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Dietary salt reduction in rural patients with albuminurea using family and community support: the Mima study

Dietary salt reduction in rural patients with albuminurea using family and community support: the... Background: Residents of rural communities are often more socially connected compared to urban dwellers. Using family and community support to motivate health behavior change may be useful in rural settings. The objective of this study was to pilot a salt reduction (SR) intervention for rural albuminuria patients using support from family and neighborhood residents compared to a usual care condition. The primary outcome was change in urine albumin-creatinine ratio (ACR). Methods: All consecutive outpatients with an ACR >= 30 mg/gCr were recruited from the Koyadaira Clinic. Patients self-selected their participation in the intervention group (IG) or the control group (CG) because the rural population expressed concern about not being treated at the same time. In the IG, patients and their families were educated in SR for 30 minutes in their home by experienced dieticians. In addition, patients, families and neighborhood residents were also educated in SR for 2 hours at a public town meeting hall, with educational content encouraging reduction in salt intake through interactive activity. The CG received conventional treatment, and ACR and blood pressure (BP) were measured after 3 months. Results: Of the 37 subjects recruited (20 male, 16 female, mean age; 72.8 ± 9.2 years), 36 completed the 3-month follow up and were analyzed. In the IG, ACR decreased significantly from baseline (706 ± 1,081 to 440 ± 656; t = 2.28, p = 0.04) and was reduced compared to the CG (213 ± 323 to 164 ± 162; F = 3.50, p = 0.07), a treatment effect approaching significance. Systolic BP in the IG (145 ± 14 to 131 ± 13 mmHg; t = 3.83, p = 0.002) also decreased significantly compared to the CG (135 ± 13 to 131 ± 14; F = 4.40, p = 0.04). Conclusions: Simultaneous education of patients, their families and neighborhood residents may be important in rural areas for treatments and interventions requiring health behavior change. Trial registration: UMIN000001972 Background the highest mortality associated with RF in Japan [3]. Albuminuria is a risk marker of renal failure (RF) and its The local government has provided the population with reduction suggests a slowing of RF [1]. Salt reduction regular community health promotion classes, some of (SR) improves the urine albumin-to-creatinin ratio which target SR, but with little success at improving RF (ACR) directly and/or via a reduction of blood pressure outcomes. In contrast, a Japanese urban hospital prac- (BP) [2]. tice showed that SR, guided individually by dieticians, The Koyadaira area is an isolated rural community of decreased urinary protein excretion [4]. There is no approximately 1,000 residents in the Mima City, and has such data available in rural communities, where the health status and health-related behaviors can differ sub- stantially from that of urban communities [5]. Succes- * Correspondence: nsakane@kyotolan.hosp.go.jp 3 sive doctors at the only clinic in this area have tried to Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center. 1-1 Mukuihata-cho, Fushimi-ku, Kyoto tackle this problem using individual dietary guidance, 612-8555, Japan © 2010 Fujiwara et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 2 of 5 http://www.apfmj.com/content/9/1/6 but without success. Patients, their families and neigh- post intervention. They reviewed participants’ food borhood residents are typically more closely related with monitoring logs and provided encouragement for dietary each other in rural areas compared to urban commu- change during monthly visits. The patients in the CG nities [6], suggesting a family and community approach received usual care, which consisted of monthly visits to health behavior change may be warranted. and physician advice to reduce salt. Mima City National Health Insurance Koyadaira Clinic (Koyadaira Clinic) provides care for almost half of Measures all the positive albuminurea patients in this area. We The primary outcome was change in ACR measured conducted a pilot study with these patients to test the before and after the 3 month intervention. ACR was deter- feasibility and effectiveness of a SR intervention that mined by turbidimetric immunoassay in the early morning included patients’ family members and