Fluid and Dietary Restriction Behavior Among Chronic Kidney Disease Patients in Bangladesh

International Academic Journal of Advanced Practices in Nursing ISSN Print : 2709-3271 | ISSN Online : 2709-3263 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iajapn

Research Article

Fluid and Dietary Restriction Behavior among Chronic Kidney Disease Patients in Bangladesh

Article History Abstract: Chronic Kidney Disease (CKD) is a global threat to health in general and for developing countries in particular, because therapy is expensive and life- Received: 05.09.2020 long. Dietary and fluid regimen for CKD patients is complicated and identifying Accepted: 28.09.2020 characteristics and reasons of those most likely to experience difficulty in Revision: 08.10.2020 adhering to dietary restrictions is important. Objective: The objective of this study Published: 10.10.2020 was to describe the fluid and dietary restriction behavior among admitted patients with chronic kidney disease. Methods: The descriptive study design was conducted among 100 admitted patients from NIKDU, Dhaka, by using purposive Author Details sampling technique. Data was collected by self-administered questionnaires. (1) Demographic Data Assessment Questionnaire, (2) Fluid restricted and (3) Diet 1 2 Hossain MA* and Sitara H Restriction Related Questionnaire. Pearson‟s correlation (r), T -Test (t) and Authors Affiliations ANOVA was used for data analysis. Results: The mean score of fluid restriction behavior is 2.04±.32 and diet restriction behavior is 2.28(±.41). A significant 1Faculty of Mental Health and Psychiatric relationship between fluid restriction behavior with age (p =.018) and Nutritional Nursing, National Institute of Adv anced education (p = .01). There is also another significant relationship between diet Nursing Education and Research (NIANER), restriction behavior and nutritional education (p= .006). Conclusion: Patients Bangladesh with Chronic Kidney Disease who have behavior with age and nutritional education, showed significantly higher fluid and diet restrictions behavior. 2Faculty of Social Welfar e, University of Hospital can consider those characteristics to guide Patients with Chronic Kidney Dhaka, Bangladesh Disease by nurses.

Corresponding Author* Keywords: Fluid restriction, Diet restriction, chronic kidney disease. Hossain MA How to Cite the Article: INTRODUCTION Hossain MA and Sitara H(2020) Fluid and Background and Significance of the study Dietary Restriction Behavior among Chronic Chronic Kidney Disease (CKD) is a slow, progressive Kidney Disease Patients in Bangladesh. Int irreversible deterioration in renal function and the prevalence is estimated Aca. J Adv Prct. Nurs. 1(1)16-25. at 8-16% around in the world (Vivekanand, Guillermo, Kunoichi, Zou & Copyright @ 2020: This is an open-access article distributed under the terms of the Creative Saarlander, 2013). In the United States of America, 30 million people Commons Attribution license which permits suffering from chronic kidney disease. Kidney disease is the ninth leading unrestricted use, distribution, and reproduction cause of death in the United States. Approximately 19 million United in any medium for non commercial use States adults have chronic kidney disease, and an estimated 80,000 (NonCommercial, or CC-BY-NC) provided the original author and source are credited. persons have chronic kidney failure diagnosed annually is a global threat to health in general and for developing countries in particular, because therapy is expensive and life-long. (Kidney Disease Statistics for the United States, 2016). In India 90%, patients cannot afford the cost. Over 1 million people worldwide are alive on dialysis or with a functioning graft. Chronic kidney disease is rapidly growing disease in Bangladesh. Results of this study also demonstrated that most of the CKD patients had type 1 diabetes (39.02%) and type 2 diabetes (41.46%) mellitus. Only 5% of the CKD patients had undergone nephro -surgery. Around 24.30% of the CKD patients had hypertension (Jabur & Abdullah, 2016). Preventing progression from earlier stages of chronic kidney disease (CKD) to end-stage kidney disease and minimizing the risk for cardiovascular events and other complications is central to the management of CKD. Patients‟ active participation in their own care is critical, but may be limited by their lack of awareness and understanding of CKD (Lopez-Vargas et al., 2016). Dietary counseling and nutritional interventions are quintessential components in the management of chronic kidney disease (CKD) patients, including those who receive maintenance dialysis therapy. To that end, in the United States it is a regulatory requirement for an outpatient dialysis clinic to have an on-site registered dietitian to prov[ide dietary monitoring and counseling to all dialysis patients (Ikizler et al., 2014). Poor diet can have serious consequences for patients, including impaired physical abilities, depression, acute pulmonary edema, congestive heart failure, and death. A poor dietary habit is associated with low quality of life, and morbidity and mortality of patients on dialysis.

