远程饮食记录法与纸质3 d饮食记录法对慢性肾脏病患者营养管理依从性的影响研究

背景　慢性肾脏病（CKD）及其并发症极大地影响了患者的生命健康，有证据表明营养管理是CKD的良好辅助治疗手段，但患者的依从性是管理难点，远程管理或可提高依从性，但其效果尚不明确。目的　比较远程饮食记录法与纸质3 d饮食记录法对CKD患者营养管理依从性的影响。方法　选取2017-11-01至2018-12-31于广东省中医院就诊的CKD 3~5期非透析患者91例为研究对象，按照随机数字表法将其分为远程组和纸质组，其中远程组43例，纸质组48例，两组均采用基础治疗及营养管理，远程组应用远程系统随访并记录3 d饮食；纸质组采用面对面随访，纸质作业记录3 d饮食。观察时间48周，每4周随访1次，共12个随访时间点。对比两组患者干预过程中的依从性指标，包括基于饮食作业计算的蛋白摄入量（饮食作业-DPI）、基于总氮排出量蛋白相当量（nPNA）计算的蛋白摄入量（nPNA-DPI）、基于饮食作业计算的热量摄入量（饮食作业-DEI）。结果　混合线性模型结果显示，分组情况、随访时间点是饮食作业-DPI及nPNA-DPI的影响因素（饮食作业-DPI：F分组=58.046，P<0.001；F随访时间=22.236，P<0.001；nPNA-DPI：F分组=95.096，P<0.001；F随访时间=14.420，P<0.001）；分组情况是饮食作业-DEI的影响因素（F分组=234.715，P<0.001）。远程组第9、12随访时间点nPNA-DPI低于纸质组，差异有统计学意义（t=-2.142，P=0.035；t=-2.191，P=0.031）；远程组第6随访时间点饮食作业-DPI合格率高于纸质组，差异有统计学意义（χ2=5.099，P=0.024）；远程组第3、6、12随访时间点nPNA-DPI合格率高于纸质组，差异有统计学意义（χ2=4.317，P=0.038；χ2=6.889，P=0.009；χ2=6.920，P=0.009）；两组第12随访时间点的估计肾小球滤过率、腰臀比、身体总水分、去脂体质量、上臂围、上臂肌围及血红蛋白、白蛋白、三酰甘油、总胆固醇水平比较，差异无统计学意义（P>0.05）。结论　运用远程或纸质3 d饮食记录法均可以优化CKD患者蛋白质及热量的摄入；一些随访时间点，远程随访优于纸质记录及线下随访，提示结合目前移动医疗的新进展进行慢性病管理的重要性。

Effects of Remote Diet Record versus Paper-based Three-day Diet Record on Nutritional Management Compliance of Patients with CKD

Background　Chronic kidney disease（CKD） and its complications greatly affect patients with CKD.There is evidence that nutrition management is a good adjuvant treatment for CKD，but patients' compliance is the difficulty of management.Remote management may improve compliance，but its effect is not clear.Objective　To compare the effects of remote diet record and paper-based three-day diet record on the nutrition management compliance of CKD patients.Methods　From November 1，2017 to December 31，2018，91 cases of CKD stage 3-5 patients（n=91） without dialysis treatment were recruited from Guangdong Provincial Hospital of Chinese Medicine.According to the random number table，they were divided into remote group and paper group.Essential treatment and nutrition management were given to them，and the information about three-day diet of 43 cases was collected and recorded via using the remote follow-up system in the remote group，and that of other 48 cases was collected by face-to-face interviews and was noted down as paper records in the paper group.The observation time was 48 weeks，during which a total of 12 follow-ups（a follow-up once every 4 weeks） were conducted.The compliance indices of the two groups during intervention were compared，including diet protein intake calculated based on diet dairy（dietary task-DPI），diet protein intake calculated based on normalized protein equivalent of nitrogen appearance rate（nPNA-DPI），and daily energy intake calculated based on diet diary（dietary task-DEI）.Results　The analysis using the mixed linear model found that，the model with dietary task-DPI was influenced by grouping and follow-up time（Fgrouping=58.046，P<0.001；Ffollow-up=22.236，P<0.001），and so was the model with nPNA-DPI（Fgrouping=95.096，P<0.001；Ffollow-up=14.420，P<0.001）.And the grouping was the influencing factor of dietary task-DEI as well（Fgrouping=234.715，P<0.001）.Compared to paper group，the remote group showed significantly lower average nPNA-DPI at the 9th and 12th follow-ups（t=-2.142，-2.191；P=0.035，0.031）.Moreover，the remote group showed much higher qualified rate of dietary task-DPI at the 6th follow-up（χ2=5.099，P=0.024），and much higher qualified rate of nPNA-DPI at the 3rd，6th and 12th follow-ups（χ2=4.317，6.889，6.920；P=0.038，0.009，0.009）.There were no significant differences in estimated glomerular filtration rate，waist-to-hip ratio，total body moisture，fat-free body mass，upper arm circumference，upper arm muscle circumference，hemoglobin，albumin，total cholesterol and triglyceride between the two groups at the 12th follow-up（P>0.05）.Conclusion　The protein and calorie intake of CKD patients can be optimized by remote diet record or paper-based three-day diet diary.In some aspects，the method of remote follow-up may be better than the paper record and offline follow-up.This suggests the importance of chronic disease management combined with the current progress of mobile medicine.