patient engagement in nephrology research through its use of focus groups of patients and clinicians to Address correspondence to Katrina L. Campbell, PhD, 2 Promenthean Way, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia 4226. E-mail: kcampbel@bond.edu.au 2017 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2017.02.006 558 Am J Kidney Dis. 2017;69(5):558-560 inform the intervention design. This concept of cocreation is particularly critical in the design of complex interventions, including nutrition. This approach fundamentally acknowledged that the causal pathways between nutrition and clinical outcomes are likely to result from intersections among behavior and environmental influences and addresses these simultaneously.7 By consciously adopting this process, the investigators were able to identify barriers, support strategies, and enablers to adopting reduced sodium intake in ways that patients liked and that then drove the trial design. Such patient engagement at the development stage of a clinical trial improves enrollment, decreases attrition, and enhances the relevance and dissemination of research among participants and the community.8 Enabling patient involvement in study design is consistent with evidence that patients with CKD prefer nutritional and fluid interventions that are individualized, provide peer support, and combine repeated coaching with regular monitoring and feedback.1 The barriers that frequently stymie attempts to achieve sustainable lifestyle modification may be addressed through individualized education and the improved skills and confidence to change specific behaviors. Furthermore, the use of motivational interviewing techniques and shared decision making can enhance adherence to the planned intervention.9 Putting this into practice, the ESMO Study used self-regulation theory by using monitoring, feedback, and risk mitigation strategies to support the reduced sodium diet. This approach resulted in consistent and sustained improvement in reported self-efficacy over several months and has important implications for evaluating and implementing nutritional interventions into clinical practice. Nevertheless, although interventions based on behavior change theories can effectively modify behavior, there is limited evidence that these altered behaviors are sustained after withdrawal of the intervention.9 This behavioral relapse (or decay) was also observed in the ESMO Study, given that sodium intake returned to baseline levels 3 months after intervention cessation despite retaining higher self-efficacy. Such health behavior decay has a well-characterized and predictable pattern, whereby the early stages of adopting new behaviors typically show high adherence and large health benefits, followed by a gradual decline and subsequent return to previous behaviors and attenuated health benefits.10 The degree of decay may be mitigated by careful intervention design, including considerations of dose, intensity, duration, and mode (face to face, telephone, online, and combination), as well as accounting for the connections between individual and environmental factors (social support, barriers, etc). Intensive interventions with aggressive follow-up demonstrate the least decay and behavioral relapse.10 However, such intensive interventions can be particularly impractical and expensive and have low scalability as a result. In order to influence practice and improve outcomes, behavioral interventions need to be cost-effective and amenable to widespread adoption. Overcoming health behavior decay and supporting sustainable change is a critical issue for effective dietary and lifestyle interventions and may be best achieved by the introduction of an “extended contact” intervention. This concept is well established in weight management, whereby a lower dose is delivered and sustained contact between practitioners and patients reduces behavioral decay and relapse.11 Such an approach replicates the real-life environment in which dietary management of a chronic condition naturally extends beyond the trial period and into the life course. With the emergence of technology and mobile health initiatives (such as wearable devices, mobile telephone apps, and video conferencing) and the increased uptake by people with CKD, a technological approach supporting extended contact lifestyle interventions offers potential to yield sustainable change within future trial interventions.12 One final lesson from the ESMO Study relates to the long-standing and narrow focus of dietary intervention strategies on single nutrients in CKD, such as sodium. This historical approach overlooks the complexity of biological interactions and individual food choices and is misaligned with qualitative research showing that patients find dietary restrictions overwhelming and unsustainable.1 There is abundant observational evidence in CKD that whole dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet, are associated with better renal and cardiovascular outcomes compared with single-nutrient interventions.13 It is possible that cumulative and synergistic health effects occur with the nutrient combinations consumed in diets rich in fruit,