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Further, malnutrition and inflammation However, CKD is a progressive disease that increase cardiovascular risk and mortality in patients on cannot be reversed and can lead to kidney failure or hemodialysis. Both dietitians and nephrologists often end-stage renal disease (ESRD) if it is not detected and impose a number of dietary restrictions on their patients treated early (CDC and Prevention, 2012). Because of related to dietary phosphorus, potassium, sodium, fluid its chronic nature and potentially serious complications, intake, and macronutrients including carbohydrate and individuals suffering from CKD experience poor quality fat. Dietitians also emphasize the importance of high of life, financial burden, and significant life changes dietary protein intake in dialysis patients, while they affect their families (Nagelkerk, Reick, & Meengs, may also recommend weight loss efforts in patients 2006) CKD require dialysis or transplant at younger with morbid obesity(Streja et al., 2011). ages than any other group. These disparities in incidence and prevalence have been proven to be a Fluid restriction is considered the most function of high levels of CKD risk factors in African difficult to accomplish and this remains a major clinical Americans, including diabetes, hypertension, and problem in individuals with CKD (Lindberg, obesity (Castren, 2017). CKD patients face a complex 2010).Contributing to severe complications include treatment regimen and many of them have difficulty to intradialytic cramping and hypotensive episodes, manage fluid and diet restrictions, which is associated treatment related fatigue and dizziness, lower extremity with high risk of mortality and the increase of health oedema, ascites, left ventricular hypertrophy and care budgets. Nephrology nurses help patients with congestive heart failure, hypertension, shortness of CKD to manage their treatment, advising them about breath, and pulmonary vascular congestion or acute self-care measures related to changes in their health. To pulmonary oedema (Lindberg, 2010; Machek et al., understand how patients, deal with treatment and what 2009). are the most effective self-care measures to manage fluid and diet restrictions in renal patients under HD, CKD impairs the proper function of kidney for can contribute to a better nursing advice. This study removal of waste substances from the food and from the aims to identify the level of the fluid and dietary body. Due to CKD a person's diet must be changed to restriction behavior among admitted patients in the maximum of the remaining normal kidney function Bangladesh. (Castren, 2017).In the early stage of kidney disease for normal functioning of the kidneys restriction of dietary General Objective: To describe the fluid and dietary protein, sodium, phosphate, potassium and fluid can restriction behavior among admitted patients with help. Dietary and fluid management like as restriction chronic kidney disease. of sodium intake is important to reduce kidney disease, more sodium in the diet can cause kidney disease more Specific Objectives of the Study quickly (Castren, 2017).In the early stage of the disease 1. To describe socio-demographic characteristics dietary protein restriction is not required and could even among patients with chronic kidney disease. result in a decline in the patient´s nutritional status and 2. To assess fluid and dietary restriction behavior overall fitness, but can be implemented in later stages of among patients with chronic kidney disease. the disease. In the progression of the kidney disease and 3. To examine the relationship between socio- kidney declines function and the nutritional status demographic characteristics of fluid and dietary typically deteriorates (Castren, 2017). restriction behavior among patients with chronic kidney disease. The dietary restriction is also vital to maintain optimal health for the CRF patients, because certain ITERATURE EVIEW substances present in the foods and drinks, when taken L R in excess, damaged kidney may not be able to remove The study aimed to assess the perception the waste, which are harmful to the body. So the foods regarding Dietary and Fluid Restriction among the and drinks containing those substances, which are CKD patients who are admitted in National Institute of harmful to the body, must be regulated. Dietary protein Kidney Diseases and Urology Hospital, Dhaka, restriction represents an important new development in Bangladesh. To gain understanding the variable of this treatment of chronic renal disease for the last 10 years study, this chapter presents literature review on the (Agarwal, Srivastava, 2009). Dietary restrictions also following topics: prevent other opportunistic diseases such as 1. Incidence of CKD. hyperkalemia and hyperphosphatemia that are common 2. Self-management behavior of CKD patients. in patients with chronic kidney disease. The key factors 3. Fluid and dietary restriction of patients with CKD. of maintaining quality of life weight management along with increased physical activity are key factors Overview of Chronic Kidney Disease (Castren, 2017). Chronic kidney disease is defined as abnormalities of kidney structure or function present for 43 months with implications for health. The definition of CKD remains intact, but there is clarified the 17

