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  1. Lim JH, Chinna K, Khosla P, Karupaiah T, Daud ZAM
    PMID: 33066603 DOI: 10.3390/ijerph17207479
    Dietary non-adherence is pervasive in the hemodialysis (HD) population. Health literacy is a plausible predictor of dietary adherence in HD patients, but its putative mechanism is scarcely studied. Thus, this study aimed to establish the causal model linking nutrition literacy to dietary adherence in the HD population. This was a multi-centre, cross-sectional study, involving 218 randomly selected multi-ethnic HD patients from nine dialysis centres in Klang Valley, Malaysia. Dietary adherence and self-management skills were assessed using validated End-Stage Renal Disease Adherence Questionnaire and Perceived Kidney/Dialysis Self-Management Scale, respectively. Validated self-developed scales were used to gauge nutrition literacy, dietary knowledge and Health Belief Model constructs. Relationships between variables were examined by multiple linear regressions and partial least squares structural equation modeling. Limited nutrition literacy was evident in 46.3% of the HD patients, associated with older age, lower education level, and shorter dialysis vintage. Dietary adherence rate was at 34.9%. Nutrition literacy (β= 0.390, p < 0.001) was an independent predictor of dietary adherence, mediated by self-efficacy (SIE = 0.186, BC 95% CI 0.110-0.280) and self-management skills (SIE = 0.192, BC 95% CI 0.103-0.304). Thus, nutrition literacy-enhancing strategies targeting self-efficacy and self-management skills should be considered to enhance dietary adherence in the HD population.
  2. Lim CK, Lim JH, Ibrahim I, Chan YM, Zakaria NF, Yahya R, et al.
    Diagnostics (Basel), 2021 Sep 23;11(10).
    PMID: 34679443 DOI: 10.3390/diagnostics11101745
    Protein-energy wasting (PEW) is a devastating metabolic derangement that leads to increased morbidity and mortality in hemodialysis (HD) patients. This study aimed to determine the diagnostic test accuracy of bioelectrical impedance analysis derived-phase angle (PhA) in detecting PEW among HD patients. This was a multi-centre, cross-sectional study conducted amongst 152 multi-ethnic HD patients in Klang Valley, Malaysia. PEW was assessed using the International Society of Renal Nutrition and Metabolism criteria as the reference method. PhA was measured using a multi-frequency bioelectrical impedance spectroscopy at 50 kHz. Multiple and logistic regressions were used to determine factors associated with PhA and PEW diagnosis, respectively. A receiver operating characteristics curve analysis was used to establish the gender-specific PhA cut-offs to detect PEW. PEW existed in 21.1% of the HD patients. PhA was found as an independent predictor of PEW (adjOR = 0.308, p = 0.001), with acceptable to excellent discriminative performance (adjAUCmale = 0.809; adjAUCfemale = 0.719). Male patients had higher PhA cut-off compared to female patients (4.26° vs. 3.30°). We concluded that PhA is a valid and pragmatic biomarker to detect PEW in multi-ethnic Malaysian HD patients and a gender-specific cut-off is necessary, attributed to the gender differences in body composition.
  3. Adanan NIH, Adnan WAHWM, Khosla P, Karupaiah T, Daud ZAM
    BMC Nephrol, 2021 02 02;22(1):48.
    PMID: 33530941 DOI: 10.1186/s12882-021-02255-8
    BACKGROUND: The festival of Ramadan is a month of spiritual reflection for Muslims worldwide. During Ramadan, Muslims are required to refrain from eating and drinking during daylight hours. Although exempted from fasting, many patients undergoing maintenance haemodialysis (HD) opt to participate in this religious practice. Many studies have explored the effects of Ramadan on health outcomes, however, the exploration from patients' own point of view pertaining to this religious practice is lacking. Thus, we aimed to explore the experiences and perceptions of Muslim HD patients observing Ramadan fasting from three HD centres in Klang Valley, Malaysia.

    METHOD: An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method.

    RESULTS: Four major themes emerged from the data, namely: (i) "fasting experiences", (ii) "perceived side effects of fasting", (iii) "health-seeking behavior" and, (iv) "education and awareness needs". Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting.

    CONCLUSIONS: Findings of this study shed light on patients' experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.

