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

https://kidney.org.au/cms_uploads/docs/how-to-look-afteryour-kidneys-fact-sheet.pdf

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.

https://kidney.org.au/cms_uploads/docs/diabetic-kidney-disease--kidney-health-australia-fact-sheet.pdf

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

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



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.


What about potassium??6

Slide 14



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.


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

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:


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.


https://kidney.org.au/cms_uploads/docs/diabetic-kidney-disease--kidney-health-australia-fact-sheet.pdf


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

http://www.firsttimemomanddad.com/2014/08/mom-score-i-figured-out-how-to-get.html

https://creativecommons.org/licenses/by-nc-nd/3.0/

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