Nutrition in DM2 & CKD 10-10

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OM2 - Edens - 2hrs

Incorporate into practice the Clinical Guidelines for Nutritional Management of CKD

Limit sodium in the diet
Target blood pressure <130/80 mm/Hg
Diabetes control early may lower CKD risk later
Spontaneous improvement in glycemic control may indicate CKD progression
Target HbA1c is individualized based on
Age
Comorbid conditions
Frequency of hypoglycemia

Urine albumin is a marker of kidney damage
Higher levels are associated with more rapid progression of CKD

Wt loss, Na restriction, certain BP medications, avoidance of excessive protein intake, & tobacco cessation may reduce urine albumin.
-CKD increases risk of CVD
-Nontraditional risk factors for CVD include certain risk complications seen in CKD.

Compare the different food groupings for normal diets

Choose healthy foods (fruits/veg/whole grains/lean protein/unsaturated fats
Set an eating schedule, i.e., Eat 3 small-to-medium sized meals; include some carbs/meal
Avoid "liquid sugar"
Meal plans to consider
Plate Method
Mediterranean Diet
DASH diet

45 to 65% total daily calories should be CHO
↑ Fiber-rich fruits and vegetables
↑ Whole grains
↑ Low-fat dairy products
↑ Beans and legumes
↓ Added sugars & refined grains, such as sugary drinks, desserts and candy, which are high in calories but low in nutrition

Eliminate trans fats from diet
Limit intake of saturated fats, <7%
Use liquid vegetable oils rich in polyunsaturated and monounsaturated fats.
Eat one or more good sources of omega-3 fats every day.
20-35% of daily calorie consumption should come from fat

RDA for protein is 0.8 g/kg/body wt
10-35% of daily calories should come from protein

Compare the different food groupings for diabetes diets

Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control.

"Saturated fat intake should be ,< 7% of total calories. Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol; therefore, intake of trans fat should be minimized. It is recommended that individualized meal planning include optimization of food choices to meet recommended dietary allowance (RDA)/dietary reference intake (DRI) for all micronutrients.

Describe the general goals for kidney diets

Managing blood pressure by ↓sodium intake
Reducing protein intake, if necessary
Controlling diabetes
in order to:
maintain good nutritional status
slow progression of kidney disease
treat complications

Explain how food preparation techniques can become problematic for the CKD patient.

Advanced Glycation End-products (AGES) are found in many food products; most notably in meat and foods with added fat, can be formed exogenously through cooking of food, may be formed by heating (e.g., cooking) & may be formed endogenously as a result of normal metabolism and aging.

When Receptor for AGE (RAGE) binds to AGEs, inflammatory diseases develop such as:
Atherosclerosis, asthma, arthritis, myocardial infarction, nephropathy, retinopathy, & neuropathy

what are the different diabetes diets?

Carbohydrate counting
Glycemic Index
Exchange lists
Controlled portions

Describe Carb counting as a diabetes diet

Method of calculating grams of CHO consumed at meals and snacks.
Foods that contain CHO have the greatest effect on blood glucose compared to foods that contain protein or fat.
Insulin is adjusted according to the amount of CHO consumed

Results:
-Tightens control of blood glucose
-Easier to fit a wide variety of foods into a meal plan
-Counting CHO allows one to decide how much carbs to to eat at a meal
-Helps control food portions to manage body weight

Describe the Glycemic Index as a diabetes diet

The glycemic index, or GI, measures how a carbohydrate-containing food raises blood glucose.
Foods are ranked based on how they compare to a reference food- either glucose or white bread.
A food with a high GI raises blood glucose more than a food with a medium or low GI.

Choose foods that have a low or medium GI.
Combine high GI foods with low GI foods.
Fat and fiber tend to lower the GI of a food.
The more processed a food, the higher the GI.
Many nutritious foods have a higher GI than foods with little nutritional value.

which is better, glycemic index or carb counting as a diabetes diet?

But the total amount of carbohydrates is a stronger predictor of blood glucose response than the GI.
thus carb counting is better.

