The hardest part: Changing habits
Effective CKD treatment must emphasize lifestyle management. You need to persuade smokers to quit and “couch potatoes” to start exercising regularly. Eating habits need to change, as well: This means fewer calories and restrictions on intake of salt and certain minerals. Medications for high blood pressure, diabetes, and kidney disease need to be taken consistently, as prescribed. The TABLE reviews the lifestyle issues that are particularly salient at each stage of CKD.
TABLE
Keying interventions to CKD stages
| Stage | Description | GFR (mL/min/1.73 m2) | Clinical action | Lifestyle management |
|---|---|---|---|---|
| At increased risk | ≥60 (with CKD risk factors) | Screening; CKD risk reduction | Healthy habits according to public health recommendations | |
| 1 | Kidney damage with normal or increased GFR | ≥90 | Diagnosis and treatment; treatment of comorbid conditions; slowing of progression; CVD risk reduction | Emphasis on heart health: physical activity, healthy diet, weight management, and stress management. Restricted sodium, potassium, calcium, phosphorus, and protein, with emphasis on plant vs animal food sources. Treatment adherence to medications and CV/diabetes/hypertension treatment plan if applicable. Assessment of depression and referral to treatment if appropriate. |
| 2 | Kidney damage with mildly decreased GFR | 60-89 | Same, plus estimation of progression | Same recommendations as stage 1 |
| 3 | Moderately decreased GFR | 30-59 | Same, plus evaluation and treatment of complications | Same recommendations as stage 1 |
| 4 | Severely decreased GFR | 15-29 | Preparation for kidney replacement therapy | Same as above, plus assessment of social support to prepare for dialysis treatment if appropriate |
| 5 | Kidney failure | <15 or dialysis | Replacement (if uremia present) | Same as above, plus restricted fluid intake and additional protein intake |
| Note: Shaded area identifies patients who have CKD; unshaded area designates individuals who are at increased risk for developing CKD. CKD is defined as either kidney damage or GFR <60 ml/min/1.73 m2 for ≥3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. | ||||
| CKD, chronic kidney disease; CVD, cardiovascular disease; GFR, glomerular filtration rate. | ||||
| Adapted from: Table 3: chronic kidney disease: a clinical action plan. National Kidney foundation. KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. 2002. | ||||
Lifestyle modifications like these are very difficult, and helping patients make them involves much more than simple patient education. In 1 study, Durose et al found that patients on hemodialysis failed to stay on their diets even when they knew which dietary restrictions they should follow and what the consequences of going off their diets would be.30
Update your persuasive techniques: take on the role of coach
Newer theories of behavior change no longer rely on simply providing information and advice, but rather address the complex interaction of motivations involved in attempts to change. These include cues to action, perception of benefits and consequences, environmental and cultural influences, sense of self-efficacy, ambivalence, and the intention to change.31
Unfortunately, health care providers are rarely trained in motivational techniques. Often, their approach to inducing change is authoritarian, confrontational, overly forceful, or guilt inducing. Such attitudes not only limit progress, but are actually correlated with negative behavioral and clinical outcomes.32,33 Recent research has verified the power of the patient–provider interaction in influencing treatment adherence and lifestyle change.33
To be successful in getting patients to adopt new behaviors, physicians need to move away from authoritarian modes and take on some of the attributes of a coach urging on the team.
How this coaching technique works
Motivational Interviewing is a health coaching technique that has been shown to be causally and independently associated with positive behavioral outcomes.34 The techniques used in the motivational interviewing approach are summarized in “The motivational interviewing tool kit”. Motivational interviewing is a goal-oriented, patient-centered counseling style for helping patients explore and resolve their ambivalence about behavior change.35 The approach has been used in diverse populations, settings, and medical conditions. Its efficacy was first demonstrated in the treatment of addictions to illegal drugs and alcohol.36 Continued research and 2 recent meta-analyses using rigorous methodology have validated the usefulness of this approach.37,38
The motivational interviewing tool kit
Express empathy
Objective: To establish rapport and avoid resistance by demonstrating your understanding of the patient’s situation.
Example: “It’s not easy making all these changes.”
Follow-up: “But you also say you know these numbers put you at risk for more serious disease.”
Roll with resistance
Objective: To avoid magnifying resistance by allowing patients to explore their barriers in a nonjudgmental, supportive manner.
Example: “You really don’t want to take the medication anymore. It’s hard to remember and you don’t feel sick, so you don’t see why you need it.”
Follow-up: “I’m wondering where you see yourself in 6 months if you stop taking the medication?”
Elicit/provide reminder/elicit
Objective: To find out what the patient already knows, fill in the gaps or correct misconceptions, and explore how the change you suggest will fit into the patient’s life. This is a time-saving strategy that both validates patient knowledge and allows time to address barriers.
Example:
Elicit: “Mrs. Roberts, can you tell me what you know about managing your chronic kidney disease?”
Provide reminder: “That’s great. You’ve pretty much got it nailed. I’d just like to remind you about taking your statin medications and keeping close track of your blood pressure.”
Elicit: “What do you think the biggest barrier is for you right now in managing this condition?”
Support autonomy
Objective: To reduce resistance by assuring patients you know you can’t make them do anything—it’s their choice.
Example: “Of course, it’s your choice, but as your doctor, I’d be concerned if you decided not to try this medication.”
Follow-up: “Nobody can make you do anything that you don’t want to do. You need to consider all your options and make the choice that’s right for you at this time. If you do decide to try this medication, I assure you that we will monitor any side effects closely and adjust the dosage to minimize any problems.”
Explore ambivalence
Objective: To help the patient consider the pros and cons of change in a relaxed yet systematic manner.
Example: “So let’s talk about the pros and cons of trying to quit smoking at this time.”
Follow-up: “Let me see if I can summarize where you are. On the one hand, it’s pretty stressful for you right now and smoking helps you cope. You’ve tried to quit before and you couldn’t keep it up for very long. On the other hand, you really do understand the damage it’s doing to your body and how it is making it more difficult for us to treat your heart disease. Your wife is willing to quit with you and you’ve heard about this new quit medication that can help curb cravings. Did I get it all? What are you thinking you are going to do?”
Elicit change talk
Objective: To evoke the patient’s reasons, desire, ability, and need for change. This “change talk” predicts increased commitment to the lifestyle change, which, in turn, is correlated to a good clinical outcome.
Examples:
“What makes it important to you to start an exercise program?”
“What benefits would come from losing weight?”
“Why do you want to quit smoking?”
Follow-up: “You know that exercise will help you manage your stress, lose some weight, and lower your cholesterol levels. Plus, when you did it before, you had more energy and slept better. You also want to be a good role model for the kids and be able to play sports with them.”
Develop an action plan
Objective: To help the patient develop a plan that is realistic and fits into his or her life. When a patient “owns” the plan, he or she is more likely to follow through.
Examples:
“So what’s the next step for you?”
“What do you think you could do (and would be willing to do) for your health right now that would make the most difference?”
“What do you think your best option is?”
Follow-up: “You’ve outlined a great plan. You’re going to try to eat more vegetables and less meat, plus cut back on portion sizes. You’re also going to try and walk more. Lastly, you’re willing to try the pill box to see if it makes it easier to take your medications correctly.” (Pause). “So, are you going to do this?”