neighbors to urine sample (N-assay TIA Micro Alb NITTOBO, Nittobo help motivate the patients to make dietary changes. Medical Co. Ltd., Tokyo, Japan). Secondary outcomes were changes in systolic and diastolic blood pressures. The Methods blood pressure was measured two times at ten-minute Study design intervals in seated subjects using a mercury sphygmoman- Non-randomized controlled trial. ometer after 5 minutes at rest. Serum creatinine (Cr) levels were determined enzyma- Subjects tically and blood urea nitrogen (BUN) was determined All consecutive outpatients with albuminurea (ACR >= by the urease method. Estimated glomerular filtration 30 mg/gCr) at Koyadaira Clinic from May to October rate (eGFR) (mL/min/1.73 m ) was calculated using the -0.287 2006 were registered with this study which was eGFR equation for Japanese, eGFR = 194 × Age × -1.094 approved by the Ethics Committee of the National Hos- Cr (×0.739, if female) [7]. After an overnight fast, pital Organization Kyoto Medical Center. Each subject body weight was measured using a body fat analyzer gave written informed consent. Participants had no clin- (HBS-354-W, OMRON, Kyoto, Japan); and body mass ical features of RF, ischemic heart disease, or stroke. All index (BMI) wascalculatedasweight inkilograms were invited to join a health promotion class and invite divided by height in meters squared. some of their family and friends to accompany them. The dieticians examined salt intake in the IG during Those who attended the class made up the intervention the group and individual sessions, using Excel Eiyokun group (IG). Those who chose not to attend the class (version 4.5, KENPAKUSHA, Tokyo, Japan) for the made up the control group (CG). assessment of dietary intake by food frequency questionnaire. Intervention Patients in the IG were educated during a 2-hour health Analyses promotion class with their family and neighbors at Statistical analyses were conducted using SPSS II for a public town meeting hall. In addition, a 30-minute windows (version 11.01J, SPSS Inc., Chicago, IL, USA). session on dietary change was held with their families at All data are reported as the means ± SD or n (%). Base- their home. Participants’ medical diagnoses were not line comparisons were performed with Mann-Whitney disclosed in front of neighborhood residents to protect U-test and Chi-square test. A paired t-test was used to patients’ privacy. Four dieticians from outside the com- compare mean systolic and diastolic blood pressures munity conducted the education sessions. They used and ACR before and after the 3 month intervention in interactive exercises, such as pair and small group dis- each group. Two-way analysis of variance (ANOVA) cussion, quizzes to estimate the amount of salt in foods, was performed to compare the difference in changes of etc., to encourage participants’ reduced consumption of ACR, systolic and diastolic pressure in two groups. The traditionally salty Japanese foods. Examples of high salt determinant of statistical significance for all analyses foods, eaten frequently by elderly people in Japan, are was p < 0.05. miso soup, pickled vegetables and soy sauce. The dieti- cians asked the participants to set goals of behavior Results change for reducing salt intake and to record their beha- Study participants vior in daily logs. One month later, the dieticians mailed Of all consecutive 37 outpatients with albuminurea all participants a reminder about their salt reduction (20 male, 16 female, mean age; 72.8 ± 9.2 years, hyperten- goal. sion 94.6%, diabetes 37.8%) enrolled in this study, 36 The doctor, three nurses at the clinic, and two public completed the 3-month follow up. One subject in the IG health nurses in the area assisted with the intervention dropped out on her own initiative. Data of 14 patients in activities and followed the subjects for three months the IG and 22 patients in the CG were analyzed. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 3 of 5 http://www.apfmj.com/content/9/1/6 Table 1 Baseline characteristics Variables Intervention group Control group P value (n = 14) (n = 22) Sex (male/female) 11/3 9/13 0.041 Age (y) 69.0 ± 11.0 75.1 ± 7.2 0.111 Body Mass Index (kg/m ) 24.1 ± 3.1 24.9 ± 3.8 0.417 Systolic blood pressure (mmHg) 145.1 ± 13.9 134.9 ± 13.1 0.041 Diastolic blood pressure (mmHg) 67.1 ± 8.3 66.4 ± 12.2 0.733 Hb (%) 6.7 ± 1.8 5.1 ± 0.4 <0.001 A1C BUN (mg/dL) 15.2 ± 3.3 18.9 ± 6.6 0.149 Cr (mg/dL) 0.8 ± 0.2 1.0 ± 0.4 0.745 ACR (mg/gCr) 706.1 ± 1082.1 212.5 ± 322.5 0.427 b 2 eGFR (mL/min/1.73 m ) 71.6 ± 23.4 59.6 ± 23.3 0.173 Stage of chronic kidney disease Stage 1: eGFR >= 90 2 (14.3) 3 (13.6) Stage 2: 60~89 7 (50.0) 10 (45.5) Stage 3: 30~59 5 (35.7) 5 (22.7) Stage 4: 15~29 0 (0.0) 4 (18.2) Stage 5: <15 0 (0.0) 0 (0.0) 0.376 Antihypertensive drugs Any antihypertensive drugs 11 (78.6) 19 (86.4) 0.541 Rennin-angiotensin system blocking drugs 11 (78.6) 15 (68.2) 0.497 Dietary salt intake (g/day) 12.0 ± 3.5 - - Abbreviation: Hb , glycosylated hemoglobin; BUN, blood urea nitrogen; Cr, serum creatinine; ACR, urine albumin-creatinine ratio; eGFR, estimated glomerular A1C filtration rate Data are mean ± SD or n (%). P value were calculated by Mann-Whitney U-test and Chi-square test if categorical variables were used. b -1.094 -0.287 Calculated using eGFR equation for Japanese, eGFR = 194 × Cr ×Age (× 0.739, if female) [7]. Only subjects in intervention group were examined by dieticians using Food Frequency Questionnaire. Baseline characteristics of the sample are shown in activities designed to encourage reduction of the in Table 1. The proportion of males and the levels of patients’ dietary salt intake. To our knowledge, this is systolic blood pressure and Hb in the IG were signif- the first report on social support to involve patients’ A1C icantly higher than that in the CG. Salt intake was esti- neighbors in a patient education intervention. mated only in the IG and found to be 12.0 ± 3.5 g/day It is meaningful for the subjects to be educated in at baseline. sodium reduction. Salt intake in the IG at baseline was 12.0 g/day, which is more than the 11.2 g/day, mean of Changes in ACR and blood pressure the Japanese population [8]. Recommended salt intake is Primary and secondary outcomes at three months are less than 10 g/day for the general population [9] and shown in Table 2. ACR decreased significantly in the less than 6 g/day for chronic kidney disease patients [7]. IG, and approached significance compared to that of the This study was conducted as a pilot study in a rural CG (p = 0.070). Systolic blood pressure decreased signif- population sensitive to not being treated at the same icantly in both the within and between-group time, therefore, we let the subjects decide whether to comparisons. join the intervention activities or not. As a result, char- acteristics were different between the IG and the CG. Discussion Randomized controlled trials, likely requiring multiple The present study shows promise for decreasing ACR in centers, are needed in the future. the group of albuminurea patients encouraged to reduce A major limitation of the present study relates to sam- salt intake with their families and neighborhood resi- ple size. Convenience sampling was used, and no sample dents together. The intervention focused on goal setting size determination was performed. Therefore it is possi- fordietary SR andusedfamilyand neighborstooffer ble that the statistically insignificant findings are the support to patients in a rural area where close human result of low power. relationships remain. The study shows innovation by In addition, there was possible treatment contamina- including patients’ families and neighborhood residents tion (sharing of intervention information) between the Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 4 of 5 http://www.apfmj.com/content/9/1/6 Table 2 Primary and secondary outcome at 3 months Variables Intervention group Control group Between-group difference (n = 14) (n = 22) (p value ) Primary outcome ACR (mg/gCr) Baseline 706.1 ± 1081.2 212.5 ± 322.5 After 3 months 440.0 ± 656.3 163.5 ± 161.5 Change -266.1 ± 436.3 -49.0 ± 261.2 0.070 Within-group difference 0.040 0.388 (p value ) Secondary outcome Systolic blood pressure (mmHg) Baseline 145.1 ± 13.9 134.9 ± 13.1 After 3 months 130.9 ± 12.9 130.9 ± 14.0 Change -14.3 ± 13.9 -4.0 ± 14.6 0.043 Within-group difference 0.002 0.212 (p value ) Diastolic blood pressure (mmHg) Baseline 67.1 ± 8.3 66.4 ± 12.2 After 3 months 62.7 ± 7.6 66.8 ± 7.8 Change -4.4 ± 7.6 0.5 ± 11.3 0.165 Within-group difference 0.048 0.853 (p value ) Abbreviation: ACR, urine albumin-creatinine ratio Data are mean ± SD. Two-way ANOVA Paired t-test Author details IG and the CG. The study community is so small that Mima City National Health Insurance Koyadaira Clinic. 295 Kawai, Koyadaira, subjects in both groups may have shared the content of Mima-shi, Tokushima 777-0302, Japan. Division of Community and Family the intervention activities when chatting in their neigh- Medicine, Center for Community Medicine, Jichi Medical University. 