Describe the exchange list as a diabetes diet

Foods are divided into 6 groups that vary in carbohydrate, protein, fat, & calorie content.
Each list contains foods comparable with about the same amount of carbohydrate, protein, fat, and calories as the other choices on that list .
Because foods differ, even on the same lists, each food is measured or weighed so that the amounts of carbohydrate, protein, fat, and calories are the same in each choice.
ex. 5 starches + 3 fruits + 2 dairy + 3 veggies + 4oz meat + 3 fats

Describe portion control as a diabetes diet

uses "plate" methods

Visually divide a 9 inch dinner plate in ½ & divide one section in ½ again so the plate will be 3 sections.
Fill the largest section with non-starchy vegetables
Fill one of the small sections with a starchy food.
Fill the other small section with protein.
Add an 8 oz glass of non/low-fat milk.
Add a piece of fruit or a 1/2 cup processed fruit
Visually divide a 9 inch dinner plate in ½ & divide one section in ½ again so the plate will be 3 sections.
Fill the largest section with non-starchy vegetables
Fill one of the small sections with a starchy food.
Fill the other small section with protein.
Add an 8 oz glass of non/low-fat milk.
Add a piece of fruit or a 1/2 cup processed fruit

= Consume the same amount of carbohydrates every day
- BS levels will remain constant from day to day.

Describe the following portion sizes in terms of self-measurement:
1. 1 cup
2. 1/2 cup
3. 3 oz
4. 1 Tbs
5. 1 tsp
6. 1 medium potato
7. 1 serving of veggies/fruit
8. 1 portion of pasta
9. 1 portion of pancake/waffle
10. 1/2 bagel
11. 1 portion of cheese
12. 1 portion of meat/fish

1. closed fist
2. cupped hand
3. palm
4. thumb
5. thumb tip
6. 1 computer mouse
7. 1 baseball/fist
8. 1/2 baseball
9. CD
10. hockey puck
11. 4 dice
12. deck of cards/palm

Describe reccommended protein intake for a CKD pt

The RDA for protein is 0.8 mg/kg
Reducing excessive protein intake will reduce nitrogenous waste, phosphorus, potassium, and metabolic acids.
A spontaneous decrease in protein intake may occur as eGFR declines.
patients may report an aversion to certain animal proteins

50% or 75% High biological value protein (% absorbed protein from food)

The 70-kg reference man needs 0.8 g/kg or 56 grams protein per day.
If we use 50% HBV to estimate his needs, he needs about 4 ounces of MEAT/day.
(.50) (56 grams) = 28 grams
If we use 75% HBV to estimate his needs, he needs about 6 ounces of MEAT/day.

Use small protein portions!

whats the bottom line for protein intake in a CKD recommended diet?

Most people eat more protein than required
Intake should be adequate, not excessive
In early CKD, reduce portions toward on serving per meal
In advanced CKD, a spontaneous retardation in protein intake may occur.
In advanced CKD, encourage intake of protein-rich foods that are tolerated and accepted by the patient.

Describe Sodium intake for a CKD diet

1,500 mg
Most people eat more than recommended
Those with CKD should consume no more than 1,500mg/day
Potassium chloride (KCl) may replace salt in low-sodium products—read labels carefully
Salt-substitutes (esp KCl) may not be appropriate for CKD

Describe Phosphorus intake for a CKD diet

Reference range 2.7-4.6 mg/dL
Phosphorus restriction may be beneficial

Describe phosphorus absorption

Only 40-60% is absorbed from whole foods (organic sources = dairy, meat, soy, nuts/seeds, whole grains)
About 90% is absorbed from inorganic sources such as food additives, dietary supps, calcium fortification
90% of the phosphorus is filtered by glomeruli and most is reabsorbed within the tubules
The kidneys play a major role in regulation

Describe the phosphorus-protein ratio

For dialysis patients, phosphorus more of a concern because protein needs are higher.
= based on phosphorus (mg)/protein (g)
- helps identify foods to avoid (high ratio)
- not easy to identify from Nutrition Facts labels.
ex. orange Phos:pro 4.5; hot dog Phos:pro 14.1

