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Article Excerpt
The successful management of diabetes mellitus within the challenges of everyday life is an art in itself for patients and their healthcare professionals. Chronic kidney disease (CKD) is increasing as a common, often covert complication of diabetes mellitus. Comparison of the National Health and Nutrition Examination Survey (NHANES) data periods of healthy adults 20 years of age or older showed an increase of 2.3% (5.4% 1988-1994; 7.7% 1999-2004) in moderate glomerular filtration rate (GFR) decline estimating kidney function (Castro & Coresh, 2009). Prevalence of CKD in adults 20 to 59 years of age was statistically higher for those with diabetes mellitus alone (33.8% versus 8.2%) and those with diabetes mellims and hypertension (43.0% versus 25.3%). In addition, the risk of CKD increased by 39.2% for those 50 years of age and older (Collins et al., 2009). The investment of time and effort to treat and potentially prevent CKD in patients with diabetes mellitus is appropriate. This review will discuss the medical nutrition therapy guidelines applicable to patients with diabetes mellitus both at risk for or diagnosed into stages of CKD with a focus on practical applications.
Nutrition Parameters: So Just What Can I Eat?
So just what can I eat? This is the question we all seek to answer for any patient. If you have ever tried to follow any type of meal plan or give up even one food item for a period of time, you can begin to imagine the complexity and frustration that diabetes mellitus and CKD bring to daily food decisions. Any CKD impairment forces an adaptation by the renal system. Eating less of selected nutrition parameters may help the damaged kidney filter less. As in diabetes mellitus management, the metabolic situation is not static. Every change, even seemingly minor, can produce a cascade of accompanying issues. The word "diet" is often associated with negative restrictions and short-term sacrifices. It is more positive to focus on "what I can eat" rather than "what I cannot, eat"
The nutrient intake must be matched to the organ ability. Table 1 outlines general nutrition parameters by CKD stages and replacement therapy, but the application of this complex matrix requires a high level of individualization for effective therapy. This table integrates the clinical guideline recommendations of the American Diabetes Association, the American Heart Association, the American Dietetic Association, and the National Kidney Foundation (Bantle et al., 2006, Giddings et al., 2009, National Kidney Foundation [NKF], 2000, 2007). Calories, protein, fat, and carbohydrates are part of routine education for people with diabetes mellitus, but the focus is primarily on the timing and ability of the body to handle the glycemic load. CKD forces the modification to the degree of organ function, classified by NKF as progressive failure (Stages 1 to 4) or total kidney failure (Stage 5) when dialysis or transplant is necessary for life. Both the amount and type of some nutrients need definition. Restriction of one parameter, such as protein to address elevated serum creatinine, can in turn result in low serum albumin unless the type of protein restricted includes high biological value choices. Furthermore, since patients make food choices based on changing opportunities and motivation scenarios, the nutrition education component is ongoing and evolving.
Individualized Nutrition Goals
There are four primary nutrient goals in kidney-focused nutrition: 1) match dietary intake to kidney output, 2) maintain or achieve glycemic control, 3) maintain or achieve healthy body weight, and 4) manage or decrease nutrient risks. The patient's stage of life imposes additional goals as shown in Table 2. The overall premise of nutritional care in CKD is individualization to a patient's specific kidney function, specific treatment modality, and own unique food issues. Other considerations that need to be integrated may include budgetary constraints, shopping and food preparation limitations, knowledge and skill levels, cultural and environmental issues, nutrient deficits, and family support/motivation status. The Center for Medicare and Medicaid Services (CMS) reimburses selected nutrition education services provided by registered dietitians for Medicare patients with CKD Stages 1 to 4 and diabetes mellitus (NKF, 2007). CMS coverage for dialysis mandates and outlines nutrition services of registered dietitians as well. The most effective education is delivered with a common mindset by each healthcare team member reinforcing each other's area of expertise.
Nutritional Assessment
The first step in planning what a patient can eat begins with a complete nutritional assessment. The American Dietetic Association has recently developed a nutrition care process standardized language initiative which seeks to use specialized terminology to describe and monitor nutritional care. The four specific steps are 1) nutrition assessment, 2) nutrition diagnosis, 3) intervention, and 4) monitoring and evaluation. This process, as in medical care, repeats itself with each patient interaction (American Dietetic Association, 2008). Assessment begins with a nutrition-focused physical examination looking for overt and covert physical findings of nutritional deficiency or toxicity (Kelly, Kight, & Castillo, 1998). A subjective global assessment has also been shown to be an appropriate assessment technique (de Mutsert et al., 2009). This is followed by a 24-hour...
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