3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329-0498, Japan. Division of Preventive borhood, at the waiting room at Koyadaira Clinic, etc. Medicine, Clinical Research Institute, National Hospital Organization Kyoto Since outcomes tended to improve in both groups, one Medical Center. 1-1 Mukuihata-cho, Fushimi-ku, Kyoto 612-8555, Japan. might assume that both groups benefited from the inter- Department of Clinical Laboratory Medicine, Jichi Medical University. 3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329-0498, Japan. Division of Public Health, vention. Finally, we should have measured salt intake in Center for Community Medicine, Jichi Medical University. 3311-1 Yakushiji, the CG as was done for the IG. Baseline characteristics Shimotsuke-shi, Tochigi 329-0498, Japan. Department of Behavioral were different between the IG and the CG, so it is possi- Medicine, Pennington Biomedical Research Center. 6400 Perkins Road, Baton Rouge, Louisiana 70808, USA. ble that salt intake was not similar between the two groups. Authors’ contributions SF conceptualized, designed, acquired funding, collected and analyzed data, and drafted the manuscript. KK, EK and NS contributed to conception, Conclusions design, analysis and interpretation of data and writing the manuscript. PJB In addition to the patients themselves, simultaneous participated in revising the manuscript critically for interpretation of data education of families and neighborhood residents may and meaning of this study design. PJB and EK gave final approval of the versions to be published. KT, YM, MD and YS managed this study, organized improve outcomes in rural patients, suggesting a possi- the intervention activities and collected data. All authors read and approved ble community element to motivation for health beha- the final manuscript. vior change in this population. Future studies are Competing interests needed to examine this hypothesis. The authors declare that they have no competing interests. Received: 14 August 2009 Accepted: 25 February 2010 Acknowledgements Published: 25 February 2010 We thank Mr. Fumiyuki Eguchi, Ms. Kazue Amaki, Ms. Kiyoko Sako, Ms. Akemi Kawaguchi and Mr. Makoto Hote (Mima City National Health Insurance References Koyadaira Clinic), Ms. Megumi Harada and Ms. Junko Izumi (Mima City 1. Basi S, Lewis JB: Microalbuminuria as a target to improve cardiovascular Koyadaira General Office) for technical assistance. This study was supported and renal outcomes. Am J Kidney Dis 2006, 47:927-946. in part by a grant-in-aid from the Foundation for the Development of the Community in Japan. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 5 of 5 http://www.apfmj.com/content/9/1/6 2. Jones-Burton C, Mishra SI, Fink JC, Brown J, Gossa W, Bakris GL, Weir MR: An in-depth review of the evidence linking dietary salt intake and progression of chronic kidney disease. Am J Nephrol 2006, 26:268-275. 3. Ministry of Health, Labour and Welfare: Vital Statistics in Japan. Tokyo 2003. 4. Kuriyama S, Tomonari H, Ohtsuka Y, Yamagishi H, Ohkido I, Hosoya T: Salt intake and the progression of chronic renal diseases. Nippon Jinzo Gakkai Shi 2003, 45:751-758. 5. Fogelholm M, Valve R, Absetz P, Heinonen H, Uutela A, Patja K, Karisto A, Konttinen R, Mäkelä T, Nissinen A, Jallinoja P, Nummela O, Talja M: Rural- urban differences in health and health behaviour: A baseline description of a community health-promotion programme for the elderly. Scand J Public Health 2006, 34:632-640. 6. Cabinet Office, Government of Japan: Public Opinion Polls, Tokyo 2004. 7. Matsuo S, Imai E, Horio M, Yasuda Y, Tomita K, Nitta K, Yamagata K, Tomino Y, Yokoyama H, Hishida A, Collaborators developing the Japanese equation for estimated GFR: Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis 2009, 53:982-992. 8. Ministry of Health, Labour and Welfare: National Nutrition Survey. Tokyo 9. Ministry of Health, Labour and Welfare: Health Japan 21. Tokyo 2000. doi:10.1186/1447-056X-9-6 Cite this article as: Fujiwara et al.: Dietary salt reduction in rural patients with albuminurea using family and community support: the Mima study. Asia Pacific Family Medicine 2010 9:6. 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Dietary salt reduction in rural patients with albuminurea using family and community support: the Mima study

