Dietary Strategies for Hyperphosphatemia: A Randomized Controlled Study on the Effectiveness of Phosphate-Specific Interventions in Reducing Serum Phosphate Levels in Hemodialysis Patients in a Dialysis Center
Phase: NA
Conditions: Hyperphosphataemia, Phosphorus, Diet Therapy, Chronic Kidney Disease 5D
Sponsor: Kufa University

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Dietary Strategies for Hyperphosphatemia: A Randomized 
Controlled Study on the Effectiveness of Phosphate-Specific 
Interventions in Reducing Serum Phosphate Levels in 
Hemodialysis Patients in a Dialysis Center 
Prepared by Authors: 
Hassan Ali Alhasnawy, FIBMS Clinical pharmacy, Lecturer. 
Department of Clinical Pharmacy, College of Pharmacy, 
University of Kufa, Najaf, Iraq. 
Shaima Alaa Janabi, BSc Pharm. 
Department of Clinical Pharmacy, College of Pharmacy, 
University of Kufa, Najaf, Iraq. 
Date: 9 /11/ 2025 
 

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Abstract 
Background: Hyperphosphatemia is a dangerous complication of chronic kidney disease (CKD), 
especially in hemodialysis (HD) patients, lead to major complications, including cardiovascular 
disease, secondary hyperparathyroidism, and CKD-mineral and bone disorders (CKD-MBD), 
which increase morbidity and mortality. Effective management requires phosphate binders, 
phosphorus-restricted diet, and dialysis. These are challenging due to complex dietary choices, 
burden of multiple medications, and lack of awareness. That underscoring the need for patient 
education to avoid foods rich in phosphorus and increase adherence to low phosphorus diet.  
Aim: Evaluate success of phosphorus-specific dietary intervention with education and counseling 
in improving dietary adherence, knowledge, and serum phosphorus levels among HD patients. 
Methods: A randomized controlled interventional study performed at the Dialysis Unit in the 
Department of Nephrology at Al-Sader Medical Teaching Hospital (Najaf, Iraq), involved 200 
patients,195 completing the study. Patients randomly grouped into the intervention group, 
received individual dietary plans, educational materials, and weekly follow-ups for a four-month 
period. The control group not received dietary attention. Monthly measurements were taken of 
the serum levels of parathyroid hormone (PTH), calcium (Ca), and phosphorus. Validated 
questionnaires were used to collect data, assessing dietary habits, phosphorus knowledge, and 
adherence. 
Results: A significant reduction occurred in the serum phosphorus level of intervention group 
(6.26 to 3.79 mg/dL, P < 0.001). Ca and PTH levels were (8.02 mg/dL to 9.26 mg/dL, P < 0.001 
and 405.07 pg/mL to 234.75 pg/mL, P < 0.001, respectively). 

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Conclusion: The results showed that supporting individualized nutrition plans and increasing 
awareness of foods rich in phosphorus are essential elements of routine care. By incorporating 
these strategies into clinical practice can improve patient management and outcomes. 
Keywords: Hyperphosphatemia, Dietary intervention, Patient education, chronic kidney disease 
(CKD), Serum Phosphorus.  
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. Introduction 
Hyperphosphatemia is a major problem in chronic kidney disease patients (CKD), in particular 
those on Hemodialysis (HD). Capacity of the kidneys to eliminate phosphorus diminished when 
kidney functions declined, which will lead to buildup of phosphorus in the bloodstream. Severe 
complications 
such 
as  cardiovascular 
disease,  soft 
tissue 
calcification, 
secondary 
hyperparathyroidism (SHPT), and renal osteodystrophy can result from high phosphorus levels in 
blood, and they increase morbidity and mortality risks (1).   Dietary restriction of phosphorus is 
necessary in control hyperphosphatemia, correcting SHPT and preventing cardiovascular 
problems. However, complex renal diets can be difficult to follow, so there is a need for useful 
teaching methods to improve adherence and health outcomes. The researchers concluded that the 
most effective way to encourage improved phosphorus management is to select an educational 
intervention that supports the style of the patient (2). 
1.1 Pathophysiology of Hyperphosphatemia in CKD Patients 
When renal excretion declines, ability of body to maintain phosphorus balance is impaired, lead 
to hyperphosphatemia (3). In early stage of CKD, in order to compensate this decline, the body 
attempts to increase secretion of parathyroid hormone (PTH). This hormone enhances removal of 
phosphorus by blocking its reabsorption in kidney tubules (4). These compensating mechanisms 
are insufficient as CKD worsens, resulting in chronic phosphorus load and related metabolic 
disorders (5). The occurrence of SHPT, a disorder marked by the chronic excessive production of 
PTH lead to bone loss and renal osteodystrophy, is greatly influenced by hyperphosphatemia in 
CKD. phosphorus buildup contributes to vascular calcification, which raises the risk of plaque 
buildup, cardiovascular diseases, arterial stiffness, left ventricular hypertrophy, and death (6). 

