Journal of Renal Nutrition
Volume 21, Issue 2 , Pages 188-195, March 2011

Self-Management and Biomedical Outcomes of a Cooking, and Exercise Program for Patients with Chronic Kidney Disease

  • Mary Flesher, RD, RN, BSN, MA

      Affiliations

    • Richmond Health Services, Vancouver Coastal Health, Vancouver, BC, Canada
    • Corresponding Author InformationAddress reprint requests to Mary Flesher, RD, RN, BSN, MA, Richmond Health Services, 7000 Westminster Highway, Richmond, BC, Canada V6X 1A2.
    • ,
  • Paula Woo, RD, BSc (Dietetics)

      Affiliations

    • Richmond Health Services, Vancouver Coastal Health, Vancouver, BC, Canada
    • ,
  • Anthony Chiu, MD

      Affiliations

    • Richmond Health Services, Vancouver Coastal Health and Providence Health Care, Vancouver, BC, Canada
    • ,
  • Ashley Charlebois, RD, BSc (Dietetics), MSc, CEP

      Affiliations

    • Cardiovascular Physiology and Rehabilitation Laboratory, Experimental Medicine Program, Faculty of Medicine University of British Columbia, Vancouver, BC, Canada
    • ,
  • Darren E.R. Warburton, PhD, CEP

      Affiliations

    • Cardiovascular Physiology and Rehabilitation Laboratory, Experimental Medicine Program, Faculty of Medicine University of British Columbia, Vancouver, BC, Canada
    • ,
  • Barbara Leslie, RD, BSc (Dietetics)

      Affiliations

    • HealthLinks British Columbia, Nutrition Services, British Columbia, Canada

published online 22 July 2010.

Article Outline

Background

Limited research has been done on integrating cooking and exercise classes into the routine care of chronic kidney disease (CKD) patients. The main purpose of the research was to determine whether the addition of these services would slow the progression of certain CKD parameters.

Methods

The study evaluated 5 endpoints, at baseline, 6 months, and 12 months: urinary protein, blood pressure, urinary sodium, glomerular filtration rate, and total cholesterol between 2 groups (control group receiving CKD standard care and experimental group receiving standard care plus cooking and exercise classes). Eighty percent of the experimental group was hypothesized to improve in 4 out of the 5 endpoints versus ≤50% in the control group with a P-value of 0.05. An overall difference of 30% was anticipated between the 2 groups. The research also compared self-efficacy and health status outcomes using a self-management questionnaire.

Results

Forty randomly assigned patients participated in the study (17 controls and 23 experimental). In the control group, 2 of 17 people improved in at least 4 of the 5 endpoints. In the experimental group, 14 of 23 people improved in at least 4 of the 5 endpoints.

Conclusions

Sixty-one percent of experimental subjects showed improvements in 4 of 5 endpoints, showing a significant difference overall when compared with the control group (12% improved in 4 out of 5 endpoints). In looking at the trend in qualitative measures from the comparison of the self-management questionnaire, the overall trend showed more improved answers with the experimental group versus the control group.

 

CHRONIC KIDNEY DISEASE (CKD) is prevalent, affecting approximately 6% of Canadians and a British Columbia (BC) estimated prevalence of 145,000 people.1 With a population of 182,826,2 the estimated prevalence of kidney disease in Richmond is approximately 11,000, many of whom are undiagnosed. Although there is no cure for CKD, the goal is to prolong the effective functioning of the kidney through early detection and treatment. For many patients, lifestyle changes including diet, exercise, and controlling blood pressure can keep their kidney functioning as long as possible.1

Although many renal clinics have an interdisciplinary approach to treating CKD, inclusion of the self-management approach is not routine. As a result, some patients may struggle with self-efficacy in the management of their disease. The self-management approach would enable patients to learn life skills and the day-to-day management of their health conditions through the following: (a) nutrition and cooking classes, (b) exercise classes, and (c) group visits with the physician and/or health professional. Promoting patient involvement has been found to improve a variety of health outcomes such as health status, self-management, and ability to cope.3 Self-management empowers patients to manage their own chronic diseases and to navigate the health care system effectively.3 Promoting this health activity and independence has been shown to be effective in reducing health care utilization.4

Routine physical activity has been shown to markedly reduce lipids5 and blood pressure.6, 7 The nutritional management of reducing sodium and protein intake has been shown to benefit blood pressure8 and improve proteinuria9 for CKD patients. Furthermore, decreasing proteinuria has the added benefit for CKD patients in improving the dose-response relationship between cardiovascular events and reductions in albuminuria.10 Although the combination of exercise with nutritional management has shown cardiovascular benefits,11 no studies were found that looked at combining a regimen of exercise and nutrition education in the form of group cooking classes to delay the progression of CKD.