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Springer Journals
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Copyright © 2010 by Fujiwara et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/1447-056X-9-6
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20184743
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Abstract

Background: Residents of rural communities are often more socially connected compared to urban dwellers. Using family and community support to motivate health behavior change may be useful in rural settings. The objective of this study was to pilot a salt reduction (SR) intervention for rural albuminuria patients using support from family and neighborhood residents compared to a usual care condition. The primary outcome was change in urine albumin-creatinine ratio (ACR). Methods: All consecutive outpatients with an ACR >= 30 mg/gCr were recruited from the Koyadaira Clinic. Patients self-selected their participation in the intervention group (IG) or the control group (CG) because the rural population expressed concern about not being treated at the same time. In the IG, patients and their families were educated in SR for 30 minutes in their home by experienced dieticians. In addition, patients, families and neighborhood residents were also educated in SR for 2 hours at a public town meeting hall, with educational content encouraging reduction in salt intake through interactive activity. The CG received conventional treatment, and ACR and blood pressure (BP) were measured after 3 months. Results: Of the 37 subjects recruited (20 male, 16 female, mean age; 72.8 ± 9.2 years), 36 completed the 3-month follow up and were analyzed. In the IG, ACR decreased significantly from baseline (706 ± 1,081 to 440 ± 656; t = 2.28, p = 0.04) and was reduced compared to the CG (213 ± 323 to 164 ± 162; F = 3.50, p = 0.07), a treatment effect approaching significance. Systolic BP in the IG (145 ± 14 to 131 ± 13 mmHg; t = 3.83, p = 0.002) also decreased significantly compared to the CG (135 ± 13 to 131 ± 14; F = 4.40, p = 0.04). Conclusions: Simultaneous education of patients, their families and neighborhood residents may be important in rural areas for treatments and interventions requiring health behavior change. Trial registration: UMIN000001972 Background the highest mortality associated with RF in Japan [3]. Albuminuria is a risk marker of renal failure (RF) and its The local government has provided the population with reduction suggests a slowing of RF [1]. Salt reduction regular community health promotion classes, some of (SR) improves the urine albumin-to-creatinin ratio which target SR, but with little success at improving RF (ACR) directly and/or via a reduction of blood pressure outcomes. In contrast, a Japanese urban hospital prac- (BP) [2]. tice showed that SR, guided individually by dieticians, The Koyadaira area is an isolated rural community of decreased urinary protein excretion [4]. There is no approximately 1,000 residents in the Mima City, and has such data available in rural communities, where the health status and health-related behaviors can differ sub- stantially from that of urban communities [5]. Succes- * Correspondence: nsakane@kyotolan.hosp.go.jp 3 sive doctors at the only clinic in this area have tried to Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center. 1-1 Mukuihata-cho, Fushimi-ku, Kyoto tackle this problem using individual dietary guidance, 612-8555, Japan © 2010 Fujiwara et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 2 of 5 http://www.apfmj.com/content/9/1/6 but without success. Patients, their families and neigh- post intervention. They reviewed participants’ food borhood residents are typically more closely related with monitoring logs and provided encouragement for dietary each other in rural areas compared to urban commu- change during monthly visits. The patients in the CG nities [6], suggesting a family and community approach received usual care, which consisted of monthly visits to health behavior change may be warranted. and physician advice to reduce salt. Mima City National Health Insurance Koyadaira Clinic (Koyadaira Clinic) provides care for almost half of Measures all the positive albuminurea patients in this area. We The primary outcome was change in ACR measured conducted a pilot study with these patients to test the before and after the 3 month intervention. ACR was deter- feasibility and effectiveness of a SR intervention that mined by turbidimetric immunoassay in the