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1.2 Management of Hyperphosphatemia 
management include many strategies to control phosphorus levels and lower health risks. Include 
dietary modification by reduction of phosphate-rich food additives, processed meats, soft drinks, 
use of phosphate binders, and increase dialysis times. These interventions together are important 
to the complete control of phosphorus levels and support general patient health and reduce 
complications (7). 
1.2.1 Dietary Phosphorus Restriction 
Diet restriction is critical part in management of hyperphosphatemia and its complications (8). 
According to the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative 
(KDOQI) CKD patients in stages 3-5 with hyperphosphatemia should limit dietary phosphorus 
intake to between (800-1,000 mg) per day (9). It is challenging to achieve proper phosphorus 
levels due to many factors. So, dietary intervention is a cornerstone in managing 
hyperphosphatemia. poor adherence to phosphate binders and reduced efficacy when phosphate 
intake is high because phosphate binders are most effective when phosphate intake below 
1000mg/ day, their efficacy decrease when higher intake of more than 1500 mg/day, and this 
contributes to hyperphosphatemia (10). Poor adherence to HD sessions contributes to phosphorus 
buildup. Because of HD remove 600-1200 mg per session and phosphate binder removes 200-
300 mg per day there is need to dietary phosphorus restriction to maintain phosphorus level 
below 5.5mg per dl (11). many patients have trouble to be educated and make decision because 
they are unaware enough about foods high in phosphorus. availability of low phosphorus food 
alternatives is limited, and adherence to low phosphate diet is difficult because of food 
preferences and dietary restrictions (12). Renal diet is naturally complex and requires careful 

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nutrient monitoring, especially balancing between phosphorus restriction and maintain adequate 
protein intake. Another problem is that processed foods contain large amounts of phosphorus that 
are not labeled by manufacturer, thereby it hard to patients to monitor their intake (13). These 
factors contribute to difficulty in dietary compliance. So, there is need to dietary intervention as a 
critical part of CKD management. Giving patients complete education about phosphorus sources 
and dietary changes can improve the ability to make decisions that will promote phosphorus 
regulation and general health outcomes (13). 
1.2.2 Phosphorus Food Sources 
It is important to identify differences in phosphorus sources and absorption rate for developing 
effective dietary strategies (11). Two forms available: organic and inorganic phosphorus (14). 
About 45% of phosphate taken comes from inorganic sources (processed food for example: 
cheese, cakes, soft drinks, and pies). In contrast, about 20% of dietary phosphorus is from organic 
sources, including chicken, milk, grains, and eggs. Bioavailability of organic form ranging from 
60% to 80%, whereas inorganic phosphorus is absorbed at a significantly higher rate 90% or 
more (11). A major concern in dietary management is the extensive use of phosphorus additives 
in processed foods, including restructured meats, processed cheese, instant products, refrigerated 
bakery items, and beverages. These additives contribute to 100% phosphorus absorption, often 
without the patient’s awareness (15). By focusing on fresh, natural foods and reducing the 
consumption of processed foods that contain phosphorus additives, patients can better control 
their phosphorus levels and improve overall health outcomes (2). Studies shown that reduction of 
phosphate additives achieved by patient education to read ingredients and avoiding products with 
phosphate additives. A study reported decrease of 0.6mg \ dl in phosphorus level among HD 
patients by this intervention (16). Recent guidelines confirm importance of check sources and 

