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Can J Diabetes 38 (2014) 344 e 348 Contents lists available at ScienceDirect Canadian Journal of

Contents lists available at ScienceDirect

Canadian Journal of Diabetes

journal homepage:

journal homepage: www.canadianjournalofdiabetes.com Review Nutrition for the Prevention and Treatment of Chronic
journal homepage: www.canadianjournalofdiabetes.com Review Nutrition for the Prevention and Treatment of Chronic

Review

Nutrition for the Prevention and Treatment of Chronic Kidney Disease in Diabetes

Dana Whitham RD, MSc *

Diabetes Comprehensive Care Program, St Michaels Hospital, Toronto, Ontario, Canada

St Michael ’ s Hospital, Toronto, Ontario, Canada article info Article history: Received 18 March 2014

article info

Article history:

Received 18 March 2014 Received in revised form 24 July 2014 Accepted 25 July 2014

Keywords:

protein

nephropathy

diabetes

sodium

nutrition

Mots clés :

protéine

néphropathie

diabète

sodium

nutrition

abstract

The prevention and treatment of chronic kidney disease (CKD) in diabetes through diet and lifestyle have been a topic of much interest over the years. Consideration of the type and amount of carbohydrate, protein and fat is required for optimal blood glucose control, for clinical outcomes related to renal function and for consideration of risk reduction for cardiovascular disease. Controversy has existed regarding the clinical signi cance of a protein-controlled diet, not to mention the ideal recommended intake in view of the bene ts and risks. Furthermore, the level of CKD with which to implement dietary changes should also be considered. This review seeks to provide guidance and clarity concerning the nutritional management of CKD in diabetes.

2014 Canadian Diabetes Association

résumé

La prévention et le traitement de la néphropathie chronique (NC) à l aide du régime alimentaire et du mode de vie lors d un diabète ont suscité beaucoup d intérêt au l des années. La prise en considération du type et de la quantité de glucides, de protéines et de matière grasse est nécessaire à la régulation optimale de la glycémie, aux résultats cliniques liés au fonctionnement rénal ainsi quà la réduction du risque de maladie cardiovasculaire. Une controverse existait concernant l importance clinique d un régime pauvre en protéines, sans parler de l apport idéal recommandé eu égard aux avantages et aux risques. De plus, le degré de NC pour la mise en pratique de changements au régime alimentaire devrait également être considéré. Cette revue cherche à fournir des conseils et des précisions sur la prise en charge nutritionnelle de la NC lors de diabète.

2014 Canadian Diabetes Association

Introduction

Diet and lifestyle are key components of an interprofessional approach to diabetes care. A treatment plan that encourages a combination of self-management education, lifestyle and phar- macotherapy has been shown to be successful (1) . Good nutrition can help to control blood glucose, blood pressure and lipids, thereby slowing the onset and progression of complications that include chronic kidney disease (CKD). Diets that reduce in am- mation and oxidative stress may also delay the progression of CKD in diabetes (2) . Controversy surrounds recommendations for low-protein diets in CKD in terms of the exact amount, when to implement any limitations and whether the bene ts outweigh the potential risks. In more advanced CKD, the restrictions required as part of a renal diet may con ict with the dietary strategies that

* Address for correspondence: Dana Whitham, RD, MSc, St Michael s Hospital, 61 Queen Street East, Toronto, Ontario M5C 2T2, Canada. E-mail address: whithamd@smh.ca

1499-2671/$ e see front matter 2014 Canadian Diabetes Association

promote optimal glycemic control. This review examines the life- style factors that in uence risk for and progression of CKD in dia- betes, notes the clinical recommendations for nutrition therapy and provides guidance about how to achieve targets while managing both diabetes and CKD ( Table ).

Nutritionally Modi able Risk Factors for Chronic Kidney Disease

Poor glycemic control, hypertension and smoking are well- known risk factors for CKD in persons with diabetes (3) . There are several novel risk factors that are also amenable to dietary interventions, including obesity, hyperphosphatemia and advanced glycation endproducts (AGEs). Obesity is associated with increased incidence of CKD (4,5) , and some experts estimate that up to 25% of cases of kidney disease could be prevented through weight loss alone (6) . Epidemiologic studies report that obesity is independently predictive of CKD (3) and that the link may occur through the physical compression of

D. Whitham / Can J Diabetes 38 (2014) 344 e 348

Table Nutritional considerations for people with chronic kidney disease in Diabetes

345

 

CKD Stages 1-2

CKD Stages 3-4

ESRD Stage 5 (on dialysis)

Glycemic control

Promote optimal glycemic control

May require medication adjustment Assess for hypoglycemia 23-35 kcal/kg/day for stage 3. 30-35 kcals/kg/day for stage 4. Encourage preservation of lean body mass and nutritional status

Assess for hypoglycemia

Calories and weight 23-35 kcal/kg BW/d or use HBE Encourage 5%-10% weight loss if appropriate

