Australian Newspapers online: A resource for educators. March 2009
Australian Diabetes Educators Association
Transcript of Australian Diabetes Educators Association
Australian Diabetes Educators Association Top End ConferenceTownsville, Queensland10th – 11th May 2019
Panel Discussion – Diabetes and Renal Health
Nutritional Management of Renal Disease and DiabetesCase Study Presentation Open Discussion
Joanna Martin
Renal Dietitian
Townsville Hospital and Health Service
Risk factors for developing Chronic Kidney Disease1
1. Kidney Health Australia, Factsheet: How to look after your kidneys, 2017: https://kidney.org.au/cms_uploads/docs/how-to-look-afteryour-kidneys-fact-sheet.pdf
Slide 2
Modifiable Risk Factors
Non-Modifiable Risk Factors
Diabetes and Kidney Disease
Slide 3
- Diabetes is a common cause of Chronic Kidney Disease (CKD)2
- Diabetic kidney disease can also lead to Cardiovascular Disease (CVD), loss of vision and nerve
damage2
- Type 2 Diabetes Mellitus (T2DM)is the most frequent cause of End-Stage Kidney Disease (ESKD)3
- In Australia, people with T2DM + ESKD increased from 32% in 2003 to 45% in 2015 – diabetic
nephropathy 3
- Research has consistently found that mortality risk is greater for patients with ESKD and diabetes than
for people with ESKD alone 3
- Epidemiological studies have established that longer duration of T2DM and its suboptimal control are
each associated with a poorer prognosis – including progression to ESKD and increased vascular
disease and all-cause mortality risks 3
2. Kidney Health Australia, Factsheet: Diabetic Kidney Disease, 2017: https://kidney.org.au/cms_uploads/docs/diabetic-kidney- disease--kidney-health-australia-fact-sheet.pdf
3. Lim, W.H., Johnson, D.W., Hawley, C., Lok, C., Polkinghorne, K.R., Roberts, M.A., Boudville, N., Wong, G. 2018 Type 2 diabetes in patients with end-stage kidney disease: influence on
cardiovascular disease-related mortality risk. The Medical Journal of Australia, Volume 209, Issue 10.
Stages of CKD4
Slide 4
Prevention of
worsening
diabetes and
other co-
morbidities is the
key to delaying
progression of
CKD
4. Kidney Health Australia, CKD Management in General Practice (3rd edition), 2015: https://kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-edition.pdf
Prevention is key
Slide 5
The following nutritional management principles apply for patients with diabetes and kidney
disease and is aimed at slowing the progression of chronic kidney disease. This is especially
important before stages 4 & 5
• Healthy Eating
• Maintain / achieve a healthy weight
• Control diabetes
• Maintain a healthy blood pressure
Fruit and vegetable-rich
diets such as the
Mediterranean diet are
recommended for primary
and secondary disease
prevention6
Dietary intervention is aimed at prevention of worsening CKD
As CKD progresses, it becomes increasingly difficult to focus on prevention but rather
managing the nutritional complications that arise as a result of deteriorating kidney function
6. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D., Fouque, D., Carrero, J.J. 2018.
Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation. 33:725-735.