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forms of phosphorus when nutritional education is given (15). Importantly, one of the aspects of 
this study is to increase awareness regarding phosphate additives and their dietary sources. 
Through targeted educational interventions, potentially leading to the control of phosphorus 
levels. 
New Developments in Dietary Interventions for Hyperphosphatemia Worldwide: Consequences 
and Prospects for Regional Studies in Iraq 
Dietary interventions, nutritional education, and creative techniques are vital global efforts made 
to deal with hyperphosphatemia. These efforts indicate the importance of developing individual 
plans to lower phosphorus intake while maintaining sufficient nutritional status. Use of low-
phosphorus dietary alternatives, and continuous nutritional education are crucial for managing 
hyperphosphatemia, according to recent American recommendations (2024). The importance of a 
multidisciplinary medical team in enhancing quality of life of patients is also highlighted in the 
guidelines (17). 
This study aims to assess effects of a phosphorus-specific diet intervention through education and 
direct consultations on dietary compliance, knowledge scores, and serum phosphorus, and its 
association with phosphate binder agents in managing phosphorus levels 
There is a notable lack of data addressing dietary phosphate management in CKD patients within 
Iraq. Cultural dietary practices, socioeconomic constraints, and limited access to healthcare 
resources create unique patient barriers. This study fills gap by providing evidence-based insights 
to the Iraqi population. By incorporating locally available food options, culturally appropriate 
nutritional plans, and accessible educational tools like WhatsApp and phone calls, the study 
presents a realistic model for phosphorus management in resource-limited settings. 

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2.Methods 
2.1 Study Design 
A randomized controlled interventional study, involving patients on HD at stage 5 CKD. patients 
are enrolled in a dietary program with a specific phosphate content for three months. This study 
occurred from October 2024 to January 2025 at the Hemodialysis Unit in the Department of 
Nephrology at Al-Sader Medical Teaching Hospital. 
2.2 Ethical Approval 
This study received approval from Scientific Committee at College of Pharmacy/University of 
Kufa, and from the Nephrology Center at Al-Sader Teaching Medical City. Written informed 
consent was also obtained from patients before initiation of the study [Appendix 1].  
2.3 Sample size calculation 
The sample size for this randomized controlled interventional study was determined based on 
previous clinical trials evaluating dietary phosphate control in patients undergoing HD. Using an 
estimated medium effect size (Cohen’s d = 0.5), a power of 80%, and a confidence level of 95%, 
the minimum required sample size was calculated using G*Power software to be approximately 
64 participants per group. To enhance statistical power and account for potential dropouts, the 
final sample size was increased to 100 patients in each group, for a total of 200 participants.  
 
 
 

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2.4 Patients of the Study 
After screening and exclusion criteria, a random sample of 200 patients HD was selected. They 
divided equally into two groups (control and intervention), 100 patients in each group. During the 
trial, five patients were lost: one opted out, two withdrew due to difficulties complying with the 
prescribed diet, one was removed while awaiting transplantation, and one succumbed to an 
infection caused by mucormycosis. Thus, 195 volunteers successfully completed the study trial 
(Figure 2.1).  
Inclusion criteria were the following: 
• Males and females aged ≥ 18 and ≤ 60 years old. 
• Diagnosis: Patients with stage 5 CKD undergoing hemodialysis. 
•  Dialysis Duration: Receiving at least two weekly dialysis sessions for at least 2 months. 
• Phosphate Binder Use: Sevelamer (the only available in the nephrology center). 
• Informed agreement: patients agreed to provide written informed consent. 
• Language competence: patients or caregivers able to read, write, and speak Arabic. 
Exclusion criteria were the following: 
• Be younger than 18 or older than 60. 
• Getting less than two sessions per week or less than two months of hemodialysis. 
• The inability or refusal to give written informed consent. 
• A history of severe mental illnesses or cognitive impairment that limits participation. 
• Acute illness, an ongoing infection, or hospitalization during the hiring process. 