early morning included patients’ family members and neighbors to urine sample (N-assay TIA Micro Alb NITTOBO, Nittobo help motivate the patients to make dietary changes. Medical Co. Ltd., Tokyo, Japan). Secondary outcomes were changes in systolic and diastolic blood pressures. The Methods blood pressure was measured two times at ten-minute Study design intervals in seated subjects using a mercury sphygmoman- Non-randomized controlled trial. ometer after 5 minutes at rest. Serum creatinine (Cr) levels were determined enzyma- Subjects tically and blood urea nitrogen (BUN) was determined All consecutive outpatients with albuminurea (ACR >= by the urease method. Estimated glomerular filtration 30 mg/gCr) at Koyadaira Clinic from May to October rate (eGFR) (mL/min/1.73 m ) was calculated using the -0.287 2006 were registered with this study which was eGFR equation for Japanese, eGFR = 194 × Age × -1.094 approved by the Ethics Committee of the National Hos- Cr (×0.739, if female) [7]. After an overnight fast, pital Organization Kyoto Medical Center. Each subject body weight was measured using a body fat analyzer gave written informed consent. Participants had no clin- (HBS-354-W, OMRON, Kyoto, Japan); and body mass ical features of RF, ischemic heart disease, or stroke. All index (BMI) wascalculatedasweight inkilograms were invited to join a health promotion class and invite divided by height in meters squared. some of their family and friends to accompany them. The dieticians examined salt intake in the IG during Those who attended the class made up the intervention the group and individual sessions, using Excel Eiyokun group (IG). Those who chose not to attend the class (version 4.5, KENPAKUSHA, Tokyo, Japan) for the made up the control group (CG). assessment of dietary intake by food frequency questionnaire. Intervention Patients in the IG were educated during a 2-hour health Analyses promotion class with their family and neighbors at Statistical analyses were conducted using SPSS II for a public town meeting hall. In addition, a 30-minute windows (version 11.01J, SPSS Inc., Chicago, IL, USA). session on dietary change was held with their families at All data are reported as the means ± SD or n (%). Base- their home. Participants’ medical diagnoses were not line comparisons were performed with Mann-Whitney disclosed in front of neighborhood residents to protect U-test and Chi-square test. A paired t-test was used to patients’ privacy. Four dieticians from outside the com- compare mean systolic and diastolic blood pressures munity conducted the education sessions. They used and ACR before and after the 3 month intervention in interactive exercises, such as pair and small group dis- each group. Two-way analysis of variance (ANOVA) cussion, quizzes to estimate the amount of salt in foods, was performed to compare the difference in changes of etc., to encourage participants’ reduced consumption of ACR, systolic and diastolic pressure in two groups. The traditionally salty Japanese foods. Examples of high salt determinant of statistical significance for all analyses foods, eaten frequently by elderly people in Japan, are was p < 0.05. miso soup, pickled vegetables and soy sauce. The dieti- cians asked the participants to set goals of behavior Results change for reducing salt intake and to record their beha- Study participants vior in daily logs. One month later, the dieticians mailed Of all consecutive 37 outpatients with albuminurea all participants a reminder about their salt reduction (20 male, 16 female, mean age; 72.8 ± 9.2 years, hyperten- goal. sion 94.6%, diabetes 37.8%) enrolled in this study, 36 The doctor, three nurses at the clinic, and two public completed the 3-month follow up. One subject in the IG health nurses in the area assisted with the intervention dropped out on her own initiative. Data of 14 patients in activities and followed the subjects for three months the IG and 22 patients in the CG were analyzed. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 3 of 5 http://www.apfmj.com/content/9/1/6 Table 1 Baseline characteristics Variables Intervention group Control group P value (n = 14) (n = 22) Sex (male/female) 11/3 9/13 0.041 Age (y) 69.0 ± 11.0 75.1 ± 7.2 0.111 Body Mass Index (kg/m ) 24.1 ± 3.1 24.9 ± 3.8 0.417 Systolic blood pressure (mmHg) 145.1 ± 13.9 134.9 ± 13.1 0.041 Diastolic blood pressure (mmHg) 67.1 ± 8.3 66.4 ± 12.2 0.733 Hb (%) 6.7 ± 1.8 5.1 ± 0.4 <0.001 A1C BUN (mg/dL) 15.2 ± 3.3 18.9 ± 6.6 0.149 Cr (mg/dL) 0.8 ± 0.2 1.0 ± 0.4 0.745 ACR (mg/gCr) 706.1 ± 1082.1 212.5 ± 322.5 0.427 b 2 eGFR (mL/min/1.73 m ) 71.6 ± 23.4 59.6 ± 23.3 0.173 Stage of chronic kidney disease Stage 1: eGFR >= 90 2 (14.3) 3 (13.6) Stage 2: 60~89 7 (50.0) 10 (45.5) Stage 3: 30~59 5 (35.7) 5 (22.7) Stage 4: 15~29 0 (0.0) 4 (18.2) Stage 5: <15 0 (0.0) 0 (0.0) 0.376 Antihypertensive drugs Any antihypertensive drugs 11 (78.6) 19 (86.4) 0.541 Rennin-angiotensin system blocking drugs 11 (78.6) 15 (68.2) 0.497 Dietary salt intake (g/day) 12.0 ± 3.5 - - Abbreviation: Hb , glycosylated hemoglobin; BUN, blood urea nitrogen; Cr, serum creatinine; ACR, urine albumin-creatinine ratio; eGFR, estimated glomerular A1C filtration rate Data are mean ± SD or n (%). P value were calculated by Mann-Whitney U-test and Chi-square test if categorical variables were used. b -1.094 -0.287 Calculated using eGFR equation for Japanese, eGFR = 194 × Cr ×Age (× 0.739, if female) [7]. Only subjects in intervention group were examined by dieticians using Food Frequency Questionnaire. Baseline characteristics of the sample are shown in activities designed to encourage reduction of the in Table 1. The proportion of males and the levels of patients’ dietary salt intake. To our knowledge, this is systolic blood pressure and Hb in the IG were signif- the first report on social support to involve patients’ A1C icantly higher than that in the CG. Salt intake was esti- neighbors in a patient education intervention. mated only in the IG and found to be 12.0 ± 3.5 g/day It is meaningful for the subjects to be educated in at baseline. sodium reduction. Salt intake in the IG at baseline was 12.0 g/day, which is more than the 11.2 g/day, mean of Changes in ACR and blood pressure the Japanese population [8]. Recommended salt intake is Primary and secondary outcomes at three months are less than 10 g/day for the general population [9] and shown in Table 2. ACR decreased significantly in the less than 6 g/day for chronic kidney disease patients [7]. IG, and approached significance compared to that of the This study was conducted as a pilot study in a rural CG (p = 0.070). Systolic blood pressure decreased signif- population sensitive to not being treated at the same icantly in both the within and between-group time, therefore, we let the subjects decide whether to comparisons. join the intervention activities or not. As a result, char- acteristics were different between the IG and the CG. Discussion Randomized controlled trials, likely requiring multiple The present study shows promise for decreasing ACR in centers, are needed in the future. the group of albuminurea patients encouraged to reduce A major limitation of the present study relates to sam- salt intake with their families and neighborhood resi- ple size. Convenience sampling was used, and no sample dents together. The intervention focused on goal setting size determination was performed. Therefore it is possi- fordietary SR andusedfamilyand neighborstooffer ble that the statistically insignificant findings are the support to patients in a rural area where close human result of low power. relationships remain. The study shows innovation by In addition, there was possible treatment contamina- including patients’ families and neighborhood residents tion (sharing of intervention information) between the Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 4 of 5 http://www.apfmj.com/content/9/1/6 Table 2 Primary and secondary outcome at 3 months Variables Intervention group Control group Between-group difference (n = 14) (n = 22) (p value ) Primary outcome ACR (mg/gCr) Baseline 706.1 ± 1081.2 212.5 ± 322.5 After 3 months 440.0 ± 656.3 163.5 ± 161.5 Change -266.1 ± 436.3 -49.0 ± 261.2 0.070 Within-group difference 0.040 0.388 (p value ) Secondary outcome Systolic blood pressure (mmHg) Baseline 145.1 ± 13.9 134.9 ± 13.1 After 3 months 130.9 ± 12.9 130.9 ± 14.0 Change -14.3 ± 13.9 -4.0 ± 14.6 0.043 Within-group difference 0.002 0.212 (p value ) Diastolic blood pressure (mmHg) Baseline 67.1 ± 8.3 66.4 ± 12.2 After 3 months 62.7 ± 7.6 66.8 ± 7.8 Change -4.4 ± 7.6 0.5 ± 11.3 0.165 Within-group difference 0.048 0.853 (p value ) Abbreviation: ACR, urine albumin-creatinine ratio Data are mean ± SD. Two-way ANOVA Paired t-test Author details IG and the CG. The study community is so small that Mima City National Health Insurance Koyadaira Clinic. 