  4. Lim JH, Lim CK, Ibrahim I, Syahrul J, Mohamed Zabil MH, Zakaria NF, et al.
    JMIR Mhealth Uhealth, 2020 06 01;8(6):e13808.
    PMID: 32478665 DOI: 10.2196/13808
    BACKGROUND: With the unprecedented growth of mobile technology, a plethora of dialysis diet apps have been developed to promote patient dietary self-management. Nevertheless, the utility of such apps remains questionable.

    OBJECTIVE: This study aimed to evaluate the content, features, and quality of commercial dialysis diet apps for adult dialysis patients.

    METHODS: This study consisted of a quantitative content analysis of commercial dialysis diet apps downloaded from Google Play and the Apple App Store available in the Asian marketplace, searched for using the following keywords in English: dialysis diet and diet for kidney disease. Free and paid apps available in English that provide nutrition information for adult dialysis patients were included. Apps that were not relevant to the dialysis diet, not meant for patient self-management, or redundant were excluded. Apps were evaluated for language medium (subscore=1), credibility (subscore=1), food database (subscore=1), valuable features (subscore=12), health-behavior theory constructs (subscore=60), and technical quality (subscore=25). The relationships among the variables of interest were determined by Pearson correlation. Stepwise multiple linear regression analysis was performed to identify the features that contribute to greater technical quality of dialysis diet apps. Statistical significance was defined as P

  5. Khor BH, Narayanan SS, Chinna K, Gafor AHA, Daud ZAM, Khosla P, et al.
    Nutrients, 2018 Sep 21;10(10).
    PMID: 30248953 DOI: 10.3390/nu10101353
    Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP.
  6. Ripon MSH, Ahmed S, Rahman T, Rashid HU, Karupaiah T, Khosla P, et al.
    PLoS One, 2023;18(9):e0291830.
    PMID: 37733829 DOI: 10.1371/journal.pone.0291830
    Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.
  7. Khor BH, Sualeheen A, Sahathevan S, Chinna K, Gafor AHA, Bavanandan S, et al.
    Sci Rep, 2020 07 23;10(1):12278.
    PMID: 32704087 DOI: 10.1038/s41598-020-68893-4
    Sources of dietary phosphate differentially contribute to hyperphosphatemia in maintenance haemodialysis (MHD) patients. This cross-sectional study in Malaysia investigated association between dietary patterns and serum phosphorus in MHD patients. Dietary patterns were derived by principal component analysis, based on 27 food groups shortlisted from 3-day dietary recalls of 435 MHD patients. Associations of serum phosphorus were examined with identified dietary patterns. Three dietary patterns emerged: Home foods (HFdp), Sugar-sweetened beverages (SSBdp), and Eating out noodles (EO-Ndp). The highest tertile of patients in HF (T3-HFdp) pattern significantly associated with higher intakes of total protein (p = 0.002), animal protein (p = 0.001), and animal-based organic phosphate (p  2.00 mmol/l was significantly 2.35 times higher (p = 0.005) with the T3-SSBdp. The SSBdp was associated with greater consumption of inorganic phosphate and higher serum phosphorus levels.
  8. Sualeheen A, Khor BH, Balasubramanian GV, Sahathevan S, Ali MSM, Narayanan SS, et al.
    J Ren Nutr, 2020 07;30(4):322-332.
    PMID: 31767516 DOI: 10.1053/j.jrn.2019.09.010
    OBJECTIVE: This study aimed to (i) determine habitual dietary patterns of Malaysian patients on hemodialysis (HD) and (ii) examine their association with nutritional status.

    METHODS: An à posteriori approach examined 3-day dietary recalls of 382 multiethnic Malaysian patients on HD, leading to short-listing of 31 food groups. Dietary patterns were derived through principal component analysis. Sociodemographic and lifestyle characteristics together with nutritional parameters were examined for associations with specific dietary patterns.

    RESULTS: Four dietary patterns emerged, namely, "Home Food," "Eating Out (EO)-Rice," "EO-Sugar sweetened beverages," and "EO-Noodle." Younger patients, male gender, Malay, and patients with working status were more likely to follow "EO-Rice" and "EO-Sugar sweetened beverages" patterns, while Chinese patients were more likely to consume "EO-Noodle" pattern (all P values 

  9. Ng HM, Khor BH, Sahathevan S, Sualeheen A, Chinna K, Gafor AHA, et al.
    Qual Life Res, 2021 Nov 08.
    PMID: 34748139 DOI: 10.1007/s11136-021-03018-6
    PURPOSE: To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients.