Hossain MA and Sitara H; Int Aca. J Adv Prct. Nurs; Vol-1, Iss- 1 (Sep-Oct, 2020): 16-25 classification and risk stratification as indicated below. be in the ranges of 2% to 81% (Theofilou, 2012) among The addition of „with implications for health‟ is CKD patients. In this regard, fluid and diet engagement intended to reflect the notion that a variety of plays a pivotal role in the effective management of abnormalities of kidney structure or function, but not all CKD as it lowers morbidity, improve rehabilitation, have implications for health of individuals, and survival and clinical outcomes (Carman et al., 2013). therefore need to be contextualized (Kidney Disease Statistics for the United States (2016).Kidney damage There is an exponential growth worldwide of refers to a broad range of abnormalities observed during patients with end-stage renal disease (ESRD). clinical assessment with insensitive and non-specific for Prevalence, outcomes, and underlying causes of ESRD the cause of disease but may precede reduction in are relatively well documented through different kidney function. The excretory, endocrine and organizations. It is, however, clear that a large part of metabolic functions decline together in most chronic the bad outcome of ESRD patients is due to deﬁcient kidney diseases. GFR (Glomeruler Filtration Rate) is follow-up during the earlier chronic kidney disease generally accepted as the best overall index of kidney (CKD) stages. According to data on CKD, prevalence function. It refers to a GFR o60 ml/min/ 1.73 m2 as of the different stages and the evolution to ESRD are decreased GFR and a GFR o15 ml/min/ 1.73 m2 as rather scant, and available data are conﬂictive. This is at kidney failure. AKI may occur in patients with CKD least partly due to the lack of an international standard and hasten the progression to kidney failure. for measurement of renal function. In addition, there is Complications include drug toxicity, metabolic and compiling evidence that presence of proteinuria, even endocrine complications, increased risk for CVD, and a with abnormal renal function, predisposes to ESRD. variety of other recently recognized complications, Most authors now prefer the term “kidney injury” rather including infections, frailty, and cognitive impairment. than “kidney failure” to indicate people at risk for Complications may occur at any stage, often leading to evolution to ESRD or for complications of CKD. death without progression to kidney failure. Detection of these patients at risk is important to Complications may also arise from adverse effects of implement measures to slow down progression of CKD interventions to prevent or treat the disease and and avoid secondary complications. As it is clear that associated comorbidity (Kidney Disease Statistics for most of these CKD patients die before they reach the United States (2016). ESRD, it might be that by taking the necessary preventive measures, the number of ESRD patients The incidence of CKD: According to Centers for might still further increase exponentially (Lameire, Disease Control and Prevention (CDC) in USA 16.8% Jager, Biesen, Bacquer, & Vanholder ,2005). people are affected by CKD in the age of 20 years or above during 1999 to 2004. And in Canada, 1.9 to 2.3 Self-Management behavior of chronic kidney million people have CKD. In Great Britain and disease patients: A study was conducted 2006 about Northern Ireland 8.8% people are affected by self-care Management in adults undergoing symptomatic CKD (Jabur, 2016). hemodialysis. The study shows that clients with end stage renal disease require continual care. Daily self- Incidence of chronic kidney disease has care includes managing a complex treatment regimen of doubled in the last 15 years. Major causes of kidney dietary restrictions, fluid limitations, medications, and failure are diabetic mellitus, chronic hypertension and vascular access care. glomerulonephritis, which account for approximately 60% of new cases (Vivekanand et al., 2013, Agarwal, A study was conducted to assess the 2005). Chronic kidney disease is rapidly effectiveness of a self-monitoring tool on perceptions of growing disease in Bangladesh. Results of this study self-efficacy, health beliefs, and adherence in patients also demonstrated that most of the CKD patients had receiving hemodialysis. Both the treatment and control type 1diabetes (39.02%) and type 2 diabetes (41.46%) groups were randomly selected and received surveys to mellitus. Only 5% of the CKD patients had undergone assess health beliefs, perceptions of self-efficacy for nephro -surgery. Around 24.30% of the CKD performing specific healthful behaviors, and renal diet patients had hypertension. (Jabur & Abdullah , 2016) knowledge at baseline, before intervention, and 6 months later. The treatment group also received Excessive fluid overload contributes to an monthly feedback of monthly phosphorus levels and increased morbidity and high mortality (Lindberg, inter-dialytic weight gains. Analysis of variance tests of 2010; Holmberg & Stegmayr, 2009). In CKD patients. repeated measures were used to examine relationships Similarly, dietary restriction in CKD forms part of the between adherence with phosphorus and fluid management of the condition and its goal is to minimize restrictions to health beliefs and perceptions of self- uremic and anemia symptoms, reduce the incidence of efficacy after training in self-monitoring. Overall, there fluid, electrolyte and acid base imbalances, decrease were no significant improvements in adherence with patient‟s vulnerability to infections and limit catabolism phosphorus and fluid restrictions between the two (Morton & Fontaine, 2009). Again, documented poor groups, although a comparison within the groups adherence to dietary restriction has been documented to revealed the treatment group had a statistically