The main purpose of the research was to determine whether a comprehensive nutrition program of individual counseling, group cooking classes, and an exercise program would reduce cardiovascular risk factors and slow the progression of certain CKD parameters. This research looked at both quantitative and qualitative measures. The primary objective of the study was to evaluate urinary protein, blood pressure, urinary sodium, A1C, and total cholesterol between 2 groups (control group receiving standard care in CKD and the experimental group receiving standard care plus cooking and exercise classes). Because there were not enough participants with diabetes (approximately 45% in both groups), a decision was made to replace the A1C as an endpoint and use the estimated glomerular filtration rate (eGFR) instead. The secondary objective was to evaluate self-efficacy, self-management, health status outcomes, and health system utilization in both groups of patients with CKD.

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Subjects and Methods 

Ethics approval was obtained from University of British Columbia Clinical Research Ethics Board and the Vancouver Coastal Health Authority Research Advisory Committees. The study was in adherence with the Declaration of Helsinki, and no authors had a conflict of interest related to the study. Preliminary calculations with a statistician from the Vancouver Coastal Health Research Institute were made in choosing the sample size. For a moderate to large effect size, 102 participants would need to be recruited (51 in the experimental group and 51 in the control group) to obtain a hypothesized difference in proportion of 0.3 (α = 0.5, power of 90%) in improvement levels of primary outcome variables. The inclusion criteria comprised individuals who met the following: (a) an eGFR of 20 to 60 mL/minute for ≥3 months; (b) presence of urinary protein; (c) adult (≥19 years of age); (d) hypertension or taking at least 1 anti-hypertensive medication; and (e) physician approval to exercise. Participants also included individuals with comorbidities such as hypertension, cardiovascular disease, and diabetes.

Patients with CKD were recruited through a nephrologist and general practitioners within the Greater Vancouver area. Most participants were residents of Richmond and 2 lived in the Vancouver area. Subjects were fluent in English, Cantonese, or Mandarin languages, reflecting the ethnic population in Richmond. The researchers recruited additional participants through other nephrologists from Richmond Hospital and Vancouver General Hospital by distributing recruitment posters to nephrology clinics within the Vancouver area. Physicians selected eligible CKD patients, referring them to the Garratt Wellness Centre in Richmond for an information session. Participants signed consents forms, and then were randomly assigned to participate in the study, to allow access to their blood and urine tests, and to participate in the exercise program.

Standard nutritional care included dietary counselling on moderate protein and low sodium, with individualized modification of potassium and/or phosphate. Participants did not complete a food record in either group, but their diet history was discussed in detail at the individual appointments. The experimental group received standard care (i.e., individual nutrition counselling) plus a group CKD nutrition class, CKD cooking classes with a dietitian and cook educator, CKD cookbook and 12-week exercise program led by a Certified Exercise Physiologist (CEP) and Nurse. The classes were offered in English, Cantonese, and Mandarin to accommodate the main languages spoken in the Richmond area. The cooking classes were offered over 4 weeks for 2 hours a session, and an additional week included a shopping tour led by a dietitian. Each cooking class focused on a different topic (self-management, sodium, protein, potassium, phosphate, label reading/eating out), with education provided by a dietitian and a cook educator leading participants in preparing and tasting recipes from the provided CKD cookbook.

The 12-week exercise class was offered in the fully equipped gym at the Garratt Wellness Centre, and consisted of 3 1-hour sessions per week with aerobic, strength training, and flexibility components led by a certified exercise physiologist and a nurse. The classes consisted of 30 minutes aerobic activity (treadmill, cross-trainer, stationary bike, recombinant bike, rowing machine), followed by resistance training with the certified exercise physiologist. Patients recorded their blood pressure, monitored their heart rates with a heart-rate monitor, and recorded both in an exercise log. All classes offered to the experimental group included a self-management focus, in using goal-setting and building confidence in the management of their disease. The control group consisted of standard care for CKD. Both experimental and control group patients were tested for fitness (weight, height, waist circumference, grip strength, flexibility, blood pressure, arterial compliance, and 6-minute submaximal walk test), blood tests, urine tests, and blood pressure at baseline, 6 months, and 12 months. This was to determine if there were changes in the chosen parameters as a result of the interventions. The testing at the 6-month mark was to determine if the cooking classes and cookbook had made any impact on the endpoint parameters. The testing at the 12-month mark was to determine whether the exercise program, which started after the 6-month testing, had made any difference to the endpoint parameters being measured.

