Dietary Phosphate Intake Patterns in Malaysian HD patients:

Understanding Determinants of Patient BehaviorsTilakavati Karupaiah, PhD, APD, AN

SRIProfessor,Taylor’sUniversityVisi7ngProfessor,Universi7KebangsaanMalaysia

KDIGO

Palm Tocotrienols In Chronic Hemodialysis (PaTCH) Study

•  Twin[MalaysiaandUnitedStates],mul5center,randomized,parallel,placebocontrolledstudyevalua5ngtheeffectsoftocotrienol-richfrac5onsupplementa5oninmaintenancehemodialysispa5ents.

•  ClinicalTrials.govIden5fier:NCT02913690•  Total380+HDpa5entsscreened–sofarthebiggeststudyevalua5ngnutri5onaspectsofoutcomesinMalaysia.

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Study Sites in Malaysia

GOVERRNMENT

NKF CENTERS

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Dietary PO4 Intakes and Serum PO4 LevelsDietary Variables Pearson’s correlation (r) p value Total Calorie (kcal) 0.149 0.004 Dietary CHO (g) 0.137 0.007 Dietary Protein (g) 0.103 0.046 Animal Protein (g) 0.059 0.251 Plant Protein (g) 0.091 0.077 Dietary PO4 (mg) 0.040 0.439 Plant PO4 (mg) -0.048 0.353 Animal PO4 (mg) 0.054 0.294 Organic PO4 (mg) 0.013 0.804 Inorganic PO4 (mg) 0.052 0.317 Dietary PO4/Protein ratio -0.098 0.057

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Serum PO4 vs Dietary Phosphorus Dietary Intake PO4 < 1.78

mmol/l (n = 203)

PO4 > 1.78 mmol/l

(n = 176)

p value

Total calorie (kcal/d) 1527.3 ± 360.3 1604.0 ± 361.8 0.040 Total protein (g/d) 55.4 ± 17.0 57.8 ± 22.0 0.220 Plant protein (g) 25.6 ± 9.4 25.4 ± 8.5 0.838 Animal Protein (g) 29.5 ± 16.4 32.5 ± 19.8 0.104 Dietary PO4 (mg) 701.2 ± 230.1 693.2 ± 272.9 0.757 Plant PO4 (mg) 314.5 ± 159.0 279.7 ± 117.5 0.017 Animal PO4 (mg) 262.4 ± 154.4 286.8 ± 201.9 0.183 Organic PO4 (mg) 576.8 ± 211.1 566.6 ± 232.7 0.653 Inorganic PO4 (mg) 123.5 ± 132.1 126.1 ± 147.7 0.861 Dietary PO4/Protein ratio 12.9 ± 3.3 12.1 ± 2.6 0.015

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Dietary PO4 ≤ 800 mg/d ( n = 283 )

Dietary PO4 > 800 mg/d

( n = 100)

p value

Age (year) 55.1 ± 13.9 53.1 ± 13.8 0.203

Gender Male Female

134 (64.4%) 149 (85.1%)

74 (35.6%) 26 (14.9%)

<0.001

BMI (kg/m2) 24.1 ± 4.6149 25.4 ± 5.6 0.029

LTI (kg/m2) 12.7 ± 2.8 13.8 ± 3.0 0.001

FTI (kg/m2) 11.4 ± 5.2 11.5 ± 5.4 0.944

MAMC (cm) 23.3 ± 3.5 24.5 ± 3.9 0.006

MAMA (cm2) 36.1 ± 13.4 40.0 ± 17.7 0.023

Handgrip strength (kg) 18.7 ± 8.0 21.1 ± 7.3 0.009

Patient characteristics vs Dietary PO4 Compliancy

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Patient characteristics vs Dietary PO4 Compliancy

Dietary PO4 ≤ 800 mg/d

( n = 283 )