Hossain MA and Sitara H; Int Aca. J Adv Prct. Nurs; Vol-1, Iss- 1 (Sep-Oct, 2020): 16-25 significant decrease in mean phosphorus levels of 7.14 functioning, permanent dialysis access to a greater to 6.22 mg/dl (P = .005) from baseline to month. No extent than the patients in the comparison group. Those significant differences existed between the two groups choosing home-hemodialysis rated their self-care ability for health beliefs and perceptions of self-efficacy. higher. The participants rated self-care and effects of Knowledge scores in the treatment group, however, treatment options on family and everyday life as the improved significantly as compared to the control group most important disease-related areas of knowledge. (P = .008) and was a significant increase from baseline (P =. 002). They concluded that benefits of patient self- An evaluative research study was conducted in monitoring and behavioral contracting upon adherence Vijaya dialysis unit to find out the effectiveness of in patients on hemodialysis are inconclusive, as serum information booklet provided to care givers of patients phosphorus and inter dialytic weight gains did not differ undergoing hemodialysis on knowledge of home care between the two groups. management. A pre-experimental one group pre-test post-test design was used to achieve the objectives of A retrospective study was conducted on the study, the sample size of 30, selected through Non- positive effect of protein restriction in patients with probability convenient sampling technique. The major chronic kidney disease in which 122 renal patients were finding of the study showed that the overall knowledge participated, among them 61 patients were treated with score obtained by the care givers in the pretest was low protein diet there was less mean weight loss in the 50.35 and 86.26 in the post test. The overall low protein diet group the year before improvement in the mean score was 35-89 with „t‟ value dialysis(0.14kg/month control group 0.36kg/month 13.4 which was highly significant. p,.05).The mean rate of progression during the 6months before dialysis was lower in the low protein group(4.1 Fluid and dietary restriction behavior of patients ml/min/year) than in the control group (13.4 with CKD ml/min/year o<.001).The low protein diet group had Patient perception refers to a patient‟s fewer days of hospitalization at the start of dialysis than knowledge, ability and willingness to manage his or her the control group(8.2 vs 15.4 days p<.01).The findings own health care, paired with interventions which of the study shows that low protein diet can reduce promote positive adherent behavior (Carman et al., patient morbidity, preserve renal function, relieve 2013). In this context, perception is conceptualized as uremic symptom and improve nutritional status. ability, willingness and active participation of CKD patients with their dietary and fluid restriction to A prospective study was conducted to assess promote highest levels of adherent behaviors. Carman the utility of Leventhal's Self-Regulatory Model (SRM) et al. further highlighted that patient perception is to predict self-care behavior with regard to dietary, required for successful treatment of CKD as medication, and fluid regimes in end-stage renal disease involvement has been shown to promote less frequent (ESRD) patients. In this study, ESRD patients treated and shorter hospital stays, lower morbidity, improve via hospital-based hemodialysis (N=73) were screened survival and clinical outcomes (Carman et al., 2013). for cognitive deficits and completed questionnaires that Consistent findings reported that perception is strongly enquired about illness perceptions, coping strategies, associated with improved adherence with treatment knowledge of kidney disease, and psychological (Skolasky, Mackenzie, Wegener & Riley ,2008). distress at Time 1. Physiological proxy measures of Therefore, perception with fluid and dietary restriction self-care behaviors regarding diet, fluid intake and is of importance to improve documented poor medication regimes were collected 3 weeks later at adherence to these management modalities (Theofilou, Time 2. They concluded that the SRM has predictive 2012) among CKD patients. Removal and control of utility. Psychological interventions should focus on excess fluid is the cornerstone of volume management alleviating disease-specific distress and challenging in CKD patients (Machek, Jirka, Moissl, Chamney & erroneous timeline perceptions in order to increase Wabel, 2009). Furthermore, low rates of adherence to adherence to dietary and medication regimes in ESRD fluid restriction have been evident from previous patients. A more specific measure of coping for ESRD studies (Chan, Zalilah & Hii, 2012) as they range is required to clarify the role of coping strategies in this from9.7% to 72%. Self-care behavior includes population. Younger, male patients should be targeted adherence to prescribed medications, caring for for extra support with fluid restrictions. vascular access, and as importantly, dietary recommendations that include selecting food items low A study was conducted to assess the impact of in sodium, potassium and phosphorus, maintaining nurse-led clinic on self-care ability, disease specific adequate protein intake, and limiting daily fluid intake. knowledge and home dialysis modality to enhance Lack of compliance to these dietary recommendations patients' disease-related knowledge, involvement, and may lead to accumulation of metabolic by products and self-care ability. Comparison of patient outcomes with excess fluid in the circulatory system, leading to the nurse-led clinic to the previous model of care was increased morbidity and mortality for renal failure seen. The participants in the nurse-led clinic chose and patients. started dialysis in a self-care alternative and also had a