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• A history of malabsorption conditions that could impact phosphate metabolism or 
gastrointestinal surgery. 
• Noncompliance with medication or dialysis regimens. 
2.5 Sampling method 
A list of all eligible patients who met inclusion criteria was created. patients selected by a simple 
random sampling method. This method involved that eligible patients in the list were assigned a 
unique identification number. Then randomly selected by a random number generator tool 
(Excel). A total of 200 patients were selected to participate in the study.  
2.5.1 Randomization process 
 Selected patients randomly assigned to either control or intervention group using a fair 
randomization method to ensure equal distribution of patients in study groups. The researcher 
flips a fair coin for each patient joined the study. If coin showed image face, the patient entered in 
control group. If it was the writing face, the patient entered intervention group, which involve 
receiving dietary counselling according to study protocol. 
2.5.2 Data collection 
Data were collected using two questionnaires, Medication Adherence Reporting Scale-5 (MARS-
5) and knowledge about phosphate questionnaire [Appendix 2]. They are validated in the study 
of Falah et al. 2021 (18), they assessed awareness, dietary habits, and phosphate management. 
They covered demographic data (age, gender, and educational level), dietary behaviors, and 
chronic conditions history. Baseline phosphorus, PTH, and calcium (Ca) levels were measured. 
The study evaluated knowledge of phosphate-rich foods, prior education, and ability to identify 

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high phosphate foods. Awareness of phosphate content in dairy products, canned foods, grains, 
nuts, and processed meats was evaluated. Participants rated their knowledge, their phosphate 
intake monitoring. challenges in reducing phosphate intake (lack of knowledge, food availability, 
and cost) also assessed. also reported whether they received dietary guidance and its clarity. 
Lastly, the study assessed their perceptions of phosphate management, including its importance 
in preventing complications and confidence in controlling phosphate levels. 
Regular follow-ups were conducted during each dialysis session to monitor adherence. Then, 
they adjusted weekly. serum phosphate and Ca were measured monthly. October 2024 was 
baseline. November, December, and January 2025 were follow-up times, respectively. control 
group underwent only baseline data without intervention. Intervention included counselling and 
education for phosphate-specific diet for each patient according to their food preferences and 
eating behavior and maintained a balanced diet in limited amounts of phosphorus (800-1000 
mg/day), and education about phosphate and Ca physiology in simple patient-friendly language, 
risks of hyperphosphatemia, and high phosphate foods. Brochures handed out to patients 
[Appendix 3] included risks of hyperphosphatemia and foods with high and low phosphate 
content, and additives. Another sheet contained amount of phosphorus allowed to be taken daily 
or weekly for each type of food, how to regulate phosphorus level, and importance of adherence 
to phosphate binders [Appendix 3]. we utilized WhatsApp and telephone calls to stay connected 
with patients, address their inquiries, and ensure they received all necessary information. This 
approach allowed us to maintain continuous communication, provide ongoing support, and 
monitor progress and challenges throughout the intervention period. As part of the program, food 
preferences and dietary habits were assessed before meal plans were assigned. primary goal was 
to ensure that daily phosphorus intake remained within 800- 1000 mg/day while maintaining a 