295 Kawai, Koyadaira, subjects in both groups may have shared the content of Mima-shi, Tokushima 777-0302, Japan. Division of Community and Family the intervention activities when chatting in their neigh- Medicine, Center for Community Medicine, Jichi Medical University. 3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329-0498, Japan. Division of Preventive borhood, at the waiting room at Koyadaira Clinic, etc. Medicine, Clinical Research Institute, National Hospital Organization Kyoto Since outcomes tended to improve in both groups, one Medical Center. 1-1 Mukuihata-cho, Fushimi-ku, Kyoto 612-8555, Japan. might assume that both groups benefited from the inter- Department of Clinical Laboratory Medicine, Jichi Medical University. 3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329-0498, Japan. Division of Public Health, vention. Finally, we should have measured salt intake in Center for Community Medicine, Jichi Medical University. 3311-1 Yakushiji, the CG as was done for the IG. Baseline characteristics Shimotsuke-shi, Tochigi 329-0498, Japan. Department of Behavioral were different between the IG and the CG, so it is possi- Medicine, Pennington Biomedical Research Center. 6400 Perkins Road, Baton Rouge, Louisiana 70808, USA. ble that salt intake was not similar between the two groups. Authors’ contributions SF conceptualized, designed, acquired funding, collected and analyzed data, and drafted the manuscript. KK, EK and NS contributed to conception, Conclusions design, analysis and interpretation of data and writing the manuscript. PJB In addition to the patients themselves, simultaneous participated in revising the manuscript critically for interpretation of data education of families and neighborhood residents may and meaning of this study design. PJB and EK gave final approval of the versions to be published. KT, YM, MD and YS managed this study, organized improve outcomes in rural patients, suggesting a possi- the intervention activities and collected data. All authors read and approved ble community element to motivation for health beha- the final manuscript. vior change in this population. Future studies are Competing interests needed to examine this hypothesis. The authors declare that they have no competing interests. Received: 14 August 2009 Accepted: 25 February 2010 Acknowledgements Published: 25 February 2010 We thank Mr. Fumiyuki Eguchi, Ms. Kazue Amaki, Ms. Kiyoko Sako, Ms. Akemi Kawaguchi and Mr. Makoto Hote (Mima City National Health Insurance References Koyadaira Clinic), Ms. Megumi Harada and Ms. Junko Izumi (Mima City 1. Basi S, Lewis JB: Microalbuminuria as a target to improve cardiovascular Koyadaira General Office) for technical assistance. This study was supported and renal outcomes. Am J Kidney Dis 2006, 47:927-946. in part by a grant-in-aid from the Foundation for the Development of the Community in Japan. Fujiwara et al. Asia Pacific Family Medicine 2010, 9:6 Page 5 of 5 http://www.apfmj.com/content/9/1/6 2. Jones-Burton C, Mishra SI, Fink JC, Brown J, Gossa W, Bakris GL, Weir MR: An in-depth review of the evidence linking dietary salt intake and progression of chronic kidney disease. Am J Nephrol 2006, 26:268-275. 3. Ministry of Health, Labour and Welfare: Vital Statistics in Japan. Tokyo 2003. 4. Kuriyama S, Tomonari H, Ohtsuka Y, Yamagishi H, Ohkido I, Hosoya T: Salt intake and the progression of chronic renal diseases. Nippon Jinzo Gakkai Shi 2003, 45:751-758. 5. Fogelholm M, Valve R, Absetz P, Heinonen H, Uutela A, Patja K, Karisto A, Konttinen R, Mäkelä T, Nissinen A, Jallinoja P, Nummela O, Talja M: Rural- urban differences in health and health behaviour: A baseline description of a community health-promotion programme for the elderly. Scand J Public Health 2006, 34:632-640. 6. Cabinet Office, Government of Japan: Public Opinion Polls, Tokyo 2004. 7. Matsuo S, Imai E, Horio M, Yasuda Y, Tomita K, Nitta K, Yamagata K, Tomino Y, Yokoyama H, Hishida A, Collaborators developing the Japanese equation for estimated GFR: Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis 2009, 53:982-992. 8. Ministry of Health, Labour and Welfare: National Nutrition Survey. Tokyo 9. Ministry of Health, Labour and Welfare: Health Japan 21. Tokyo 2000. doi:10.1186/1447-056X-9-6 Cite this article as: Fujiwara et al.: Dietary salt reduction in rural patients with albuminurea using family and community support: the Mima study. Asia Pacific Family Medicine 2010 9:6. 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Asia Pacific Family MedicineSpringer Journals

Published: Feb 25, 2010

References