    METHOD: Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model.

    RESULTS: MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS 

  10. Ahmed S, Rahman T, Ripon MSH, Rashid HU, Kashem T, Md Ali MS, et al.
    Nutrients, 2021 Dec 17;13(12).
    PMID: 34960076 DOI: 10.3390/nu13124521
    Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh.
  11. Khor BH, Sahathevan S, Sualeheen A, Ali MSM, Narayanan SS, Chinna K, et al.
    Sci Rep, 2021 01 14;11(1):1416.
    PMID: 33446880 DOI: 10.1038/s41598-020-80812-1
    The metabolic impact of circulating fatty acids (FAs) in patients requiring hemodialysis (HD) is unknown. We investigated the associations between plasma triglyceride (TG) FAs and markers of inflammation, insulin resistance, nutritional status and body composition. Plasma TG-FAs were measured using gas chromatography in 341 patients on HD (age = 55.2 ± 14.0 years and 54.3% males). Cross-sectional associations of TG-FAs with 13 markers were examined using multivariate linear regression adjusted for potential confounders. Higher levels of TG saturated fatty acids were associated with greater body mass index (BMI, r = 0.230), waist circumference (r = 0.203), triceps skinfold (r = 0.197), fat tissue index (r = 0.150), serum insulin (r = 0.280), and homeostatic model assessment of insulin resistance (r = 0.276), but lower malnutrition inflammation score (MIS, r =  - 0.160). Greater TG monounsaturated fatty acid levels were associated with lower lean tissue index (r =  - 0.197) and serum albumin (r =  - 0.188), but higher MIS (r = 0.176). Higher levels of TG n-3 polyunsaturated fatty acids (PUFAs) were associated with lower MIS (r =  - 0.168) and interleukin-6 concentrations (r =  - 0.115). Higher levels of TG n-6 PUFAs were associated with lower BMI (r =  - 0.149) but greater serum albumin (r = 0.112). In conclusion, TG monounsaturated fatty acids were associated with poor nutritional status, while TG n-3 PUFAs were associated with good nutritional status. On the other hand, TG saturated fatty acids and TG n-6 PUFAs had both favorable and unfavorable associations with nutritional parameters.
  12. Khor BH, Sahathevan S, Sualeheen A, Ali MSM, Narayanan SS, Chinna K, et al.
    Nutrition, 2019 01 15;63-64:14-21.
    PMID: 30927642 DOI: 10.1016/j.nut.2019.01.005
    OBJECTIVES: The aims of this study were threefold: first, to assess the dietary fatty acid (FA) intake and blood FA status in Malaysian patients on hemodialysis (HD); second, to examine the association between dietary FA intakes and blood FA profiles in patients on HD; and third, to determine whether blood FAs could serve as a biomarker of dietary fat intake quality in these patients.

    METHODS: Using 3 d of dietary records, FA intakes of 333 recruited patients were calculated using a food database built from laboratory analyses of commonly consumed Malaysian foods. Plasma triacylglycerol (TG) and erythrocyte FAs were determined by gas chromatography.

    RESULTS: High dietary saturated fatty acid (SFA) and monounsaturated fatty acid (MUFA) consumption trends were observed. Patients on HD also reported low dietary ω-3 and ω-6 polyunsaturated fatty acid (PUFA) consumptions and low levels of TG and erythrocyte FAs. TG and dietary FAs were significantly associated respective to total PUFA, total ω-6 PUFA, 18:2 ω-6, total ω-3 PUFA, 18:3 ω-3, 22:6 ω-3, and trans 18:2 isomers (P < 0.05). Contrarily, only dietary total ω-3 PUFA and 22:6 ω-3 were significantly associated with erythrocyte FAs (P < 0.01). The highest tertile of fish and shellfish consumption reflected a significantly higher proportion of TG 22:6 ω-3. Dietary SFAs were directly associated with TG and erythrocyte MUFA, whereas dietary PUFAs were not.

    CONCLUSION: TG and erythrocyte FAs serve as biomarkers of dietary PUFA intake in patients on HD. Elevation of circulating MUFA may be attributed to inadequate intake of PUFAs.

  13. Rahman T, Khor BH, Sahathevan S, Kaur D, Latifi E, Afroz M, et al.
    Nutrients, 2022 Apr 01;14(7).
    PMID: 35406082 DOI: 10.3390/nu14071469
    Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000−40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60−90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.
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