Endpoints were chosen in collaboration with the Nephrologist and based on the literature. There were 5 endpoints measured along with the self-management questionnaire (Table 1) that were measured at baseline, 6 months, and 12 months. The experimental and control groups both had the same endpoint parameters measured for comparison. The endpoints included the following: urinary protein, blood pressure, urinary sodium, total cholesterol, and eGFR. The CEPs measured their own testing parameters during the study as this was a joint study with a Masters Student and CEP from the University of British Columbia's (UBC) Department of Experimental Medicine and the Richmond Health Services. The parameters measured by the UBC Department of Experimental Medicine included a Physical Activity Readiness Questionnaire, anthropometrics and musculoskeletal fitness measures, resting measures of cardiovascular health, and a 6-minute submaximal walk test.12 The results of the fitness testing by the CEP are not reported in this portion of the study.

Table 1. Analysis of Quantitative Data
EndpointNumber From Control Group Who Improved (n = 17)Experimental Group Who Improved (n = 23)P-value (Fisher Exact Test)
eGFR (≤10% reduction)8/17 (mean reduction 11.2%)19/23 (mean reduction 1.2%).209
Total cholesterol (≥10% reduction)9/1719/23.271
Urinary sodium (≥20% reduction)2/17 (mean increase 12%)19/23 (mean reduction 52%).007
Urinary protein (≥25% reduction)8/17 (mean reduction 15%)12/23 (mean reduction 25%).539
Blood pressure (reduction of systolic by ≥13 mm Hg and diastolic by ≥8 mm Hg)3/17 (mean systolic increase 4.2 mm Hg and mean diastolic reduction 1.5 mm Hg)14/23 (mean systolic reduction 12.3 mm Hg and mean diastolic reduction 8.9 mm Hg).065
Total30 improved endpoints83 improved endpoints.028

The hypothesized changes in the following 5 endpoints: urinary protein, total cholesterol, eGFR, blood pressure, and urinary sodium.

Urinary Protein 

Microalbuminuria and increases in urinary protein are found to be associated with hypertension, a risk factor in CKD.13 Urinary protein was collected at each of the 3 time periods. The chosen endpoint was to reduce the individual's urinary protein by >25% in the study group as compared to no reduction or <25% reduction in the control group. This number was based on studies,14, 15 which showed improvements in proteinuria of 22% to 30% with exercise. A lower protein diet was also shown to improve proteinuria.16 Diabetic patients with persistent albuminuria, who had frequent dietary instruction, showed a 36% reduction in proteinuria by following a restricted protein diet (0.6 to 0.8 g/kg/day), whereas no significant changes in urinary protein were observed in those with normal protein intakes (1.5 g/kg/day).16 Study participants in both the experimental and control groups were instructed on 0.8 g/kg/day of protein.

Total Cholesterol 

Dyslipidemia in patients with CKD are demonstrated through changes in their cholesterol levels, especially through reductions of their high-density lipoproteins (HDL) levels.17, 18, 19 This is significant as HDL promotes the removal of cholesterol through the liver for excretion, thereby reducing a person's cardiovascular risk factors. Regular exercise and a healthy diet are shown to positively impact cardiovascular risk factors by raising HDL levels.18 Research on exercise and cholesterol showed improvements of 27%20 and 10%.21 A ≥10% improvement was chosen for the experimental group and less than 10% improvement for the control group.

Estimated Glomerular Filtration Rate 

Using the BC Ministry of Health Physician Guidelines on Chronic Kidney Disease,1 the target for eGFR is that there be <10% to 15% decline in eGFR annually.1 This was also chosen as an endpoint for the experimental group. The control group was hypothesized to achieve a >10% annual reduction in eGFR.

