Motivational interviewing is key to success with the renal diet
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When Alexandra Lautenschlaeger, RDN, LD, counsels a patient with end-stage kidney disease who is starting dialysis, she understands the long journey the patient has already logged.
“Patients who are getting started on dialysis have already dealt with the trauma of realizing their kidneys no longer work effectively. They have to deal with a new access. The doctor has told them about the new kidney drugs and binders they need to take,” Lautenschlaeger, a dietitian with Dialysis Clinic Inc., told Healio/Nephrology News & Issues. “They also need to deal with the new burdens this will place on their family.
“What they don’t want to hear from me is more things they can’t do anymore,” especially related to restrictions on foods that many enjoy and are part of their heritage and lifestyle.
For Lautenschlaeger, who is from Spartanburg, South Carolina, that means working with patients who love the rich food of the South.
After meeting resistance to change, she started modifying her handouts to focus on telling patients “what they can eat as opposed to what they can’t eat,” she said. She networks with local food co-ops, the U.S. Department of Agriculture Farm to Families programs and the Hub City Farmers Market’s mobile market in Spartanburg and nearby towns to help patients living in “food deserts” – areas with limited access to healthy foods – obtain fresh fruits and vegetables.
“If I can get access to the foods that will help them eat healthier, and still include foods in the kidney diet they want to eat, it’s a win-win for us and the patient,” she said.
Loss of control
Patients can struggle with “even the idea of changing their diet,” Rory C. Pace, MPH, RD, CSR, FAND, senior director of nutrition services at Satellite Healthcare, told Healio/ Nephrology News & Issues. “I try to frame it as a choice.
“It is important to understand that they may feel a loss of control once they start dialysis. They may feel helpless,” Pace said. “Changing their diet can be the tipping point for them.”
Fluid overload can be one of the most difficult things to control. Pace gives every new patient a plastic bottle with measurements so they can track and manage fluid intake. But sometimes, no matter how much education there is on the harm fluid overload can do, Pace can see when progress stalls. She may then employ a “structured pause,” allowing the patient to take a break, along with the dietitian, on a particular change in the diet.
“It is an opportunity to step away for a while. ‘We have been talking about the harm of fluid overload every month. Let’s just take a break from it,’ I would tell my patients.
“The first time I tried it, I was concerned about the outcome. What if the progress we made disappeared?” Pace said. “But many times, the patient does come back after a month and starts talking about it again.
“That means they are showing they want to regain control over their health.”
Part of the challenge with encouraging patients to look at changes in their diet is early education before kidney failure sets in. Medical Nutrition Therapy (MNT) is a Medicare covered benefit for patients in stages 3 to 5 of chronic kidney disease.
“Less than 18% of patients who receive Medicare and qualify for the Medical Nutrition Therapy benefit receive it,” Pace said. MNT “can offer individual personalized therapy that Google just can’t provide,” Pace said. “It’s an opportunity in our industry to offer a personal connection.”
Motivational interviewing
Part of what Pace practices is motivational interviewing (MI) – getting patients to be part of the treatment protocol and getting “buy-in” to the idea of changing their behavior. Jamie Freleng, RD, LD, a senior manager for nutritional services at DaVita Kidney Care, is a trainer in DaVita’s Engaging Patients In Their Care (EPIC) program. She has taken part in training 2,100 dietitians on MI through EPIC.
“The intent with MI and EPIC is to improve patient engagement,” Freleng told Healio/Nephrology News & Issues. “We want to be a partner to our patients and work with them to follow nutritional guidelines they can live with,” she said.
When Freleng joined DaVita, she already had 8 years of experience educating and counseling patients on the renal diet. “In the beginning, I practiced very traditionally with patients. I sat down with them and their labs and told them what they needed to do to improve their outcomes,” Freleng said. “Then I was exposed to motivational training and counseling patients. It showed me, through lots of research and training, that my approach doesn’t really work for patients who aren’t motivated to make changes yet.”
With EPIC and motivational interviewing, “we focus a lot on the fundamentals,” Freleng said. “Engagement is one of those fundamentals. Getting to know the patients is important - finding connections and building a rapport,” Freleng said.
Key principles of MI include partnership, acceptance, compassion and evocation, members of DaVita Clinical Research wrote in a 2020 abstract. “While each coaching session is tailored to the individual and their needs, there is guidance toward a targeted goal and structure to each session,” the researchers wrote. “Coding and assessment of recorded clinician-patient sessions using a validated tool provides the only way of establishing staff proficiency in, and adherence to, MI techniques.”
“Education is helpful but without addressing behaviors it is futile,” Rebecca Brosch, MS, RDN, CSR, LD, national senior director of nutrition services for DaVita who helped develop the EPIC program and was a co-author on the clinical research abstract. “An example is education about smoking. Education is not enough as we see many continue to struggle with smoking cessation.
“Understanding the why and providing support for behavior change is an important aspect for any significant lifestyle change,” Brosch, a Nephrology News & Issues Editorial Advisory Board member, said.
Food insecurity, islands
Sometimes the challenge of behavioral change is not about education, but environment, sources said. Patients with kidney disease may make poor food choices because of a scarcity of healthy foods to eat.
“The SARS-CoV-2 pandemic has substantially affected the way of life of the general population. The distribution, availability and access to food, and even the food security of households around the world, have all changed,” Cristina Vargas-Vázquez, BD, RD, from the nephrology and mineral metabolism department at the National Institute of Health Sciences and Nutrition “Salvador Zubirán” in Mexico, and colleagues wrote in a recent article published in the Journal of Renal Nutrition.
In a cross-sectional study, researchers evaluated the prevalence of different degrees of food insecurity and its association with sociodemographic and dietary factors in 588 adults with CKD, some with and some without renal replacement therapy, between May and October 2021.
Vargas-Vázquez and colleagues used the Mexican Food Security Scale to measure food security as the following categories: food security, mild food insecurity, moderate food insecurity and severe food insecurity. Patients completed a food frequency questionnaire consisting of 12 yes-or-no questions that were ordered from least to greatest severity.
Analyses revealed more than 70% of patients experienced some degree of food insecurity, with modest insecurity being the most prevalent. Households reported consuming more beans, eggs, sweets/desserts, soft drinks and artificial juice as food insecurity increased, whereas households with food security reported higher consumption of vegetables, fruits and meats.
Vargas-Vázquez and colleagues identified diabetes, hypertension, unpaid occupation, living in the country’s capital, having children at home or a decrease in income due to the pandemic as risk factors of food insecurity.
“Renal health professionals need to include an assessment of the presence of food insecurity of their patients in their daily professional practice. The results of these assessments could help improve the implementation of programs that provide food and/or nutritional support to vulnerable populations, which include patients with CKD,” Vargas-Vázquez and colleagues wrote.
Lautenschlaeger understands the fragile balance of motivating patients to spend the time to eat the right things – and still allow for keeping some foods patients like.
“My 19 years of experience has taught me there has to be a balance. Access to good foods is important, but patients must make the choice.”
- References:
- Butterworth S, et al. Motivational interviewing: success integration. Presented at: Institute for Healthcare Improvement National Forum General Conference; Dec. 5-6, 2016; Orlando.
- www.healio.com/news/nephrology/20220720/study-food-insecurity-should-be-considered-in-ckd-treatment
- For more information:
- Jamie Freleng, RD, LD, can be reached at jamie.freleng@davita.com.
- Alexandra Lautenschlaeger, RDN, LD, can be reached at alexandra.lautenschlaeger@ dciinc.org.
- Rory C. Pace, MPH, RD, CSR, FAND, can be reached at pacer@satellitehealth.com.
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