Dietary PO4 > 800 mg/d

( n = 100)

p value

Serum albumin (mg/dl) 38.9 ± 4.1 39.1 ± 4.0 0.702

Serum phosphate (mmol/l) 1.76 ± 0.5 1.77 ± 0.5 0.844

hsCRP (mg/l) 6.8 ± 9.6 7.1 ± 8.6 0.838

Kt/V 1.7 ± 0.4 1.6 ± 0.4 0.139

nPCR 1.1 ± 0.4 1.0 ± 0.3 0.405

Dietary kcal (kcal/d) 1447.5 ± 288.2 1875.9 ± 372.5 <0.001

Dietary protein (g/d) 49.6 ± 12.4 75.7 ± 23.2 <0.001

DEI (kcal/kg/d) 24.3 ± 5.1 29.5 ± 6.0 <0.001

DPI (g/kg/d) 0.8 ± 0.2 1.2 ± 0.3 <0.001

Dietary phosphate (mg/d) 579.7 ± 134.1 1026.1 ± 206.0 <0.001

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Phosphate Intake Categories vs Serum Phosphate Levels

1.88 1.80 1.63

0

0.5

1

1.5

2

2.5

<600 mg/d 600 - 800 mg/d > 800mg/d

Seru

m p

hosp

hate

leve

ls

(mm

ol/l)

Dietary phosphate intake per day Univariate analysis adjusted for age, gender, phosphate binder compliance, Kt/V, dietary calorie and protein intake.

p for trend = 0.081, p = 0.088 pairwise comparison < 600 mg/d vs. > 800 mg/d

Mean 1307.6 ± 246.1 kcal/d Mean

1595.8 ± 255.6 kcal/d Mean

1875.9 ± 372.5 kcal/d

•  Suboptimal nutrition evident in patients with high ser.PO4 levels

•  Likely that it is patient responding to warning from healthcarers!

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DIETARY PATTERNS Our patients are Malays, Chinese and Indians.

Their food intake yields much information about food choices, quantity consumed, where food is consumed and diet quality

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Dietary patterns (Tertiles)

HomeFood[HF]

Ea,ngOut[EOrice]

Sugarsweetenedbeverages[EOssb]

Monotonousdiet[EOmd]

Nutrients Tertiles N Mean

P_trend

N Mean

P_trend

N Mean

P_trend

N Mean

P_trend

Overall T3vsT1 OverallT3vsT1 OverallT3vsT1 Overall

T3vsT1

Calories kcal

T1 121 1501.13 ± 358.31 .635 1.000

169 1431.27 ± 323.32 .000 .001

123 1439.11 ± 325.66 .000 .001

148 1495.15 ± 342.69 .016 .045T2 128 1529.33 ± 343.50 75 1554.01 ± 295.80 124 1481.42 ± 312.08 97 1479.75 ± 310.64

T3 117 1541.05 ± 291.23 122 1633.26 ± 331.75 119 1655.35 ± 322.18 121 1594.01 ± 327.84

Protein g

T1 121 53.27 ± 19.67 .183 .197

169 54.12 ± 19.38 .301 .378

123 57.34 ± 22.63 .386 .920

148 53.45 ± 20.10 .021 .033T2 128 55.34 ± 18.93 75 54.96 ± 16.05 124 54.16 ± 17.74 97 53.59 ± 13.76

T3 117 57.82 ± 18.29 122 57.58 ± 20.11 119 54.83 ± 15.96 121 59.37 ± 20.74

DEI_IBW T1 121 24.83 ± 5.35

.904 1.000169 23.68 ± 4.84

.000 .001123 23.48 ± 4.78

.000 .001148 24.49 ± 5.23

.227 .257T2 128 25.12 ± 5.61 75 25.74 ± 5.10 124 24.82 ± 4.98 97 25.03 ± 5.06 T3 117 25.02 ± 4.32 122 26.34 ± 5.14 119 26.73 ± 5.15 121 25.58 ± 5.04

DPI_IBW T1 121 0.88 ± 0.30

.332 .427169 0.89 ± 0.29

.693 1.000123 0.93 ± 0.32

.437 .596148 0.87 ± 0.30

.119 .118T2 128 0.90 ± 0.27 75 0.90 ± 0.25 124 0.90 ± 0.27 97 0.90 ± 0.23 T3 117 0.93 ± 0.28 122 0.92 ± 0.28 119 0.88 ± 0.24 121 0.94 ± 0.29