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balanced nutrition. (Table 2.1) summarizes the modified Dietary Plan with Iraqi Meals designed 
for patients, ensuring phosphorus intake remains within the recommended range (19), (20). 
2.6 Statistical analysis  
All statistical analysis were performed using statistical package for social sciences (SPSS) 
version 30.  First, we checked if the Data were normally distributed. Descriptive statistics were 
presented as mean, standard deviation (SD), median, frequencies, and simple percentages. The 
comparison between the two groups (intervention and control) was done using the independent t-
test. For within-group comparisons (pre- and post-intervention), the paired t-test was used. A p-
value less than 0.05 was considered statistically significant.  
3.Results 
In intervention group 50% aged 31–50, 40% were 51-60, and 10% were 18-3. 60% was females. 
Hypertension and diabetes mellitus were major chronic conditions (70% and 80% respectively). 
In control group, 30% were aged 18-30, 50% were 31-50, 20% were 51-60. 60% was males. 
Major chronic conditions (40% hypertension, 50% Diabetes mellitus) (Table 3.1).  Total of 99 
participants responded to questionnaire (Table 3.2). 36% not received prior phosphate education, 
73% were unable to list phosphate-rich foods. Main barriers to phosphate restriction included 
lack of knowledge (37%), cost of low-phosphate foods (30%), and limited alternatives (25%). At 
baseline serum phosphorus levels were for intervention and control groups (6.26 ± 1.72 mg/dL, 
5.84 ± 1.79 mg/dL; P = 0.089, respectively), on November intervention group showed a reduction 
to 4.93 ± 1.37 mg/dL. On December and January declined to 4.29 ± 1.13 mg/dL and 
3.79 ± 1.51 mg/dL, respectively (Table 3.3), Figure 3.1. The intervention group showed 
significant reductions in serum phosphorus levels over time. The mean level decreased from 6.26 ± 

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1.72 mg/dL at baseline to 4.93± 1.37 mg/dL in November (P < 0.001). Further reductions occurred 
in December (4.29 ± 1.13 mg/dL) and January (3.79 ± 1.51 mg/dL), with all pairwise comparisons 
being significant (P < 0.001). Table 3.4, Figure 3.2 presents within-group comparisons at different 
time points, paired t-tests confirmed significant mean score reductions, indicating the 
intervention's effectiveness. Mean Ca levels increased from 8.02 at baseline to 9.26 in January 
(P < 0.001) and PTH levels decreased from 405.07 at baseline to 234.75 in December (P < 0.001) 
(Table 3.5). 
4. Discussion 
 dietary restriction is a foundational component that poses challenges in patient adherence and 
long-term implementation. This study sought to assess how structured dietary interventions and 
continuous patient education and support could influence serum phosphorus levels and overall 
phosphorus management. One of the distinguishing aspects of this research lies in its context-
specific contribution. Results of this study demonstrated a significant reduction in serum 
phosphorus of intervention group 6.26 ± 1.72 mg/dL at baseline to 3.79 ± 1.51 mg/dL after three 
months, nearly a 40% decline. In contrast, increased progressively in the control group. These 
findings underline the effectiveness of combining targeted dietary modifications with ongoing 
education and personalized support to improve phosphorus control. Several previous studies 
corroborate current findings. A 2022 study in Qatar showed decline in phosphorus from (~7.2 to 
5.2 mg/dL), p < 0.05, but did not include a strong educational aspect (21). In contrast, the present 
study provided structured education and ongoing support, likely contributed to better adherence. 
A 2025 Chinese study with 8.8% reduction (6.35 to 5.79 mg/d, p-value 0.048), the smaller 
reduction may be due to the lack of continuous education and follow-up support (22), which were 
key elements in the current study’s approach. A 2021 Egyptian study showed 13.8 ± 21.41% 

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reduction in serum phosphorus levels (p = 0.02) following a 12-week educational program (23). 
This highlights the benefit of patient education in phosphorus management, but modest reduction 
compared to the current study suggests that combining education with practical dietary planning 
and regular follow-up as done in the current research yields better outcomes. A 2023 Californian 
study showed education in phosphorus levels after a 30-day educational intervention (p = .001), 
not detailed but emphasizing short-term effectiveness, also supported the effectiveness of 
continuous education, digital support tools, and individualized plans in achieving positive 
outcomes (12). A 2012 Spanish study reported a six-month dietary intervention, decreasing 
phosphorus levels by 1.67 mg/dl, (p = 0.003) (24). These results align closely with the current 
study, reinforcing the importance of structured and sustained dietary interventions. The Chinese 
study emphasized diet but excluded education, likely limiting behavioral change. The Egyptian 
study involved education but no dietary follow-up or monitoring. The Qatari study focused on 
counseling without in-depth education on phosphorus risks. These variations emphasize that 
success in phosphorus management hinges on a holistic, personalized approach combining 
education, culturally adapted diets, and consistent patient engagement strategies all central to this 
study. The implications of this study are far-reaching. It not only validates the effectiveness of 
phosphate restriction but also the value of education and cultural adaptation in enhancing 
adherence. The proposed model can serve as a blueprint form future dietary management 
program in Iraq and similar low-resource environments. It highlights the importance of patient 
empowerment, continuous monitoring, and practical, context-aware solutions. This study paves 
the way for further research exploring long-term adherence, technology's role in dietary 
counseling, and the cost- effectiveness of such interventions. Additionally, it underscores the 
need for national dietary guidelines and educational campaigns targeting both patients and 
healthcare providers. Future initiatives should consider leveraging community-based 