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Summary of the Literature Review: Optimal Due to missing data 6 data was cleaned. Finally the management of patients with chronic kidney disease sample size was 100. (CKD) requires appropriate interpretation and use of the markers and stages of CKD, early disease recognition, Data collection instruments: The data collection and collaboration between primary care physicians and instrument that was employed in this study was nephrologists. Because multiple terms have been consisted of three self-administered questionnaires. applied to chronic kidney disease (CKD), eg, chronic Based on the literature review and getting ethical renal insufficiency, chronic renal disease, and chronic consideration, researcher-built questionnaire with renal failure, the National Kidney Foundation Kidney Part I Demographic Data Assessment Questionnaire Disease Outcomes Quality Initiative (NKF KDOQ) has (DDAQ) defined the all-encompassing term, CKD. Using kidney Part II Fluid restricted Related Questionnaire (FRRQ) rather than renal improves understanding by patients, Part lll. Diet Restriction Related Questionnaire (DRRQ) families, healthcare workers, and the lay public. This –The researcher will be used existing instrument. term includes the continuum of kidney dysfunction Part - I: Demographic Data Assessment Questionnaire from mild kidney damage to kidney failure, and it also (DDAQ) -14(Fourteen) items (Age; Gender; Religion; includes the term, end-stage renal disease (ESRD). Marital status; Educational Background; Employment However, from the literature review, there is no any status; Number of Family member; Monthly family study about family member‟s perception regarding income; BMI; Years of treatment for CKD in Months; chronic renal disease patients in Bangladesh. Smoking history; Co-morbidity history and Nutritional education. RESEARCH METHODOLOGY Part - ll: had 31 questions related to fluid restriction. Part – III: had 19 questions related to Dietary Restriction This chapter describes the research related questionnaire. methodology of the study which were covered by the The frequency measures were assessed using a 5-points following areas: study design, study participants, data Likert scale with scores from 1(almost never/ 0 days per collection instruments, and data collection methods and week) to 5 (almost always/ 7days a week). data analysis. Study design: An exploratory study design was used to Data collection methods: Data was collected examine the socio-demographic characteristics and after obtaining approval from the Institutional Review perception on fluid and dietary restriction among CKD Board (IRB) of National Institute of Advanced Nursing patients in Bangladesh. Education and Research (NIANER), Mugda, Dhaka, the Institutional Review Board (IRB) of Bangabandhu Study participants: The target population in this study Sheikh Mujib Medical University (BSMMU), Dhaka, was patients with CKD who visited the in-patient Bangladesh and permission was received from the department at the National Institute of Kidney Diseases Director and Nursing Superintendent of selected and Urology Hospital (NIKDU), Dhaka, Bangladesh. specialized hospital in Bangladesh. The researcher The NIKDU is the only one specialized tertiary care highly considered about the human rights of the hospital in Bangladesh for treatment of all types of participants of this study. The researcher explains the kidney patients. The hospital was established in 2001. purpose of the study, the procedure, the possible The hospital has two parts: academic and clinical benefits, and risks of the study to the participants. The services. On the clinical part there are treated and researcher informed the participants that they had right managed all Acute and chronic kidney diseases, Renal to choose whether they were willing to participate or stone diseases, Obstructive uropathy and genito-urinary not and that they can withdraw from the research at any malignancies are the major diseases and all forms of time after consenting to participate in the study. The renal replacement therapy including kidney researcher explained all the instruments in Bangla transplantation. The NIKDU has 150 beds for inpatient language. If the agreement to participate was approved department, and also OPD treatment facilities. A large verbally, they have further asked to sign the informed number of patients came to the hospital to the OPD and consent form and return it to the researcher. Subjects‟ dialysis center. On the academic part it provides autonomy and confidentiality was strictly maintained postgraduate courses like MD (Nephrology), MS and participation was voluntary. The anonymity of (Urology), and conducting a number of community participants was strictly maintained. based research works for early detection and prevention The researcher read the questionnaire to subjects, of kidney diseases. In the year 2017, a total of 5636 explain details repeatedly until the subject understood, CKD patients were admitted at this hospital (Health and ensured time that was appropriate for each subject Bulletin, 2018). to answer the questionnaire. Then the researcher checked the questionnaires to ensure that it was Sample size: Sample size was estimated by using G completed properly. Power analysis. The estimated sample size calculated for an acceptable medium level of significant (α) 0.05 and acceptable power of 0.90 (1-β) and effect size 0.3 (Y). The sample size was 106 with 20% attrition rate. 20

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Data Analysis: The collected data was entered using a RESULTS data analysis program and the editing and cleaning of data was performed. Data was analyzed as per Table 1. Showed the distribution of Socio- objectives of the study and additional analysis was demographic characteristics of the participants. The completed to support the research findings. The average age was 44.20 ±13.04 years with an age range collected data were processed using SPSS 23 version from 20-60 years.61.0% were male, 95.0% were Islam for analysis including descriptive statistics and among the participants 88% were married. For the inferential statistics. Descriptive statistics consisting of educational background of the participant, 38.0% were frequency, percentage, range, mean, and standard illiterate and only 1% was post-graduate. Among deviation were to used analyze the subjects‟ Socio- participants,54% of participants were unemployed and demographic characteristic, fluid and dietary 74% of participants who had family member 5 or more. restrictions. Inferential statistics was used to find out An annual income of family ranges from 12000-35000 the relationship between socio-demographic and fluid taka and mean was 22710 takas. Maximum participants restriction & dietary restriction among CKD patients. were normal BMI (59%) with the mean of 24 and Data were analyzed by using independent t test (t), pattern of treatment range were 36% in month. More correlation (r), and ANOVA (F) a significance level of than 50% of participants were smoker. Whereas more p< 0.05 was considered as a statistically significance. than participants‟ comorbidity history was absent. Only 11% of respondents had received nutritional education. Table 1: Distributions Socio-Demographic characteristics among CKD patients (N=100) Variables n(% ) M(SD) Age 44.20±13.04 Male 61(61) Gender Female 39(39) Religion Islam 95(95)