Progression of Chronic Kidney Disease and Nutritional Implications
Slide 6
• Hyperkalaemia requires dietary education and usually some restriction
• Oedema if retaining fluid can put pressure on the heart
• Metabolic Bone Disease / Hyperphosphataemia requires dietary education +/-
phosphate binders; increases risk of CVD
• Anaemia fatigue, loss of appetite, SOB, heart failure, increased risk of mortality
• Metabolic Acidosis hyperkalaemia, protein breakdown
• Malnutrition (protein-energy wasting) increased risk of mortality
• Decreased insulin requirements (for diabetics) at risk of hypoglycaemia
• Uraemic symptoms poor appetite, taste changes, unintentional weight loss
These are usually seen
in CKD stages 4/5, as
disease progresses
Prevention is key – Healthy Eating
Slide 7
Follow the recommendations for healthy eating:
• Australian Guide To Healthy Eating (AGHE)
• Variety of foods from the 5 core food groups
• Limit discretionary choices as they are high in kilojoules, saturated fat,
added sugars, added salt or alcohol (should only be eaten sometimes
and in small amounts)
Food Group Gender 19-50 years 51-70 years 70+ years
Vegetables and Legumes Men 6 5 ½ 5
Women 5 5 5
Fruit Men 2 2 2
Women 2 2 2
Breads/Cereals/Grains Men 6 6 4 ½
Women 6 4 3
Meat & Meat Alternatives Men 3 2 ½ 2 ½
Women 2 ½ 2 2
Dairy Men 2 ½ 2 ½ 3 ½
Women 2 ½ 4 4
Prevention is key – Maintain / achieve a healthy weight
Slide 8
• Body Mass Index (BMI): Australian’s >18 – 65 years of age
• Healthy weight range for older Australia’s (>65 years of age) is 24-30kg/m2
• If overweight/obese, a loss of 5 – 10% body weight can improve overall health
• Losing weight is one of the best ways to improve blood sugar control and lower risk of diabetes
complications
Prevention is key – Control diabetes
Slide 9
• Optimal blood glucose control significantly reduces the risk of developing microalbuminuria,
macroalbuminuria and/or overt nephropathy in people with type 1 or type 2 diabetes4
• Target for BGL should be 6-8mmol/L fasting; 8-10mmol/L postprandial4
• Diet control, oral hypoglycaemic agents (OHA), insulin
• Carbohydrates: the types and amounts of carbohydrate in foods, spread carbohydrate intake
throughout the day; aim for low glycaemic index and low glycaemic load
• Healthy eating to include a variety of foods from the five food groups
• Manage cholesterol levels including limiting high saturated fats (animal based), healthier
options include unsaturated fats (poly unsaturated fats and mono unsaturated fats)
• Exercise: aiming for 300 minutes of physical activity per week (~40 mins / day)
4. Kidney Health Australia, CKD Management in General Practice (3rd edition), 2015: https://kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-edition.pdf
Prevention is key – Maintain a healthy blood pressure
Slide 10
• Salt plays a key role in homeostasis of fluid and blood volume5
• Salt is recognised as a modifiable risk factor for cardiovascular disease and key for the
management of BP and albuminuria5
• Low salt diet for patients with diabetes and all stages of CKD
• Target intake 80-100 mmol sodium / day (~2.3g)
• Fresh is best – cook from fresh foods
• Limit take-aways and processed foods – these all contain a lot of added salt
• Choose low salt, reduced salt, no salt added & salt alternatives
• Avoid using the salt shaker, herbs and spices should be encouraged
5. Campbell, K.L., & Rossi, M. 2014. Salt, protein, phosphate and sugar: nutrition trends in kidney disease. Renal Society of Australasia Journal, 10(3), 141-145.
Why is it so important to lower sodium intake in patients with diabetes and CKD?5
Slide 11
High
sodium
intake
Direct effects:- Arterial stiffness
- Endothelial dysfunction
- Oxidative stress
- Inflammation
Albuminuria
Proteinuria
Blood
Pressure
Fluid
Overload
5. Campbell, K.L., & Rossi, M. 2014. Salt, protein, phosphate and sugar: nutrition trends in kidney disease. Renal Society of Australasia Journal, 10(3), 141-145.
Prevention is key – Mediterranean Diet for Chronic Disease
Slide 12
“Dietary patterns that are more plant-based, lower in meat (including processed
meat), sodium and refined sugar, and have a higher content of grains and fibres
are now included in multiple clinical guidelines for chronic disease prevention.”6
The traditional Mediterranean dietary pattern has the following characteristics:6
• High consumption of fruits, vegetables, bread and wholegrain cereals, potatoes,
beans, nuts and seeds
• Extra virgin olive oil (cold pressed) as an important monounsaturated fat source
• Dairy products, fish and poultry are consumed in low-to-moderate amounts
• Eggs are consumed zero to four times a week
• Sweets are seldom consumed
• Red meat is eaten less often and in connection with special occasions
• Wine is consumed in low-to-moderate amounts, during meals
6. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D., Fouque, D., Carrero, J.J. 2018.
Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation. 33:725-735.
Summary of arguments and evidence in prescribing MD in both CKD and non-CKD populations6
Slide 136. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D., Fouque, D., Carrero, J.J. 2018.
Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation. 33:725-735.
What about potassium??6
Slide 14
6. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D., Fouque, D., Carrero, J.J. 2018.
Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation. 33:725-735.
Considerations for implementing the MD in CKD6
Slide 156. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D., Fouque, D., Carrero, J.J. 2018.
Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation. 33:725-735.
Comparing disease and diets
Slide 16
Mediterranean
Diet
CKD
AGHE
Diabetes
Comparison of dietary requirements for disease and diets
Slide 17
Food Group
AGHE (average for age and
gender)
Appropriate for diabetes
CKD MD
Vegetables and Legumes 5 3-5 6
Fruit 2 2-3 3-6
Breads/Cereals/Grains 4-6 4-6 3-6
Meat & Meat Alternatives 2.5 – 3 >50% high-biological value* 2.5
Dairy 2.5 – 4 1 2
*0.75g/kg/day protein
Diabetes Diet versus Renal Diet
Slide 18
• Competing priorities as CKD stage progresses / function declines
• If potassium and phosphate are elevated, often need to restrict however
must be individualised not one size fits all
• Important not to unnecessarily restrict
Potassium Phosphate
Avoid Include Avoid IncludeFruit high in potassium
Some high potassium vegetables
Excessive intake of any food group
Excessive intake of discretionary
choices
Low potassium fruits
High potassium vegetables boiled
Wholegrain products
Processed cheese
Processed meat (ham, bacon,
sausages)
All Bran
Flavoured milk
Chocolate
Coke/Diet Coke/Pepsi/Pepsi Max
Pies/Sausage Rolls/Pastry items
Takeaway foods
Instant coffee type sachets
Milk
Yoghurt
Soft cheese (cottage/ricotta)
Lean meats
Tinned tuna/salmon
Fresh white fleshed fish (perch/cod)
Eggs
Legumes
Wholegrain bread
Weetbix
Always refer to an Accredited Practising Dietitian with renal experience
Phosphate – Bioavailability7
Slide 19
Organic plant
sources
20 – 40%
bioavailability
Organic animal
sources
40 – 60%
bioavailability
Inorganic sources
– food additives
Up to 100%
bioavailability
Phosphate attached
to phytates and little
absorbed by body
Not protein bound,
absorbed in the
intestinal tract, into
blood stream
Phosphate is protein
bound, reduces
absorption
7. Kalantar-Zadeh, K., Gatekunst, L., Mehrotra, R., Kovesdy, C.P., Bross, R., Shinaberger, C.S., Noori, N., Hirschberg, R., Benner, D., Nissenson, A.R., Kopple, J.D. 2010. Understanding
Sources of Dietary Phosphorus in the Treatment of Patients with Chronic Kidney Disease. Clinical Journal of the American Society of Nephrology. Vol. 5, Issue 3, 519-30.
Summary of Requirements for CKD & RRT8
Slide 20
Non-Dialysis CKD Haemodialysis Peritoneal Dialysis
Energy 30-35kcal/kg
(125-146kJ/kg)
35kcal/kg 35 kcal/kg
(incl kJ from dialysate)
Protein 0.8-1.0 g/kg >1.2 g/kg >1.2 g/kg/day
Peritonitis >1.5 g/kg/day
Sodium 80-100 mmol/day 80-100 mmol/day 80-100 mmol/day
Phosphorus 800-1000mg & binders if
elevated
800-1000mg & binders if
elevated
800-1000mg & binders if
elevated
Potassium <1mmol/kg if elevated <1mmol/kg if elevated Not usually an issue
8. Ash, S., Campbell, K.L., Bogard, J., Millichamp, A. 2014. Nutrition Prescription to Achieve Positive Outcomes in Chronic Kidney Disease: A Systemic Review. Nutrients, 6, 416-451.
What’s New?