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interventions and digital platforms to expand the reach and sustainability of phosphorus control 
strategies. This study has important aspects, but it also lacks some features. The short follow-up 
period of 3 months is a limitation because it does not allow for the evaluation of long-term 
sustainability. Also, adherence to diet and phosphate binders use were self-reported, which may 
introduce some biases. Finally, because the study was conducted at a single center, external 
generalizability of the study findings could be limited. 
Conclusion 
The results showed that supporting individualized nutrition plans and increasing awareness of 
foods rich in phosphorus are essential elements of routine care. By incorporating these strategies 
into clinical practice can improve patient management and outcomes. 
Recommendations 
1. It is recommended that larger multicenter studies be conducted to assess the broader 
applicability of their findings and to identify the most significant components of dietary practices 
education. 
2. Exploring the effects of dietary education on clinical outcomes like cardiovascular events, 
hospital admissions, and mortality, both short-term and long-term, should be evaluated. 
 

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Table 2.1. Dietary Plans with Iraqi Meals.  
Meal 
Food items 
 
Phosphorus content  
(mg) 
Breakfast 
 
Bread (1 piece) + 
Boiled egg (1) + 
Cucumber (½ cup) 
 
120mg 
 
Bread (¼ piece) + White cheese (2 
tbsp) + 
Tomato slices (½ cup) 
 
110 mg 
 
Labneh (2 tbsp) + Bread 
(¼ piece) + Olive oil (1  tsp) + Mint 
leaves 
100mg 
 
Semolina porridge (½ cup) + Low-fat 
milk (½ 
cup) + Cinnamon (1 
tsp) 
 
115mg 
Snack 
Low-fat yogurt drink (½ cup) + 
Cucumber (½  cup) 
90mg 
 
Bread (¼ piece) + Low fat white 
cheese (2 tbsp) 
100mg 
Lunch 
White rice (½ cup) + 
Grilled chicken tikka 
(85g) + Okra stew 
(without meat) (½ cup) 
 
 
280mg 
 
 
Red kidney bean stew 
(without meat) (½ cup) 
+ Bread (¼ piece) + 
Tomato & cucumber salad (½ cup) 
260mg 

20 
 
Grilled masgouf fish 
(85g) + White rice (½ cup) + Grilled 
vegetables (½ cup) 
 
 
 
310mg 
 
Lentil stew (without meat) (½ cup) 
+ Bread 
(¼ piece) + Green salad 
(½ cup) 
 
 
270mg 
 
Oven-roasted chicken 
(85g) + Vermicelli rice 
(½ cup) + Light lentil soup (½ cup) 
 
 
290mg 
 
 
 
 
 
Grilled eggplant stew 
(without meat) (½ cup) 
+ Bread (¼ piece) + 
Tomato & cucumber salad (½ cup) 
 
 
280mg 
 
Grilled dolma (without meat) (½ 
cup) + Low- 
fat yogurt (½ cup) + 
Bread (¼ piece) 
 
 
270mg 
Snack 
Date (1 piece) + Bread 
(¼ piece) + 
Unsweetened tea 
 
 
95mg 
 
Unsalted biscuits (4 pieces) + 
Honey (1 tsp) 
 
 
100mg 
 

21 
 
Unsalted popcorn (1 cup) + Unsalted 
nuts (1 tbsp) 
 