Hindu 05(05) Single 12 (12) Marital status Married 88 (88) Illiterate 38(38) High School 34(34) Educational Background Under Graduate 27(27) Post Graduate 01(01) Un-employed 54(54) Employment status Employed 46(46) ≤4 26(26) Number of Family member ≥5 74(74) ≤23000 50(50) Monthly family income 22710 ±5494 ≥ 250000 50(50) BMI 24 ±13.00 Under Weight 03(03) BMI Normal 59(59) Over Weight 38(38) ≤9 31(31) Years of treatment for CKD in Months 10-14 36(36) 13 ±5.02 ≥15 33(33) Smoker 51(51) Smoking history Non-Smoker 49(49) Absent 59(59) Co-morbidity history Hypertension 39(39) DM 02(02) Yes 11(11) Nutritional education No 89(89)

Table 2 shows the mean scores to measures management of fluid restriction related characteristics. The mean score of the management of fluid restriction related characteristics was 2.04. The most common management of fluid restriction related characteristics actions were: drinking warm water (3.32); use unsalted butter or margarine (3.25) and rinse the mouth with warm water (3.16). Among the frequent measures we found: avoid eating spicy food (1.29); record the amount of daily fluid intake (1.24) and check the amount of salt on product labels (1.23).

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Table 2: Distribution of management of fluid restriction behavior related characteristics (N=100) Variables M(SD) Avoid eating spicy food 1.29 (±.47) Avoid foods with plenty of water 1.49(±.61) Avoid to exceed the amount of liquid daily allowed 2.77(±1.17) Eat thick soup 3.00(±.69) Reduce soup consumption 2.75(±.73) Drinking only half a glass or cup half 2.02(±.79) Drink cold liquids 2.92(±.63) Drink only at meals 1.85(±.73) Distributing the allowed volume of fluids day along 1.64(±.59) Use small glass or cup to drink 1.96(±.76) Gargle with water without swallowing 2.74(±.81) Fill a bottle with the allowed liquid volume for the whole day 1.59(±.66) Estimate the amount of fluid you can drink daily 1.49(±.55) Eat a piece of fruit to reduce thirst 2.68(±.82) Control the fluid amount by symptoms 1.53(±.61) Sucking lemon slice 2.80(±.73) Rinse the mouth with warm water 3.16(±.83) Drinking warm water 3.32(±.82) Adjust the amount of liquid according diuresis 1.34(±.06) Record the amount of daily fluid intake 1.24(±.42) Avoid instant food 1.39(±.54) Avoid ketchup 1.86(±.69) Avoid fast food 2.11(±.97) Avoid pre-prepared sauces 1.47(±.57) Avoid salt at the table 1.37(±.52) Reduce salt when cooking 1.41(±.49) Avoid sausage/smoked food 1.68(±.75) Avoid using meat or fish broth to cook 1.78(±.91) Use unsalted butter or margarine 3.25(±1.08) Check the amount of salt on product labels 1.23(±.56) Total 2.04(±.32) Table 3 showed the relationship between demographic characteristic and management of fluid and dietary restriction related characteristics intake. Those who had age trend to have higher management of fluid restriction related characteristics compared to measures to control fluid intake(r=.23), they were statistically different (p=.03). Those who have received nutritional education trend to have significantly more measures to control fluid intake compared to those who did not receive (t=2.72), but there was highly statistically significant (p=.004). Other variables had no significant relationship.

Table 3: Relationship between Demographic characteristic and Management of fluid and diet restriction behavior Related characteristics (N=100). Fluid restriction Dietary restriction Variables M±SD t/F/r(p) M±SD t/F/r(p) Age .23(.018) .13(.18) 20-40 1.96 ±.33 2.23 ±.41 -2.17(.03) -.928(.35) 40-60 2.10 ±.31 2.31 ±.42 Male 2.05 ±.34 2.26 (.45) Gender -.167(.86) -.561 (.57) Female 2.04 ±.29 2.31 (.36) Religion Islam 2.05±.31 2.28±.41 .587(.58) -.152(.88) Hindu 1.91±.53 2.24±.55 Single 1.88±.35 2.12±.46 Marital status 1.75(.10) .125(.23) Married 2.07±.31 2.30±.40 Primary/ bellow 2.11±.05 2.35±.43 Educational Under Graduate 2.03±.07 .94(.44) 2.29±.38 1.14(.34) Background Post Graduate 1.89± -- Employment Un-employed 2.05±.30 2.31±.41 .361(.71) .689(.49) status Employed 2.03±.35 2.25±.42