Hemo: 30-35 kcal/kg/day PD: 30-35 kcal/kg/day Encourage preservation of lean body mass and nutritional status 45%-60% of energy < 10% of calories from sugar (as part of a mixed meal) Hemo: 1.2 g/kg/day

CHO and sugar

45%-60% of energy < 10% of calories from sugar 45%-60% of energy < 10% of calories from sugar

(as part of a mixed meal)

(as part of a mixed meal)

Protein

Encourage 0.8 g/kg/day

0.8g/kg/day with avoidance of intakes

 

>

1.3g/kg/day

PD: 1.2-1.3 g/kg/day < 30%-35% of energy < 7% of energy 14-25 g/1000 kcal Encourage lower GI, renally appropriate choices

Fat saturated fat

< 30%-35% of energy < 7% of energy 14-25 g/1000 kcal Promote low GI grains, fruit, dairy products

< 30%-35% of energy < 7% of energy 14-25 g/1000 kcal Encourage stepwise modi cations in GI Watch overall carbohydrate content as GI of diet changes Usually unrestricted Watch for excessive thirst with hyperglycemia

Fibre

Glycemic index

Fluid

Usually unrestricted Watch for excessive thirst with hyperglycemia

Hemo: 1L þ urine output PD: Individualized Watch for thirst caused by hyperglycemia Educate on non uid sources of carbohydrate for treatment of hypoglycemia < 2400 mg/day

Sodium

< 2000 mg/day Individualized restriction if hyperkalemia present Individualized restriction if elevated serum levels DASH/Mediterranean/Portfolio

< 2000 mg/day

Potassium

< 2400 mg/d if hyperkalemia present Hemo: < 2400 mg/day

Phosphorus

PD: Individualized 800-1000 mg/day Hemo: 800-1200 mg/day

Dietary patterns

Progressing dietary restrictions limit patterns based on protein content, potassium or phosphorus. Modi cations as required

PD: 800-1000 mg/day Progressing dietary restrictions limit patterns based on protein content, potassium or

 

phosphorus. Modi cations as required

CKD , chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; ESRD, end stage renal disease; GI , glycemic index; HBE , Harris Benedict equation; Hemo, hemodialysis; PD , peritoneal dialysis. Adapted from Whitham D, Sharma Parpia A. (37) .

the kidneys, the activation of the renin-angiotensin aldosterone system (RAAS) or hyper ltration (6) . American guidelines for dia- betes and CKD encourage attaining a normal body weight as a potential means of reducing risk (6) . Recent observational studies have shown an association between serum phosphorus levels and rate of progression of CKD (7,8) . The hypothesis is that dietary phosphorus intake leads to calci cation and vascular damage, although direct links have not been demonstrated in clinical trials (7) . AGEs have been associated with both vascular damage (2) and structural changes in the kidney, which may lead to the progression of renal disease and to a higher prevalence of cardiovascular disease in those with CKD (2) . AGEs are a group of highly oxidant com- pounds also known as glycotoxins (9) , which may be consumed in the diet or may be produced as a part of normal metabolism. AGEs accumulate in tissues, binding to and cross-linking proteins, thereby altering cell structure and function (9) as well as causing oxidative stress and in ammation (9) . AGE formation is accelerated in states of high blood glucose and uremia (9) . Dietary AGEs (dAGEs) are naturally found in uncooked animal- derived foods. Cooking, particularly frying, broiling and grilling at high temperatures, can lead to very signi cant increases in dAGE levels (10) . Simple alterations of cooking methods have been shown to decrease serum levels of AGEs, oxidative stress, in ammation and insulin resistance (9) . In addition to the avoidance of very high temperatures, the addition of moisture through either water or marinades can reduce the formation of AGEs (9) . Prevention of oxidative stress may be important in many chronic diseases, including CKD. With conditions such as hyper- glycemia and uremia, which lead to increases in oxidative stress, and a typical North American dietary pattern that promotes oxidative stress and yet has insuf cient antioxidants, it could be speculated that increasing the intake of antioxidants would be of

bene t to the progression of complications. Although not shown in humans, some animal-model studies have demonstrated a bene t of antioxidant supplementation on vascular disease (11) . In summary, management of hyperglycemia, hypertension and lipids and a more healthful dietary pattern that promotes an ideal body weight plus balanced intake may be of bene t to minimizing the progression of CKD in persons with diabetes.