Slide 21
Easy Diet Diary – Renal App
For iphone only
https://itunes.apple.com/au/app/easy-diet-diary-renal/id1007054961?mt=8
References
Slide 22
1. Kidney Health Australia, Factsheet: How to look after your kidneys, 2017:
https://kidney.org.au/cms_uploads/docs/how-to-look-afteryour-kidneys-fact-sheet.pdf
2. Kidney Health Australia, Factsheet: Diabetic Kidney Disease, 2017:
https://kidney.org.au/cms_uploads/docs/diabetic-kidney- disease--kidney-health-australia-fact-sheet.pdf
3. Lim, W.H., Johnson, D.W., Hawley, C., Lok, C., Polkinghorne, K.R., Roberts, M.A., Boudville, N., Wong, G. 2018 Type 2 diabetes in patients with end-
stage kidney disease: influence on cardiovascular disease-related mortality risk. The Medical Journal of Australia, Volume 209, Issue 10.
4. Kidney Health Australia, CKD Management in General Practice (3rd edition), 2015: https://kidney.org.au/cms_uploads/docs/ckd-management-in-gp-
handbook-3rd-edition.pdf
5. Campbell, K.L., & Rossi, M. 2014. Salt, protein, phosphate and sugar: nutrition trends in kidney disease. Renal Society of Australasia Journal, 10(3),
141-145.
6. Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko, A., Molina, P., Sezer, S., Wanner, C., ter Wee, P.M., Teta, D.,
Fouque, D., Carrero, J.J. 2018. Mediterranean diet as the diet of choices for patients with chronic kidney disease. Nephrology Dialysis Transplantation.
33:725-735.
7. Kalantar-Zadeh, K., Gatekunst, L., Mehrotra, R., Kovesdy, C.P., Bross, R., Shinaberger, C.S., Noori, N., Hirschberg, R., Benner, D., Nissenson, A.R.,
Kopple, J.D. 2010. Understanding Sources of Dietary Phosphorus in the Treatment of Patients with Chronic Kidney Disease. Clinical Journal of the
American Society of Nephrology. Vol. 5, Issue 3, 519-30.
8. Ash, S., Campbell, K.L., Bogard, J., Millichamp, A. 2014. Nutrition Prescription to Achieve Positive Outcomes in Chronic Kidney Disease: A Systemic
Review. Nutrients, 6, 416-451.
Case Study
Slide 23
58 year old male, seen in CKD outpatient clinic
Past Medical History:
T2DM; CKD stage 3b; Hypertension; Dyslipidaemia
Anthropometry:
Wt 95kg
Ht 170cm
BMI = ~33kg/m2 (obese for age)
Biochemistry:
K 4.5 (normal)
eGFR 42 (CKD stage 3b)
PO4 0.9 (normal)
HbA1c 10.2% (high)
ACR 280 (high)
Chol 7/TG 5/HDL 0.7/LDL 2.9 all out of normal limits
Clinical:
Appetite – good; Bowels – regular
Nil N/V
Medications – metformin, atorvastatin, perindopril, linagliptin, amlodipine
BP: 180/100
Diet: (average per day)
No fruit
1-2 serves vegetables
>8 serves breads/cereals
5 serves meat/meat alternatives
4 serves dairy
~4-5 discretionary choices per day
Uses salt in cooking and at the table
Exercise:
Nil
Case Study
Slide 24
Dietary Issues:
- Inadequate fruit and vegetable intake
- Excessive meat/meat alternatives, dairy, breads/cereals, discretionary
choices
- Excessive sodium intake
- Inappropriate and inconsistent carbohydrate intake
Medical Issues:
- According to stages of CKD, is in the red zone – high risk for CKD progression to ESKD
- Obesity
- Uncontrolled hypercholesterolaemia and dyslipidaemia
- Hypertension
- Proteinuria
- Suboptimal blood sugar control
Also seen by CKD Multidisciplinary team to address medical issues
Case Study
Slide 25
Dietitian Management plan:
• Education regarding increasing fruit and vegetable intake, decreasing
breads/cereals/dairy/meat & meat alternatives
• Education regarding CHO types and spreading throughout the day
• Wholegrains encouraged
• Cut out all added salt
• Low fat dairy encouraged
• Decrease discretionary choices
• Patient to find a form of physical activity he enjoys and discuss with GP
High risk for fast progression to ESKD
Review in 3 months
Thank you for your participation
Questions?
Slide 26
This Photo by Unknown Author is licensed under CC BY-NC-ND