Validity of Dialysis-FFQ

Predictive validity may be examined to determine whether the results of the FFQ are related to other outcomes of interest such as survival. The earlier Block’s FFQ has been recently tested in the NIED Study and shown to be associated with survival, whereas the higher dietary phosphorus or potassium intake are reported as predictors of increased death risk.5, 6 The exact version of the Dialysis-FFQ presented here has not undergone de novo validation against other forms of dietary assessments in

Conclusions

Dietary evaluation and nutritional management are essential to provide optimal care to the patients with CKD, particularly those undergoing dialysis.. Accurate assessment of dietary intake is also important for outcomes research in patients with CKD including studies related to the putative relationship between food intake and clinical outcomes.² Imposed dietary restrictions are used routinely in dialysis patients, some of which may cause harm rather than help, such as restricting protein

Acknowledgments

The manuscript was supported by Dr. Kalantar-Zadeh’s research grants from the National Institute of Diabetes, Digestive and Kidney Disease of the National Institute of Health (K2361162 and R21 DK078012), a research grant from DaVita Clinical Research, and a philanthropic grant from Mr. Harold Simmons.

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Nutritional epidemiology seeks to understand nutritional determinants of disease in human populations using experimental and observational study designs. Though randomized controlled trials provide the strongest evidence of causality, the expense and difficulty of sustaining adherence to dietary interventions are substantial barriers to investigating dietary determinants of kidney disease. Therefore, nutritional epidemiology commonly employs observational study designs, particularly prospective cohort studies, to investigate long-term associations between dietary exposures and kidney disease. Due to the covarying nature and synergistic effects of dietary components, holistic characterizations of dietary exposures that simultaneously consider patterns of foods and nutrients regularly consumed are generally more relevant to disease etiology than single nutrients or foods. Dietary intakes have traditionally been self-reported and are subject to bias. Statistical methods including energy adjustment and regression calibration can reduce random and systematic measurement errors associated with self-reported diet. Novel approaches that assess diet more objectively are gaining popularity but have not yet fully replaced self-report and require refinement and validation in populations with chronic kidney disease. More accurate and frequent diet assessment in existing and future studies will yield evidence to better personalize dietary recommendations for the prevention and treatment of kidney disease.
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Citation Excerpt :
The Cronbach's standardized alpha calculated with the 85 items was 0.71, which is considered adequate and indicates acceptable internal consistency and reliability among the food items.30 We chose to develop a quantitative FFQ because it allows to estimate potassium intake as per the portion size, what is considered important for the control and the adequacy of nutrient intake of patients on dialysis.15 Although the reference portion was determined by the most frequently reported by the patients, it reflects the dietary behavior of this population and increase the accuracy of the estimative of nutrient intake.10
To develop and to validate a food frequency questionnaire (FFQ) to assess potassium intake of patients on hemodialysis.
This is a cross-sectional study that included 41 patients in the FFQ development step and 53 patients in the FFQ validation step. In the FFQ development step, the patients completed a 3-day food record (used as a reference method). Total potassium intake and potassium from each food item were calculated. Food items that contributed up to 90% of the total potassium intake were considered to be included in the FFQ food list. Then the FFQ was applied in person through the google-forms platform. The result of potassium intake obtained by the FFQ was compared with that obtained by the 3-day food record.
A total of 94 patients were included: 53.2% women; age 55.7 ± 15.0 years; 47.9% had diabetes; body mass index 25.0 ± 4.5 kg/m²; and dialysis vintage 34.5 (17.0-68.2) months. Demographic, clinical, and laboratory parameters did not differ between the development and validation groups. From the 255 registered food items, 85 comprised the FFQ. The standardized Cronbach's alpha obtained was 0.71. No difference was found between the potassium intake obtained by the FFQ and by the 3-day food record (1,438.5 ± 659.4 mg/d vs. 1,464.8 ± 529.4 mg/d; P = .753, respectively) with an intraclass correlation coefficient of 0.66 (P = .001). No systematic bias or proportionality bias between the methods was observed in the Bland-Altman graphical analysis.
The quantitative FFQ presented strong relative validity and may constitute a practical tool in the analysis of potassium intake of patients on hemodialysis.
Dietary inflammatory index and mortality in hemodialysis patients by path analysis approach (NUGE-HD study)
2021, Nutrition
The aim of this study was to evaluate the interrelationships between dietary, nutritional, and inflammatory factors in predicting all-cause mortality among individuals in hemodialysis (HD) treatment.
Participating in this study were 137 patients undergoing HD (58.4% men, 61.7 ± 15.4 y of age) from the NUtrition and GEnetics on HemoDialysis outcomes (NUGE-HD study) cohort. Sociodemographic, anthropometric, and clinical data were collected. Dietary inflammatory index scores were calculated from a quantitative food frequency questionnaire. Plasma C-reactive protein was used as an inflammatory marker. Data were analyzed by path analysis.
During the 2-y follow-up, 27 patients (19.7%) died. Compared with survivors, non-survivors were older (P = 0.01) and had lower body mass index (P = 0.04). In relation to direct (unmediated) associations, dietary inflammatory index (P = 0.049) and C-reactive protein (P = 0.016) were positively associated, whereas body mass index was negatively associated with mortality (P = 0.012). There were no indirect (mediated) associations of the variables evaluated with mortality.
More proinflammatory diet and systemic inflammation have a direct association with mortality among patients undergoing HD therapy. Additionally, more proinflammatory diet is associated with unhealthy dietary pattern.
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Citation Excerpt :
The initial search yielded 2,374 articles, of which 29 were included in this review. Table 1 lists DI studies in MDPs.22-50 Antunes et al.24 studied 79 adult patients on HD and PD with a follow-up period of 38 months.
Protein-energy wasting affects many maintenance dialysis patients (MDPs) and decreases survival. Suboptimal dietary energy intake (DEI) and dietary protein intake (DPI), secondary to reduced dietary intake (DI), are important risk factors in the development of protein-energy wasting. Multiple investigations of DEI and DPI in MDPs have occurred but few authors have synthesized these data. A comprehensive review of DI studies in MDPs was completed with the purpose of providing timely data on DI in MDPs until updated clinical practice guidelines for nutrition in nephrology care are published. A majority of DI investigations in MDPs confirm that DEI and DPI are below current nutrition guidelines. MDPs also have significantly lower DEI and DPI when compared with healthy controls. These findings inform the direction of further guidelines for nutrition in nephrology care as well as spark future research interests.

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: Relevant Potential Conflict of Interest: TB, GB and JN are related to NutritionQuest (Berkeley, CA), which owns and provides Block FFQs including the Dialysis FFQ. Other authors have declared none.

View full text

Original ResearchDesign and Development of a Dialysis Food Frequency Questionnaire

Objectives

Design

Setting

Patients

Main Outcome Measure

Results

Conclusions

Section snippets

Design and Development of the FFQ

Patients

Dietary Data Recording and Analyses

The Dialysis-FFQ

Validity of Dialysis-FFQ

Conclusions

Acknowledgments

Am J Kidney Dis

J Ren Nutr

Am J Kidney Dis

J Ren Nutr

Am J Kidney Dis

Am J Kidney Dis

Am J Clin Nutr

Kidney Int

J Ren Nutr

Am J Clin Nutr

Original Research
Design and Development of a Dialysis Food Frequency Questionnaire