Carbohydrates g

T1 121 208.26 ± 51.89 .020 .017

169 202.78 ± 48.39 .000 .001

123 192.53 ± 44.88 .000 .001

148 215.99 ± 52.30 .441 1.000T2 128 215.08 ± 50.72 75 223.17 ± 50.21 124 209.51 ± 41.54 97 211.80 ± 50.52

T3 117 226.19 ± 46.20 122 231.03 ± 47.76 119 248.18 ± 47.18 121 220.52 ± 47.04

Phosphate mg

T1 121 607.67 ± 245.444 .236 .277

169 598.49 ± 241.18 .020 .067

123 618.66 ± 245.11 .274 .425

148 663.15 ± 262.69 .121 .142T2 128 638.14 ± 219.87 75 672.55 ± 224.33 124 623.31 ± 238.14 97 623.69 ± 205.68

T3 117 657.64 ± 219.32 122 660.40 ± 207.18 119 661.93 ± 198.68 121 607.53 ± 197.35

Fluids ml

T1 121 973.11 ± 299.62 .000 .001

169 1031.66 ± 345.06 .103 .374

123 1000.09 ± 325.50 .000 .001

148 1076.14 ± 343.92 .554 1.000T2 128 1050.56 ± 291.81 75 1119.00 ± 304.79 124 1007.30 ± 307.14 97 1090.30 ± 306.67

T3 117 1189.40 ± 350.84 122 1091.01 ± 306.39 119 1205.55 ± 304.13 121 1044.21 ± 318.53

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Dietary PO4 trends within Dietary Patterns

HomeFood[HF]

Ea,ngOut[EOrice]

Sugarsweetenedbeverages[EOssb]

Monotonousdiet[EOmd]

TypeofPhosphate Ter7les N Mean±std

P_value

N Mean±std

P_value

N Mean±std

P_value

N Mean±std

P_value

Overall

T3vsT1

Overall

T3vsT1

Overall

T3vsT1

Overall T3vsT1

PlantPO4Organic(mg)

T1 121 279.10 ± 135.54

0.286 0.435

169 271.87 ± 134.26

0.014 0.737

123 275.10 ± 127.16

0.367 0.520

148 290.87 ± 138.66

0.526 1.000 T2 128 282.43 ± 120.58 75 323.12 ± 129.61 124 291.53 ± 127.18 97 296.39 ± 114.49 T3 117 303.04 ± 121.36 122 289.19 ± 107.25 119 297.40 ± 123.62 121 277.85 ± 119.22

AnimalPO4Organic(mg)

T1 121 228.27 ± 130.30

0.010 0.007

169 251.40 ± 154.28

0.693 1.000

123 266.74 ± 159.34

0.596 0.972

148 258.42 ± 147.45

0.716 1.000 T2 128 261.28 ± 148.22 75 264.82 ± 153.15 124 261.35 ± 144.08 97 249.66 ± 111.98 T3 117 286.93 ± 160.43 122 264.86 ± 137.13 119 247.69 ± 141.43 121 266.22 ± 173.57

InorganicPO4(mg)

T1 121 117.32 ± 102.03

0.024 0.032

169 91.86 ± 94.09

0.057 0.056

123 80.48 ± 76.80

0.000 0.001

148 100.06 ± 96.81

0.615 1.000 T2 128 111.26 ± 102.92 75 109.19 ± 97.93 124 90.34 ± 91.07 97 102.80 ± 96.88 T3 117 84.74 ± 81.91 122 119.25 ± 99.04 119 144.22 ± 109.43 121 111.65 ± 98.00

PO4toproteinra7o

(mg/g)