Blood Pressure 

Hypertension is a significant risk factor for CKD, both in its cardiovascular effects and added stress on compromised kidneys. A decline in kidney function can cause hypertension, while hypertension can contribute to kidney function because of reduced renal blood flow and vasoconstriction.17, 22

Studies on blood pressure and exercise have showed improvements of 10% to 20%.14, 23 Blood pressure was reduced by 1.6 mm Hg systolic and 1.1 mm Hg diastolic for every 1 kg of weight lost in overweight patients and 11.4 mm Hg systolic and 5.5 mm Hg diastolic in those with hypertension following a restricted sodium diet.24 An analysis of randomly controlled studies showed that a reduction of each 100 mmol/day of dietary sodium was associated with a decline of 5 to 7 mm Hg/2.7 mm Hg in hypertensive subjects.25, 26 On the basis of the literature, the experimental group was hypothesized to have a reduction of 10% of both systolic and diastolic blood pressure (or a systolic decrease of 13 mm Hg or more, and diastolic reduction of 8 mm Hg or more) versus a <10% reduction in the control group. Study participants in both the experimental and control groups were instructed on approximately 2000 mg of sodium per day. Weight was measured but not compared for the purpose of this study.

Urinary Sodium 

Despite variability in urinary sodium results, there have been correlations found between diastolic blood pressure and 24-hour urinary sodium excretion, especially in hypertensive patients.27, 28 Patients who consumed low sodium diets had a 17% reduction in diastolic blood pressure in their study.27 Because our cooking classes and nutrition counseling sessions focus on low sodium (essential for CKD and hypertension), patients would be anticipated to reduce their dietary sodium intake and therefore show reductions in their urinary sodium.

The 5 quantitative endpoints compared in experimental and control groups were as follows:

(a)Urinary protein would reduce by more than 25% in the experimental group and less in the control group.

(b)Total cholesterol would be reduced by more than 10% in the experimental group and less in the control group.

(c)eGFR would have less than a 10% annual reduction in the experimental group and more than 10% annual decline in the control group.

(d)Blood pressure would reduce by at least 10% in the experimental group and less in the control group.

(e)Urinary sodium would be reduced by more than 20% in the experimental group and by less in the control group.

Eighty percent of the experimental group was hypothesized to improve in 4 of the 5 endpoints versus 50% or less in the control group with a P-value of .05. An overall difference of 30% was anticipated between the 2 groups, with the experimental group having at least 80% improvement and the control group having 50% or less improvement.

Self-Management Parameters 

Consumers are becoming active participants in their care and this is driving their desire to self-manage their own health care choices.29 Longer life expectancy in the aging population places higher demands on the health care system. Promoting patient involvement has been found to improve health status through enhancement in coping skills, confidence, and satisfaction with care.3 Self-management empowers patients to learn to manage their own chronic diseases and teach them to navigate the health care system effectively. Promoting this health activity and independence has been shown to be effective in reducing health care utilization.4 Primary health care providers who integrate this technique into their teaching can enable patients to gain confidence in the management of their CKD.1

Significant work has been done in chronic disease self-management by the Stanford School of Medicine Patient Education Research Center, and because of this, their questionnaire was chosen for baseline, 6 month, and 12 month testing with both experimental and control groups.30 These qualitative measures were compared for overall changes in the trend of how each patient answered the self-management questionnaire in each of the 3 time periods, and these were recorded as improved, unchanged, or declined. The number of improved answers was compared with the same questions and answers in the control group and noted for their trend; these were not statistically compared.

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Results 

A recommended sample size of 102 was made with a statistician before starting the study. However, despite extensive attempts, only 45 subjects were recruited who met inclusion criteria and who were willing to participate in our program. Two participants in the control group and 3 from the experimental group did not complete the study. One experimental participant died during the research project for an unrelated health reason. The total number of participants who completed the study was 40, 17 in the control group and 23 participants in the experimental group. The average age for the experimental group was 63.4 ± 12.1 years, with about half being of Asian ethnicity. The experimental group included 14 males and 9 females, and their average eGFR at baseline was 37.2 ± 3.2 mL/minute. The control group comprised 7 males and 10 females, with an average age of 63.4 ± 11.8 years and average baseline eGFR of 38.4 ± 3.0.

Statistical Analysis of Quantitative Data 

Analysis of the data was done to see whether the hypothesis was achieved, where 80% of the experimental group would improve in 4 of 5 endpoints versus 50% or less of the control group improving in 4 of 5 endpoints. Each endpoint was compared for the baseline and final result (12-month result) for each person in the control group and experimental group. If a person's endpoint changed according to the hypothesized difference (i.e., urinary protein reduced by 25% from baseline to 12-month measurement, etc.), this was counted as a “success” or improvement in the endpoint. For each individual, the number of “improved” endpoints was counted out of the 5 endpoints measured. If a person “improved” in at least 4 of the 5 endpoints, he/she was considered to have shown an overall “success” according to the hypothesis. In the control group, 2 of the 17 people (12% of control group participants) improved in at least 4 of the 5 endpoints. In the experimental group, 14 of the 23 people (61% of experimental group participants) improved in at least 4 of the 5 endpoints.

