Table 1.

Common problems experienced by hemodialysis patients and examples of SCT-based behavioral solutions to enhance self-efficacy

Common problems	Counseling approach
Knowledge deficits, nonadherence to dietary restrictions. The HD diet is complex, requiring patients to be knowledgeable, and aware of their intake of several key nutrients.	The intervention fosters a sense of mastery in adopting the HD diet. PDA self-monitoring permits the patient to become self-aware of their dietary patterns. In collaboration with the dietician the patient sets short-term, achievable goals that permit them to experience success in adhering to their dietary regimen.
Lifestyle change. Giving up favorite foods and otherwise changing dietary patterns require significant motivation and self-discipline.	SCT interventions acknowledge that lifestyle changes do not occur overnight. Using individual counseling, patient values and goals regarding treatment are clarified, and behavior changes required to meet those goals are defined with the patient. “Stepped”, achievable goals are negotiated with the patient, allowing the patient to develop a sense that they are able to succeed in adhering to their diet (mastery). Verbal persuasion is used to reinforce to the patient that they are capable of making dietary changes. Stimulus control methods are use to help patients avoid cues to unhealthy food choices (eg, avoiding the chips and soda aisle when shopping) or change their response to cues by building healthier habits (eg, eating unsalted pretzels instead of potato chips). Involving the patient’s social support system is employed to encourage sustained healthy food choices.
Disruption of meals by dialysis. Our preliminary data and our clinical observations support the notion that dialysis treatments disrupt normal meals (either because of the timing of dialysis, or because patients feel “washed-out” after dialysis and do not feel like cooking or eating).	The dietician works with the patient to problem solve around meal disruptions. Example solutions could be drinking a can of Boost when the patient does not feel like eating, packing a meal the night before to take to the dialysis center, preparing meals in advance, cooking in volume and freezing single serving size meals.
Intra- and post-dialytic symptoms. Intradialytic hypotension and post-dialysis symptoms are associated with the rapid removal of fluid during dialysis and are particularly problematic in patients with large interdialytic weight gains. During dialysis patients may experience malaise, muscle cramping, nausea, diarrhea, diaphoresis, chest pain, and visual changes. After dialysis, those who have experienced the removal of large amounts of fluid are likely to feel extreme fatigue.	The dietitian works with the patient to identify the physiologic symptoms associated with high interdialytic weight gains, and recognize improvements that occur as a result of successes in reducing dietary sodium intake.
Anorexia, change in sense of taste. As a result of these changes, many HD patients do not eat properly.	Similar to giving-up favorite foods, eating a sufficient amount of food may be a challenge to HD patients; motivation and self-discipline are required. As described in the “lifestyle” section above, verbal persuasion, mastery performance, stimulus control, and use of social support systems will be useful in assisting patients in making healthy food choices. Problem solving methods are used to identify and maximize incorporation of food preferences into the daily diet.
Dietary intolerances, diarrhea	The dietician will work with the patients to problem solve around dietary intolerances, eg, suggesting alternative foods, gradual increases in serving sizes, etc.
Limited economic resources. Patients may have difficulty with the cost of healthy food choices.	The dietician will problem solve with the patient to identify inexpensive food choices, and will refer to the social worker as necessary to obtain assistance whenever possible.
Periodic illness and hospitalization. Progress toward achieving a healthier diet may be interrupted by illness, hospitalization, or dietary lapses.	Patients will be counseled with regard to how they can deal with lapses and relapses. They will be told that lapses and relapses are common, and that they should not be discouraged by these. When lapses occur they are counseled to reformulate goals, as appropriate, to get back “on-track” toward achieving a healthier diet.