 
120mg 
 
 
 
 
 
Fresh orange juice (½ cup) + 
Unsalted tea biscuits (3 pieces) 
 
 
115mg 
 
 
Sliced apple (½ piece) 
+ Unsalted walnuts (1 tbsp) 
 
 
95mg 
 
Pomegranate seeds (¼ cup) + Low-
fat yogurt 
(½ cup) 
 
 
115mg 
 
Dates (1 piece) + Low fat milk (½ 
cup) + 
Cardamom for flavour 
 
 
125mg 
 
Boiled egg (1) + Bread 
120mg 
 
Dinner 
(¼ piece) + Cucumber 
(½ cup) 
 
 
 
 
White rice (½ cup) + 
Light chicken soup (½ cup) + 
Cucumber & tomato salad 
 
 
140mg 

22 
 
Grilled kofta (85g) + 
Light lentil soup (½ cup) + Low-fat 
yogurt 
(½ cup) 
 
 
145mg 
 
Mashed chickpeas 
(without tahini) (2 tbsp) 
+ Bread (¼ piece) + 
Olive oil (1 tsp) 
130mg 
 
 
 
 
 
 
Lentil stew (without meat) (½ cup) + 
Thin flatbread (¼ piece) + 
Fresh vegetable salad 
 
 
 
 
120mg 
 
Vermicelli rice (½ cup) 
+ Grilled chicken (85g) 
+ Low-fat yogurt (½ cup) 
 
 
155mg 
 
Grilled fish (85g) + 
Roasted potatoes (½ cup) + Bread 
(¼ piece) 
 
150mg 
 
 
 
 
 
 

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Table 3.1. Demographic Data   
  
 
Group 1   
Group 2  
 
n= 100  
n= 100  
               
 
    
Age Group   
 
 
Years 18-30  
10  
30 
Years 31-50  
50  
50 
Years 51-60   
40  
20 
Gender   
 
 
Male  
40  
60 
Female  
60  
40 
Chronic Conditions   
 
 
Hypertension   
70  
40 
Diabetes   
80  
50 
Obesity  
30  
10 
Heart Disease   
15  
5  
Epilepsy/ seizures   
10  
5  
 
 
 
 
 
No                                                               No 
  

24 
Table 3.2 Response to Questionnaires  
 
  
Total (n=99)   
%  
Knowledge of phosphate    
  
Educated about Phosphate    64 
64%  
Not Educated  
35  
36%  
Ability to list phosphate- rich foods  
  
Can list  
27  
27%  
Cannot list  
72  
73%  
Attention to phosphate   intake  
  
Pay Attention  
41  
41%  
Not pay Attention  
58  
59%  
Reduction of phosphate- rich foods  
  
Reduced based on advice   41  
41%  
Did not reduce   
58  
59%  
Use phosphate binder  
  
  
Yes  
57  
58%  
No  
42  
42%  
Awareness of blood  phosphorus level  
  
Aware  
43  
43%  
Unaware  
56  
57%  
 
 
 
 
  

25 
 
Barriers to reducing    phosphate intake  
Lack of knowledge  
37  
37% 
Cost of low phosphorus    30  
foods  
30% 
Difficult finding  
25  
alternatives   
25% 
Guidance on low phosphate diet  
 
Received guidance  
53  
53% 
Did not received  
46  
46% 
Ease of understanding   
 
information  
Easy  
45  
45% 
Maybe   
31  
31% 
Difficult  
24  
24% 
Importance 
of
controlling phosphate   
  
 
Very important  
23  
23% 
Important   
48  
48% 
Somewhat important   
26  
26% 
Not important   
2  
2%  
Confidence 
in 
managing phosphate   
  
 
Confident  
67  
68% 
Unsure  
24  
24% 
Not confident  
8  
8%  
 
 
 
 
 
 
 
 

26 
 
  
 