Data was compared for individuals and for group averages. Overall the eGFR declined by an average of 1.2% annually within the experimental group, whereas in the control group it declined by 11.2% overall annually. Blood pressure data changes were noted for individuals, and average changes in blood pressure were noted for both the control group and the experimental group. The mean baseline blood pressure for the control group was 139.5/76 mm Hg, and at the third measure, the mean blood pressure was 143.7/74.5 mm Hg (+3%/−2% change from baseline average). For the experimental group, the mean baseline blood pressure was 138.9/78.3 mm Hg and this reduced to 126.6/69.4 mm Hg (−9%/−11% change from baseline average).

Because of the challenges in recruiting participants, the groups could not be statistically compared with the original recommended 102 participants to show a significant difference. However, in comparing the difference between the control group and experimental group, there was a 49% difference between the 2 groups (12% of controls improved, whereas 61% of experimental participants improved). The hypothesized difference was deemed to be 30% between the 2 groups based on a sample size of 102. Using the sample size of 40, the data were compared using the Fisher exact test for smaller sample sizes using the 2 × 2 tables. The total probability or P-value was calculated to be .028 for all 5 endpoints, indicating statistical significance despite the smaller sample size. The P-value for the endpoints done individually showed the most significance in the urinary sodium, with a P-value of .007 and a least significant P-value in urinary protein of .539. On the basis of the original hypothesis where the significance level was set at 0.1, the P-value of .028 for all 5 endpoints was deemed as showing a significant difference between the control and experimental groups (Table 1).

Analysis of Qualitative Data 

Each participant in both the control and experimental groups completed questionnaires at baseline, 6-month, and 12-month periods. Answers from each subject were compared with his or her own baseline responses. Baseline and 12-month were compared. Each individual trend was recorded as improved, unchanged, or declined. Using the standardized scoring of the Self-Management Questionnaire,4 the control group was compared with the experimental group. Overall, the experimental group showed “improvement” in their exercise frequency, concern over health condition, and frequency of visits to health providers or hospitalization. Overall the control group answers indicated an improvement in their communication with health providers in asking questions and discussing personal issues.

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Discussion 

CKD benefits from interdisciplinary treatment in preventing the progression of the disease.1 Lifestyle changes like diet and exercise, and controlling their blood pressure can prolong kidney functioning as long as possible.1 This study examined the impact of quantitative measures of 5 endpoints, and qualitative measures of self-management to determine the impact of CKD cooking classes, exercise program, and self-management techniques on the 40 participants.

Twelve percent of participants from the control group demonstrated improvements in 4 of 5 of their quantitative endpoints. Sixty-one percent of experimental subjects showed improvements in 4 of 5 endpoints, and this was shown to be a significant difference overall when compared with the control group. Specifically, the endpoints that showed the greatest change in the experimental group were urinary sodium and blood pressure. The endpoints eGFR, urinary protein, and total cholesterol, although more improved than the control group, did not show significance for individual participants. These differences may require a larger sample size to demonstrate whether there is a correlation between these programs and these individual parameters.

In looking at the trend in qualitative measures from the comparison of the self-management questionnaire,4 the overall trend showed more improved answers with the experimental group versus the control group. More frequent contact with the healthcare practitioner and application of self-management techniques to care and treatment of patients with CKD may appear to be strong reasons for these improved trends. It is yet unknown whether patients' active participation in self-management exercises (activities taught and modeled in cooking and exercise classes) could have led to improved healthcare self-efficacy as this was not specifically asked in the questionnaires.

This study demonstrated a significant difference in improving the measured endpoints in the experimental group, who participated in CKD cooking classes, and a 12-week exercise program when compared with the control group who received standard care only. With a smaller than anticipated sample size, it may be beneficial to conduct further similar studies with a larger group, and possibly over a longer period of time. Additional qualitative measures would also be useful in determining whether specific classes were perceived to increase self-management by CKD patients.

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References 

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 The only financial support for this study came from $1500 grant from the Vancouver Coastal Health Professional Research Award 2008.

 The manuscript has been seen and approved by all authors and is not being considered for publication elsewhere in a similar form, or language.

PII: S1051-2276(10)00080-4

doi:10.1053/j.jrn.2010.03.009

Journal of Renal Nutrition
Volume 21, Issue 2 , Pages 188-195, March 2011

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