Hossain MA and Sitara H; Int Aca. J Adv Prct. Nurs; Vol-1, Iss- 1 (Sep-Oct, 2020): 16-25

Family member .85(.39) .09(.34) ≤4 1.96±.32 2.22±.40 -1.60(.11) .773(.44) ≥5 2.07±.32 2.30±.42 Income .61(.54) .37(.71) ≤25000 2.04±.31 2.28±.38 .256(.80) -.201(.84) ≥ 25000 2.06±.38 2.25±.52 BMI .11(.27) .00(.95) ≤23 2.08±.32 2.26±.41 -.132(.18) -.314(.75) ≥23 1.99±.33 2.29±.42 Years of ≤9 1.96±.36 2.27±.48 treatment for 10-14 2.09±.29 1.6(.20) 2.32±.33 .41(.66) CKD in Months ≥15 2.08±.31 2.23±.43 Smoker 2.02±.35 2.24±.48 Smoking history -.648(.51) -1.03(.30) Non-Smoker 2.07±.29 2.32±.33 Absent 2.23±.35 2.36±.21 Co-morbidity Hypertension 2.35±.41 .85(.19) 2.31±.25 .65(.23) history DM 2.21±.52 2.38±.35 Nutritional Yes 2.25±.26 2.49±.21 2.72(.01) 3.04(.006) education No 2.02±.32 2.25±.26

ISCUSSION adaptive effort of patients. Measures to the management D of fluid restriction related characteristics a mean score The aim of this study was to explore the of 2.04. Patients seem to be aware of the importance of pattern of the dietary and fluid restriction behavior avoiding spicy foods and candy, conditions that cause among admitted patients with chronic kidney disease in thirst. They also seem to respect the need to not exceed Bangladesh. This study focused on describing the socio- the daily amount of fluids allowed, attentive to use demographic characteristics, dietary and fluid unsalted butter or margarine, rinse the mouth with restrictions behavior among admitted patients with warm water and to reduce soup consumption. Weight CKD in Bangladesh. The Fluid restriction behavior control, estimate the amount of fluid daily intake and which were consisted of measures to manage the dietary adjust the fluid intake according to diuresis, they were restrictions to cover two areas; fluid intake and salt less used measures, perhaps because they are complex reduction. The Dietary restriction behavior which were and impractical actions. Sucking ice temporarily consisted of self-care measures to manage fluid relieves thirst, but may increase the water intake if used restriction to cover two areas; potassium restriction and very often ( Cristovao, 2015). over phosphorus restriction. Restrictive measures prevail among actions to Socio-demographic characteristics of the reduce salt, stressing the limitations imposed by disease participants participating in the study were presented in and by treatment. It is possible that patients are Table 1. A total of 100 participants recruited in the avoiding Asian food and fast food due to nutritional study. The average age was 44.20 ±13.04 years with an habits of Portuguese elderly people. High scores age range from 20-60 years.61.0% were male, 95.0% regarding avoid salt at table and when cooking, and were Islam among the participants 88% were married. avoiding smoked and salty food, suggest that patients For the educational background of the participant, are aware and make some effort to prevent thirst. 38.0% were illiterate and only 1% was post-graduate. Patients may also rarely check the salt content on labels Among participants, 54% of participants were due to visual problems, due to poor food diversification, unemployed and 74% of participants who had family or because labels do not always provide clear member 5 or more. An annual income of family ranges information. These results suggest that subjects from 12000-35000 taka and mean was 22710 takas. perceive the importance of salt restriction to reduce Maximum participants were normal BMI (59%) with thirst ( Cristovao, 2015, Tomson, 2001 & Porcu et al., the mean of 24 and pattern of treatment range were 36% 2007). in month. More than 50% of participants were smoker and only1% of the respondents was consumed alcohol. The measures to Management of Dietary Whereas more than participants‟ comorbidity history Restriction Related characteristics a mean score of 2.58. was absent. Only 11% of respondents had received The most common Management of Dietary Restriction nutritional education. Related characteristics actions were: Cook vegetables and potatoes twice; reduce the consumption of raw Among the frequent measures we found: avoid vegetables, avoid pulses and Reduce salt when cooking. eating spicy food; record the amount of daily fluid Among the frequent measures we found: Avoid food intake and check the amount of salt on product labels. with high containing potassium; avoid eating more than Table 2 show that the measures most commonly used to two piece of fruit per day and reducing the consumption control fluid intake are restrictive, revealing a strong 23