Table 3.3 Comparison of Mean Scores Between Intervention and Control Groups Over Time  
Groups 
Intervention 
(100) 
Control 
(n=100) 
P-Value 
95% Confidence Interval of the 
Difference 
Mean±S.D 
Mean±S.D 
Lower 
Upper 
Baseline 
6.26±1.72 
5.84±1.79 
0.089 
0.235 
1.216 
Nov. 
4.93±1.37 
5.87±1.51 
<0.001 
-1.335 
-0.530 
Dec. 
4.29±1.13 
6.35±1.86 
<0.001 
-2.485 
-1.625 
Jan. 
3.79±1.51 
7.24±2.22 
<0.001 
-3.973 
-2.911 
  
 
 
 
 
 
 
 
 
 
 
 
 
 

27 
Table 3.5 Calcium and PTH levels distribution. 
Category 
Ca (Mean ± SD) 
P- value 
PTH (Mean ± SD) 
P- value 
Baseline 
8.02 ± 1.13 
 
<0.001 
 
405.07 ± 269.73 
 
<0.001 
 
Nov. 
8.35 ± 0.97 
 
 
 
 
Dec. 
8.82 ± 0.79 
 
 
234.75 ± 182.55 
 
 
Jan. 
9.26 ± 0.90 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

28 
Appendices 
Appendix 1: Written consent form 

29 
 
Appendix 2: study questionaries  
A- English validated version of MARS-5 questionnaire  
Patient Demographics 
1. Age: What is your age? 
2. Gender: What is your gender?  
3. Medical History: Do you have any chronic conditions?)(  
4.  Current Treatment:  
Knowledge of Phosphate-Rich Foods:  
1.Understanding of Phosphate:  
Have you ever been educated about the role of phosphate in your diet? 
(Yes/No)  
Can you list any foods you know are high in phosphate?  
4. 
Awareness of Phosphate Content in Foods:  
How would you rate your knowledge of which foods contain high levels 
of phosphate? (Poor/Fair/Good/Excellent)  
5. 
Food Groups:  
Do you think dairy products are rich in phosphate? (Yes/No/Not Sure)  
 Are you aware that processed foods (e.g., canned meats, soft drinks) often 
contain added phosphates? (Yes/No/Not Sure)  

30 
Do you know that whole grains, nuts, and certain types of meat are high in 
phosphate? (Yes/No/Not Sure) 
  
Dietary Habits:  
1. Phosphate-Rich Food Consumption:  
 How often do you consume dairy products (e.g., milk, cheese, yogurt)? 
(Daily/Weekly/Rarely/Never)  
 How often do you eat processed or fast foods? (Daily/Weekly/Rarely/Never) 
 2. Phosphate Intake Management:  
 Have you ever reduced your intake of phosphate-rich foods based on advice 
from a healthcare professional? (Yes/No) If yes, what changes have you made 
in your diet?  
3. Use of Phosphate Binders:  
Are you currently taking any phosphate binders to help control your 
phosphate levels? (Yes/No)  
Perceived Barriers to Dietary Changes:  
1. 
Challenges in Reducing Phosphate-Rich Foods:  
What are the main challenges you face in reducing phosphate-rich foods from 
your diet? (Select all that apply):  
• Lack of knowledge  
• Difficulty finding alternative foods  
• Expense of low-phosphate foods  
• Other (please specify)  

31 
2. 
Education on diet:  
Have you received educational materials or counseling about a lowphosphate 
diet? (Yes/No)  
Was this information easy to understand and apply to your daily life? 
(Yes/No/Somewhat)  
Patient Attitudes and Beliefs:  
1. Perception of Importance:  
 How important do you think it is to control phosphate levels in your diet to 
avoid complications like hyperphosphatemia? (Not important/Somewhat 
important/Very important)  
2.Confidence in Managing Phosphate Levels:  
How confident are you in your ability to manage phosphate levels in your diet? 
(Not confident/Somewhat confident/Very confident) 
 
 
 
 
 
 
 
 

32 
 
B- English version of Phosphate Knowledge Questionnaire 
 
 
 
 
 
 

33 
 
Appendix 3: Educational materials  
A- Brochures 

34 
B- Sheets  

35 
 

36