Text Messaging Improves Dietary Intake in Dialysis Patients

Pam Harrison

June 16, 2020

Text messages that remind dialysis patients about healthy eating habits improve adherence to dietary recommendations and lower the burden of phosphate binder therapy, the KIDNEYTEXT study indicates.

"Dietary management for people receiving hemodialysis is an important component of treatment, and we know that people on dialysis receive tangible and symptomatic benefits from following dietary recommendations," said Jessica Dawson, a PhD candidate at the University of Sydney Westmead Clinical School in Australia.

Results showed that sending text messages to patients is "feasible and acceptable," she said during her presentation at the virtual European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) 57th Congress.

And the improvements seen in clinical parameters, such as fluid management, "justify a larger trial to confirm our results," she added.

KIDNEYTEXT Trial

For their randomized controlled trial, Dawson and her colleagues assessed patients from six dialysis units in Sydney.

All 130 participants received standard dietary care. The 87 patients in the intervention group also received three semitailored, text messages delivered each week for 6 months. The other 43 served as the control group.

"Messages were one-directional, in that no response was required from participants," Dawson explained. They "included advice and reminders regarding potassium, phosphorus, sodium, and fluid intake, along with general healthy eating and lifestyle messages," such as:

  • Phosphate is added to prepackaged foods. Choose fresh foods to reduce how much phosphate you eat.

  • Know what is in your foods! Look for foods that contain less than 400 mg per 100 g of sodium.

  • Try including pasta, rice, and sweet potato 3–4 times a week in place of regular potato as they are lower in potassium.

The primary outcomes of the study were feasibility of the intervention, retention rate, the acceptability of text messaging to dialysis patients, and patient adherence to renal dietary recommendations, defined as meeting at least three of four renal dietary recommendations for potassium, phosphorus, sodium, and protein intake.

The study was completed by 115 of the 130 participants (88%). Two patients in each group asked to be removed.

Adherence to at least three dietary guidelines increased from 34% at baseline to 45% at 6 months in the text group. In the control group, adherence decreased from 46% at baseline to 41% at 6 months.

Changes in protein, potassium, phosphorous, and sodium intake during the study period were greater in the text group than in the control group.

Intake Change From Baseline to 6 Months
Intake per Day Text Group Control Group P Value
Protein (g/kg of body weight) –0.17 –0.1 .024
Potassium intake (mmol) –8 +1 .01
Phosphorous (mg) –197 +97 .003
Sodium (mg) –400 –119 .031

Importantly, the burden of phosphate binder therapy fell from 4.2 to 3.5 pills in the text group, whereas in the control group, that burden rose from 3.0 to 3.6 pills (–0.7 vs +0.6).

And the proportion of patients who met interdialytic weight-gain guidelines increased from 74% to 89% in the text group, but decreased from 77% to 63% in the control group (+15% vs –14%; P = .005).

The proportion of patients who met the serum potassium and phosphate guidelines was similar in the two groups.

Semistructured interviews confirmed that the text intervention was highly acceptable. Participants indicated that it helped "keep them on track," that the messages were "informative and simple," and that three messages per week was "just right."

Older patients managed the text messages as well as younger patients did. "Everyone who signed up used mobile phones regularly or they had a family member who could help them with the text messaging," Dawson said.

"So family might have been quite involved in the text messaging as well, but it was seen as an easy intervention and we had no technical problems," she noted.

DIET-HD Study

The need to improve adherence to dietary guidelines in dialysis patients was underscored by results from the DIET-HD study, which were presented at the ERA–EDTA congress by Valeria Saglimbene, MScMed, from the School of Public Health at the University of Sydney.

She and her colleagues assessed 6906 hemodialysis patients from 10 European countries using the Global Allergy and Asthma European Network (GA2LEN) food frequency questionnaire. They used estimated dietary intakes to evaluate adherence to nutritional recommendations of the European Best Practice Guidelines.

Although adherence to recommended-intake guidelines varied in the participating countries, it was low everywhere for all variables measured. "Only 1% of patients adhered to all six recommendations at the same time," the investigators report in their abstract.

DIET-HD Participants Meeting the Recommended Targets
Nutrient Recommended Daily Intake %
Phosphorous <1000 mg 25
Potassium <2730 mg 28
Energy >30 kcal/kg 45
Calcium <800 mg 53
Sodium <2300 mg 85
Protein 1.1 g/kg 67

Any attempt to improve protein intake in maintenance dialysis patients is worth it, said Denis Fouque, MD, professor of nephrology at University Claude Bernard in Lyon, France.

Up to 60% of patients have some degree of protein-energy wasting, a state of decreased body protein and fat mass and strong predictor of mortality in maintenance hemodialysis patients, he told Medscape Medical News.

"Some patients can also have anorexia, which may be improved by reminding them by text message to eat differently," he added.

Because "the effects of text messages were clear and significant in this study, a larger randomized trial now needs to be performed," Fouque said.

Dawson and Saglimbene have disclosed no relevant financial relationships. Fouque reports being a speaker for and receiving travel grants from Fresenius Kabi.

European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) 57th Congress: Abstracts MO027 and MO003. Presented June 8, 2020.

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