T1 121 12.60 ± 3.04

0.338 0.439

169 12.04 ± 2.75

0.014 0.969

123 11.89 ± 3.00

0.014 0.011

148 13.17 ± 3.02

0.001 0.001 T2 128 12.42 ± 2.87 75 13.17 ± 2.63 124 12.31 ± 2.83 97 12.38 ± 2.61 T3 117 12.08 ± 2.33 122 12.36 ± 2.79 119 12.93 ± 2.34 121 11.42 ± 2.24

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Serum PO4 as per DP tertiles

HomeFoodPa<ern Ea,ngOut Sugarsweetenedbeverages Monotonousdietarypa<ern

N Mean

Pvalue

N Mean

Pvalue

N Mean

Pvalue

N Mean

Pvalue

Overall

T3vsT1

Overall

T3vsT1

Overall

T3vsT1

Overall

T3vsT1

Serum Phosphate

mmol/L

T1 121 1.74 ± 0.52 0.584 1.000

169 1.74 ± 0.48 0.178 0.275

123 1.74 ± 0.46 0.002 0.048

148 1.75 ± 0.53

0.894 1.000

T2 128 1.75 ± 0.48 75 1.73 ± 0.46 124 1.67 ± 0.50 97 1.77 ± 0.51 T3 117 1.81 ± 0.53 122 1.84 ± 0.57 119 1.90 ± 0.54 121 1.78 ± 0.48

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What DPs tell us…. •  3Ea5ngOutpaXerns[rice-based,beverage-basedandmonotonous]emergescomparedtotheHomeFood(HF)paXern-socioeconomicissues???

•  T3 groups report greater energy intake vs HF •  EOssb (1655kcal) >EOrice (1633kcal)> EOmd (1594kcal) >HF (1541kcal)

•  EOssb and EOrice achieve significantly highest DEIs [T3 vs T1] •  EOvsHF(p=0.047)

•  FluidintakehighestwithEOssb(1206ml)andHF(1189ml)•  HFP vs MDP (p=0.003); EO vs SSB (p=0.034); SSB vs MDP (p=0.001)

•  HFisbasedontradi5onalpaXernthatcombinescarbswithvegies,proteinfoodgroups-higherdietaryquality

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Type of Dietary PO4…. •  HFpaXernishighestinorganicPO4fromanimalfoods(287mg)andplantfoods(303mg)andleastfrominorganicPO4(85mg).

•  EoricepaXernalsohighestinplantorganicPO4(323mg/T2and289mg/T3).Expectedascereal-rich.

•  EOmdpaXernwithlowestPO4toProteinra5o(11.42)becauseitsmonotonous.•  EOssbpaXerncarriessignificantlyhighestriskofcontribu5ngtohighserumPO4levels(1.90±0.54mmol/L)

•  Highest inorganic PO4 content (144mg) •  Highest PO4 to Protein ratio (12.93) •  Dominated by beverages (fluid =1200ml) which carry inorganic phosphates

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EOssb carries Potential PO4-rich Beverages?

25.2

34.2

11.7

9.5

7.7

11.7

0 5 10 15 20 25 30 35 40

Tea/Coffee (with condensed milk)

Tea/Coffee (with sugar)

Tea/Coffee (Instant)

Chocolate/Malted Beverages

Carbonated drink

Tetrapack/Cordial

Percentage

mg serving kcal Inorganic PO4 condensed milk 70.8 28g or 2 tab 90 calcium lacto-phosphate coca-cola 60 350ml 145 Phosphoric acid NDC liquid 10 per sachet 20 dipotassium PO4 NDC powder 13 per sachet 16 dipotassium PO4

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Achieving Optimal Ser.Phosphate Levels

Serum Phosphate ≤ 1.78 mmol/l

ORcrude (95% CI) p value ORadj (95% CI) p value

Dietary Patterns

HFP 1.00 1.00

EOrice 1.09 (0.65, 1.82) 0.740 1.27 (0.67, 2.41) 0.472

EOssb 1.53 (0.91, 2.56) 0.105 1.53 (0.80, 2.95) 0.203

EOmd 1.02 (0.61, 1.70) 0.936 0.90 (0.48, 1.66) 0.726

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PHOSPHATE BINDER COMPLIANCY

What about binder use? KDIGO

Phosphate Binder Compliance vs Serum Phosphate Levels (self-reported)

