Phosphorus Improvement Pilot Study
Phosphorus Improvement Pilot Study
Specific Aim: To determine the effect of a phosphorus additives educational intervention on
 serum phosphorus levels.

 Hypothesis: Educating dialysis patients regarding phosphate containing additives will result
 in improved serum phosphorus levels.
The amount of phosphorus in the American diet has increased considerably, primarily from
 phosphorus-containing additives in convenience and ready to eat foods (Calvo 1996). It is
 estimated that, depending on individual food choices, additives add as much 1000 mg/day of
 phosphorus to the diet (Bell). Phosphorus in additives is almost entirely absorbed while only
 60% of naturally occurring phosphorus is absorbed (Uribarri 2003). Education regarding high
 phosphorus foods is a key component of hyperphosphatemia management (Ford 2004, Cupisti
 2004), but the use of phosphorus additives may make it difficult for patients and dietitians
 to estimate phosphorus content of foods. It has been suggested that hyperphosphatemia is a
 nutritional barrier to preventing renal bone disease and that an intervention focusing on
 phosphate containing food additives has great potential (Sherman). Our objective is to
 determine the effect of an educational intervention regarding phosphate additives on serum
 phosphorus about 300 chronic hemodialysis patients at Centers for Dialysis Care (CDC) and
 Fresenius Medical Care (FMC) in Cuyahoga County. Facilities will be randomized to
 intervention and control groups. All dietitians and eligible patients at the intervention
 facilities will be invited to take part in the intervention. All dietitians and consenting
 eligible patients at control facilities will form a usual care group. Prior to the trial,
 demographic and medical characteristics, lab data and medications will be collected for the
 previous three months using a chart abstraction and patient interview form. Demographic
 characteristics include age, sex, race, education and insurance status. Medical
 characteristics include dialysis dose, binder prescription, vitamin D dosing, cause of renal
 failure, number of months on dialysis, and major co-morbid conditions. Lab data will include
 albumin, calcium, phosphorus, serum bicarbonate, and PTH. Medication data will include binder
 prescription and bone medications. In the first month of the trial study coordinators will
 meet with intervention and control subjects and assess basic knowledge regarding phosphorus
 content of foods and label reading. Intervention subjects will also receive education
 regarding phosphorus additives and their effect on the phosphorus content of foods, a
 laminated card listing common phosphorus additives, and a handout about additives in foods
 from fast food restaurants where they eat. The subject will be instructed to use the
 materials when shopping or eating out to avoid phosphorous additives. During the 2nd month of
 the trial, study coordinators will contact intervention subjects by phone to reinforce
 educational materials and answer questions. Control subjects will be contacted and asked
 about shopping and eating habits. During the 3rd month the interviews from month 1 will be
 repeated for both intervention and control subjects to assess changes in knowledge.
 Intervention subjects will also be asked to evaluate the phosphorus additives tool and
 provide feedback for evaluating the ease of use and utility. Having a control group that
 receives attention but not the key intervention (phosphorus containing additives education
 and tools) will allow us to distinguish the effect of attention from the effect of the
 intervention. Chart abstraction data on labs, dialysis dose, binder prescription, and vitamin
 D dosing will be collected for all three months of the trial.
Inclusion Criteria:

 -  Most recent phosphorus and mean phosphorus over last 3 months > 5.5 mg/dL

 -  Age ≥ 18 years

 -  On chronic hemodialysis ≥ 6 months

 -  English speaking

 Exclusion Criteria:

 -  Mentally incompetent

 -  AIDS

 -  Cancer

 -  Terminal illness

 -  Pregnancy

 -  Nursing home residence

 -  No telephone access

 -  In another phosphorus related study

 -  Unable to identify written words