- 學位論文
以飲食蛋白質與磷教育改善血液透析患者蛋白質營養狀態及血磷值
Dietary Protein and Phosphorus (DPP) education program for improving protein nutritional status and serum phosphorus level in hemodialysis patients
摘要
根據2003年美國國家腎臟基金會（National Kidney Foundation, NKF）提出「腎臟疾病治療成果品質建議指南」（Kidney / Disease Outcomes Quality Initiative, K/DOQI），建議血液透析患者血磷值控制目標訂為3.5~5.5 mg/dL。但是50%血液透析患者未達此目標（Voormolen et al., 2007），導致血液透析患者高血磷的原因為血液透析療程無法完全移除由飲食所獲得的磷量，若患者又不遵從飲食或藥物處方會導致血磷升高。當患者對食物和營養素認知不充足時，「限磷飲食」造成患者因害怕攝取過多磷而減少飲食蛋白質攝取量，導致患者發生營養不良及蛋白質─熱量耗損情形（Shinaberer et al., 2006）。因此本研究欲整合健康教育理論架構，使血液透析患者在獲得充足熱量和蛋白質攝取情況下，針對限磷飲食與配合正確使用磷結合劑為目標，藉由營養師一對一營養教育介入方式，期望提升患者對飲食磷控制的認知、態度和實行，並維持營養狀態及血磷值的理想目標。 研究在2010年9月至2011年3月於台北市立萬芳醫院進行收案，對象為20至85歲之規律血液透析患者，長期血液透析治療達3個月以上，篩選條件為由病歷取得近3個月抽血報告中至少1次以上之血磷值 ≧ 5.0 mg/dL或白蛋白值 ≦ 4.0 g/dL。共招募130位患者，符合篩選條件者為123位，並徵求願意參加教育介入，將受試者分為介入組及控制組，兩組人數分別為40人及83人。本研究為實驗型研究，期間共6個月。介入組接受3個月期間的飲食蛋白質與磷教育計畫，共6次課程，並追蹤觀察介入後3個月；控制組僅接受常規照護流程，並追蹤觀察6個月。由知識、態度和行為問卷分析得，介入組受試者（n = 36）在教育介入後顯著增加對足夠營養、限磷飲食及藥物的認知、態度和實行，且較控制組高。由第3個月飲食紀錄分析得介入組受試者顯著增加熱量及蛋白質攝取量，而飲食磷與蛋白質比例並未改變。由6個月內血液生化數值分析得，介入組受試者營養狀態指標，包括：血清白蛋白值及老年人營養風險指標（geriatric nutritional risk index, GNRI）有維持；而血磷及鈣磷乘積在教育介入期內顯著較起始期降低，但未持續至追蹤期。控制組受試者（n = 80）在6個月期間，由血液生化數值分析得營養狀態指標亦維持穩定，而蛋白質攝取量顯著較起始期增加，但其血磷亦隨之增加。結論，課程設計在教育理論下，結合健康信念模式、行為修正理論，經過3個月由臨床營養師執行密集的飲食蛋白質與磷教育計畫介入後，加強血液透析患者在增加飲食熱量和蛋白質攝取情況下，提升患者對飲食磷控制的認知、態度和實行，且有良好的食物選擇行為，達到維持理想的營養狀態及血磷控制目標。
並列摘要
Fifty percent hemodialysis (HD) patients have hyperphosphatemia. The phosphorus clearance isn’t enough to remove the phosphors absorbing from food. If patients didn’t comply diet and medications, may accelerate increasing serum phosphorus level. Unfortunately, phosphorus restriction is the most misunderstood and the most difficult renal diet for patients to comply (Durose et al., 2004). When there is not sufficient knowledge of nutrients, phosphorus restriction may lead to reduce protein intake, therefore increasing risks of protein-energy wasting and malnutrition (Shinaberer et al., 2006). The aim of this study was to evaluate the education model designed Dietary Protein and Phosphorus (DPP) education program. To achieve adequate dietary intake, complying phosphorus restriction with proper use of phosphorus binders and improving the knowledge, attitude and practice of dietary phosphorus management; witch was conducted by dietitian one-to-one consulting to maintain nutritional status and optimal serum phosphorus level among HD patients. Subjects were recruited from adult outpatients with end-stage renal disease (ESRD) undergoing regular hemodialysis in Wanfang Hospital between September 2010 and March 2011. Inclusion criteria comprised age between 20 to 85 years, chronic dialysis therapy at least 3 months. Before entry into the program, serum phosphorus and albumin levels were monitored for 3 months. Patients with either serum phosphorus above 5.0 mg/dL or serum albumin level less than 4.0 g/dL during last 3 months were invited to participate. A total of 123 patients were eligible, and were classified to intervention or control group according to individual intention. Our study is a 6-months experimental study among 6-months periods. Intervention group received 3-months DPP education program and 3-months follow-up observation periods. Inversely, control group received standard practice and 6-months follow-up observation periods. The results showed that the knowledge, attitude and practice (KAP) scores had significantly increased in intervention group and significantly higher than control group after DPP intervention. Daily dietary calorie and protein intake had significantly increased in intervention group at month 3, whereas dietary phosphorus-to- protein ratio did not change. Serum phosphorus level and calcium phosphorus product had significantly decreased in intervention periods, whereas indicators of nutritional status, including serum albumin and geriatric nutritional risk index (GNRI) score had maintained in intervention group. Inversely, indicators of nutritional status had also maintained in control group, whereas serum phosphorus and calcium phosphorus product had significantly increased with protein intake increasing. This 3-months education theoretical designed Dietary Protein and Phosphorus Program had successfully reinforced subjects increasing dietary calorie and protein intake, improving the knowledge, attitude and practice of dietary phosphorus management and obtaining better food choice behavior to maintain nutritional status and optimal serum phosphorus level.