Whats the bottom line for recommended phosphorus intake in a CKD pt

The RDA is 700 mg/day
Most people eat more than they need
Serum levels may be normal until advanced CKD
Absorption increases with 1,25(OH)2D
Phosphorus binders, taken with meals, may be prescribed
Inorganic PHOS in food additives is absorbed more readily
Read ingredient lists for PHOS to find added phosphorus

what's the bottom line for recommended potassium intake in a CKD pt

Most US adults do not get enough potassium in their diets.
An adequate intake of potassium (4,700 mg) may help lower BP in the general population.
Restrict dietary K when serum levels are ↑
Products with KCl should be avoided
Some low-sodium products may use KCl in place of NaCl; read ingredient lists to ID

Identify the unique requirements for CKD MNT in special populations:
1. children

1. CKD can cause:
Weak bones,
Lack of appetite
Lack of energy
Slowed growth
↓ resistance to infection

Describe protein requirements for children w/CKD

Children need 0.45 g protein/pound of weight/day
Protein helps build & maintain muscle, bone, skin, organs, & blood
Protein Need ↑ with dialysis
Hemodialysis 0.6 g/pound
Peritoneal 0.8 g/pound
Restricting protein can prevent growth & may lead to malnutrition
The goal is to eat enough protein for growth, no more

Describe sodium requirements for children w/CKD

Too little Na can lead to
Dehydration
Poor weight gain
Too much Na
↑ thirst;
↑ blood pressure;
Water retention;
Weight gain;
Fluid buildup in the lungs
Avoid salt substitutes that use KCl

Describe potassium requirements for children w/CKD

Too much or too little potassium causes heart & muscle problems
Avoid high-K fruits & vegetables
↓ number & portion sizes of fruits & vegetables with moderate amts of K
Check nutrition labels for potassium additives

Describe phosphorus requirements for children w/CKD

When serum PHOS levels are high, healthy kidneys remove the extra through the urine.
In children with CKD
The kidneys do a poor job of removing PHOS
Serum PHOS levels increase

Describe fluids requirements for children w/CKD

The child's damaged kidneys may produce too little or too much urine.
Too little urine
Swelling of face, legs, arms, & abdomen
Elevated blood pressure

Too much urine
Dehydration

Dialysis
May need to limit fluid intake
Dialysis does not remove all excess fluid

Describe nutrition for CKD in infants

Rapid infant growth creates unique problems for the infant with CKD and for their health care team
Special formulas with calorie enhancers are needed

Tube feeding may be the best option
Ensures fluids and nutrients needed for growth & development are consumed.

Describe nutrition for CKD in pregnancy

Combining the suggested energy and protein needs for CKD recommended by the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines with those for the general population seems feasible during pregnancy.
Vitamin and mineral requirements are also a combination of those for CKD and pregnancy

How do different cooking methods affect formation of AGES?

Frying, grilling, or broiling with fat results in higher levels of AGES compared to steaming or stewing.

-use water-based cooking techniques
-marinate in high acidic base
-use low-AGE proteins (ie soy, legumes, rice, corn, eggs

How can you remove potassium from food?

Leaching
Overnight soaking of foods to remove potassium
Immediately boiling shredded potatoes lowers potassium content more than an overnight leaching.
Double cooking lowers the potassium content of many tuberous root vegetables.

Describe simple carbs

Broken down quickly by the body to be used as energy.
Found naturally in foods such as fruits, milk, and milk products.
Found in processed and refined sugars such as candy, table sugar, syrups, and soft drinks.
Foods with added sugars have less nutrients than foods with naturally-occurring sugars.

Describe complex carbs

Starch and dietary fiber
Starches are digested more slowly & stabilize BS to maintain energy at an even level
Help one feel satisfied longer after a meal

Describe fiber & its health benefits

Fiber is the indigestible part of plant foods
RDA for adults 20-35 grams of fiber per day
Fiber should come from foods and not dietary supplements.
↓ Cholesterol levels
↓ BS levels in diabetes
↓ Risk of colon cancer
↓ Intestinal disorders
↓ Heart disease
↓ Constipation
↓ LDL's
↑ Satiate
↑ Weight loss
↑ Amount of antioxidants & phytochemicals

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