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.
KDIGO
Study Sites in Malaysia
GOVERRNMENT
NKF CENTERS
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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!
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
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
KDIGO
Acknowledgement
• Pa5entsatallourCenters• Na5onalRenalRegistry,MalaysianSocietyofNephrology• PEMANDU,WayneStateUniversity,MalaysianPalmOilBoard
KDIGO
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
KDIGO
Thank you for Listening
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