Hossain MA and Sitara H; Int Aca. J Adv Prct. Nurs; Vol-1, Iss- 1 (Sep-Oct, 2020): 16-25 of bread and toasts. In order to reduce potassium from fluid restriction behavior among admitted patients with diet, patients can avoid dried fruits so often because chronic kidney disease in Bangladesh. they are mainly consumed during festive seasons. Patients show their commitment to restrict potassium in For the relationship between demographic the diet when implementing so often those restrictive characteristic and management of fluid and dietary measures. However, it seems they follow less often restriction behavior related characteristics intake among recommendations as vegetables and potatoes twice and admitted patients with CKD who had age trend to have reduce the consumption of raw vegetables. It is possible higher management of fluid restriction related that those are impractical measures. Patients also can characteristics compared to measures to control fluid eat more bread and milk, because they are common and intake(r=.23), they were statistically different (p=.03) inexpensive food, and being well tolerated by people. and who have received nutritional education trend to Eat less meat or fish meal may be due to the weak have significantly more measures to control fluid intake economic power of elderly people. Oilseeds compared to those who did not receive (t=2.72), but consumption also can be less common because it is there was highly statistically significant (p=.004). Other mainly consumed. variables had no significant relationship.

(Cristovao, 2015) For the Relationship between Demographic Dietary restriction in CKD forms part of the characteristic and total Fluid and Dietary Restriction management of the condition and its goal is to minimize Related behavior of participants who had age trend to uremic and anemia symptoms, reduce the incidence of have higher behavior (r=.19), they were statistically fluid, electrolyte and acid base imbalances, decrease different (p=.05) and who have received nutritional patient‟s vulnerability to infections and limit catabolism education trend to have significantly more behavior (Morton & Fontaine,2009). Yet diet plays a pivotal role about fluid and diet restriction (t=2.27), but there was in the effective management of CKD as it lowers highly statistically significant (p=.03). morbidity, improve survival and clinical outcomes (Carman, Adams et al., 2013) This study explored statistically significance between demographic characteristic and management of As mentioned by Fitzsimons, "the sensation of fluid and dietary restriction related characteristics intake thirst is basic to our very existence. Its gratification is among admitted patients with CKD who have had universally held to be one of the pleasures of life; it higher age and nutritional education, showed cannot be ignored, and if water be lacking, the sensation significantly higher fluid and diet restrictions behavior. comes to dominate our thoughts and behavior”. So, Hospital can consider those characteristics to guide fighting against this vital instinct might be really Patients with Chronic Kidney Disease. arduous and stressful. In our sample, younger participants and the ones with higher BMI > 23 kg/m2 Limitations of the Study perceived even more difficult to control fluid intake. It The study was conducted in only specialized hospital in was found that Dialysis Thirst Inventory score was Dhaka city which doesn‟t represent the whole directly correlated with BMI and inversely with age. characteristics of patients with CKD in Bangladesh. (Bellomo, Coccetta, Pasticci , Rossi & Selvi , 2015). In this study, those who have 40 years or more, they can‟t Recommendations management of fluid restriction behavior compare to Based on the study findings, the researcher dietary restriction behavior. They require nutritional proposes the following recommendations- education as well.  Nurse and patients‟ communication should improve for the development of treatment of CKD patient. The present study revealed that, most of  Patient‟ counselling should be developed in the indoor participants had poor nutrition knowledge. Although and outdoor settings. only 11 % of the participants had basic nutrition  Dietician should be enrolled in every hospital especially education from different hospital setting and majority specialized hospital. didn‟t have. That‟s why current study found gaps in Further larger scale studies require to explore the their nutrition-related knowledge. The knowledge level pattern of the dietary and fluid restriction behavior among admitted patients with chronic kidney disease in of healthcare workers was found to be higher (Adeline E. Monomial author, Beatrice W. Mugendi, Onesmo A. Bangladesh from different settings to compare results of Kisanga and George O. Otieno, 2015) due to the the current study. nutrition education received and higher level of professionalism in the application of their knowledge. Acknowledgement All praises to almighty Allah, the

compassionate and merciful who have given me the CONCLUSION opportunity to complete this thesis. I am very much The purpose objectives of an exploratory study humble and grateful to him for providing me with design was to explore the pattern of the dietary and enough energy and patience to carry out and complete this work. It is the enormous necessity to writing this 24

Hossain MA and Sitara H; Int Aca. J Adv Prct. Nurs; Vol-1, Iss- 1 (Sep-Oct, 2020): 16-25 page in an effort to acknowledge those who in all their Lancet, 382(9888), 260-272. possible ways have facilitated me in carrying out and 13. Kidney Disease Statistics for the United States. (2016). completing this work, though this small return in a few retrieved fromhttps://www.niddk.nih.gov/health- words is only a fraction of what I was given by them. information/health-statistics/kidney-disease 14. Lameire, N., Jager, K., Biesen, W. V., Bacquer, D. D., & Vanholder, R. (2005). Chronic kidney disease: A I would like to express my heartiest European perspective. Kidney International, 68, gratefulness to family, friends and colleagues for their Supplement 99 (2005), pp. S30–S38 valuable suggestion, encouragement and wholehearted 15. Lindberg, M. (2010). Excessive Fluid Overload among co-operation. Hemodialysis Patients: Prevalence, Individual Characteristics and Self -regulation of Fluid Intake. 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