1.68

1.80

1.5 1.55

1.6 1.65

1.7 1.75

1.8 1.85

1.9 1.95

Yes No

Seru

m p

hosp

hate

leve

ls

(mm

ol/l)

Compliance to Phosphate Binders

Univariate analysis adjusted for age, gender, Kt/V, dietary calorie and protein intake

p = 0.005

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NATURE of DIETARY PHOSPHATE education

Center vs Dietitian Accessibility KDIGO

Association of Serum Phosphate Levels with HD Center Sector and Dietitian Accessibility: A Nationwide Survey

1.64

1.84

1.76

1.7 1.73

1.81

1.5 1.55

1.6 1.65

1.7 1.75

1.8 1.85

1.9

Government (n=1072)

Private (n=1949)

NGO (n=1341)

No dietitian (n=2618)

Dedicated dietitian (n=934)

Visiting dietitian (n=810)

Ser.

PO4

(mm

ol/L

) p for trend <0.001a p for trend <0.001b

Univariate analysis adjusted for age, gender, dialysis vintage, Kt/V, center sector, and dietitian accessibility aBonferroni post hoc test indicates p < 0.05 for all pairwise comparisons bBonferroni post hoc test indicates p < 0.05 for pairwise comparison shared/visiting dietitian vs. no dietitian and shared/visiting dietitian vs. dedicated dietitian

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Achieving Optimal Serum Phosphate Levels HD Sector and Dietitian Accessibility

Serum Phosphate ≤ 1.78 mmol/l ORcrude (95% CI) p value ORadj (95% CI) p value

HD Sector Private 0.61 (0.53, 0.72) < 0.001 0.40 (0.32, 0.51) < 0.001 NGO 0.66 (0.56, 0.78) < 0.001 0.50 (0.40, 0.64) < 0.001 Government 1.00 1.00

Dietitian Accessibility Shared/visiting

0.96 (0.82, 1.13) 0.629 0.59 (0.48, 0.74) < 0.001

Dedicated 1.20 (1.03, 1.39) 0.021 0.80 (0.63, 1.02) 0.072 No dietitian 1.00 1.00

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Phosphate Education Material

?

New Phosphate Education Materials 2018

KDIGO

Phosphate Education Material

Calendar incorporating education materials distributed to clinics and dialysis centers for healthcare use

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Some thoughts here! •  Inadversecondi5ons,limita5onsbecomeopportuni5es(lackofdedicateddie55anslocatedatclinics):

•  Some level of patient-education delivered by doctors/nurses •  Dietitian researchers enabled in Malaysia to conduct screening for patient

selection vs US study patient selection criteria is computer-generated •  Collected 3-day records vs 1-day records •  Collected data for nutritional status and its dietary coordinates •  Explore PEW and its dietary coordinates •  Explore lipoprotein particle size and its dietary coordinates

•  Capacitybuildingforfuturerenaldie55ans•  Nutrientdeclara5onshouldincludePO4contentforourbeverages

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Acknowledgement

•  Pa5entsatallourCenters•  Na5onalRenalRegistry,MalaysianSocietyofNephrology•  PEMANDU,WayneStateUniversity,MalaysianPalmOilBoard

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Supportive Network of Collaborators Nephrologists:

Ghazali Ahmad, Hospital Kuala Lumpur Goh Bak Leong, Hospital Serdang Dato’ Zaki Morad, National Kidney Foundation Abdul Halim Abd Gafor, Pusat Perubatan Universiti Kebangsaan Malaysia Soo Kun Lim, University Malaya Medical Center Sunita Bhavanandan, Hospital Kuala Lumpur Rosnawati Yahya, Hospital Kuala Lumpur Bee Choon Cheak, Hospital Selayang Ravindran, Hospital Kuala Lumpur

Sta5s5cian:KaruthanChinna,Universi5Malaya

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Thank you for Listening

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