Weight management

For those who are overweight, lifestyle therapy aimed at achieving and maintaining an ideal body weight may improve multiple risk factors for kidney disease, including blood glucose, blood pressure, lipids and proteinuria (12e16). One systematic review found that for each kg of weight loss, there was a reduction of 110 mg of proteinuria (17). Both body weight and waist circumfer- ence targets should be considered when setting goals. Waist circumference is strongly associated with visceral fat in patients with CKD (18) and carries a greater risk than does body mass index (1). For overweight and obese people with stage 1 to 3 CKD and diabetes, moderate weight loss of 5% to 10% of body weight is recommended. Moderate reductions in energy intake (500 to 1000 kcal/day) combined with an increase in physical activity is the preferable weight-loss plan for this population (3,6) . High-protein diets, such as Atkins, Protein Power, South Beach, Sugar Busters and Zone (de ned as 20% of total daily calories from protein) are not recommended. Higher protein intakes have adverse effects on kidney hemodynamics and increase hyper ltration, intra- glomerular pressure and albuminuria. These deleterious effects are more pronounced in people with diabetes (6) . Epidemiologic evi- dence suggests an association between high-protein diets and the development of proteinuria in people with diabetes and hyper- tension and in women, a loss in kidney function (6) .

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D. Whitham / Can J Diabetes 38 (2014) 344 e 348

The Academy of Nutrition and Dietetics (AND) recommends a calorie intake of 23 to 35 kcal/kg BW/day in patients with CKD but without dialysis (19). Energy requirements in this population are similar to those of healthy individuals; however, in more advanced stages of CKD, higher caloric intakes (30 to 35 kcal/kg BW/day) may be required to maintain nitrogen balance while also maintaining serum albumin and the anthropometric markers of normal nutri- tional status. So, as the glomerular ltration rate (GFR) declines, caloric intake should increase toward the higher end of the range (6). Regular monitoring to ensure that weight goals are attained is key to success. Assessment of uid status and edema should be considered when evaluating progress toward weight-loss goals.

Dietary fats

Because people with CKD are at high risk for cardiovascular disease (20) , lipid targets and dietary recommendations should align with those of the Canadian Diabetes Association and Canadian Cardiovascular Society to reduce intake of alcohol, saturated and trans fatty acids, dietary cholesterol and simple sugars (12,21) . In people with CKD, substituting lean meats, poultry, sh and low-fat dairy products in place of high-fat animal-derived foods will have little adverse impact on serum potassium or phosphorus. However, care should be taken in recommending an increase in the consumption of nuts, some sources of vegetable protein (soy and legumes) and certain sources of soluble bre because these may exacerbate hyperkalemia. Several guidelines recommend 2 to 3 servings of cold-water fatty sh weekly to increase omega-3 fatty acids. Omega-3 fatty acids may have favourable effects on the progression of kidney disease as evidenced by reductions in proteinuria, although trial data are limited (12,20) . Supplementation of omega-3 fatty acids had no effect on cardiovascular disease in the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial (22) . No clinical studies have been conducted concerning the use of plant sterols to lower cholesterol in patients with CKD, but they are considered safe food additives, a dose of 2 g per day may lead to bene cial reductions in cholesterol for those not achieving targets.

Dietary sodium intake

High dietary sodium intake is associated with high blood pres- sure (23) , worsening of proteinuria and a blunting of the response to agents that block the RAAS (24) . Therefore, irrespective of blood pressure, dietary sodium restriction should be a component of nutrition therapy for all patients with proteinuria, including those on RAAS blockade. The effect of the restriction may be more pro- nounced in those with pre-existing hypertension, older adults and African Americans (24) . The Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend a sodium restriction of less than 2000 mg per day in people with stages 1 through 4 CKD (24) based on evi- dence that suggests that excess dietary sodium (4600 mg) affects proteinuria. The Canadian Hypertension Education Program (CHEP) guidelines recommend limiting sodium intake to no more than

restriction, for nutritional treatment of hypertension in people with diabetes because of its potent reductions in both blood pressure and its effect on insulin resistance. Principles of the DASH diet include the use of whole grains, fruits and vegetables, and low-fat dairy products. As a result, the diet is designed to be high in potassium and phosphorus and may be best suited to individuals with stage 1 to 2 CKD (26) and those without need for dietary restrictions to manage hyperkalemia.

Carbohydrates and glycemic control

For most people with diabetes and CKD, the dietary strategies of the Canadian Diabetes Association (CDA) that are aimed at reducing hyperglycemia are appropriate (12) . As kidney function declines (CKD stages 4 and 5), both food choices and portions may have to be adjusted to meet the required restrictions in potassium and phos- phorus. Unfortunately, diets high in bre and low in glycemic index are also commonly high in potassium and phosphorus. Neverthe- less, a higher bre intake and the use of low-glycemic index foods should be encouraged within the constraints of the progressing renal restrictions. The rst step in managing a diet for a person with diabetes and CKD is to ensure that the intake of carbohydrates is not excessive for the caloric requirements and is within the recommended range of 45% to 60% of total calories (27,28) . A bre intake similar to that of the general population (14 g/1000 kcal/day) (28) or slightly higher (15 to 25 g/1000 kcals/day) if achievable should be encouraged because it is unlikely to achieve bre intakes at the high end of the CDA recommendations (50 g/day). Low-potassium fruits and vegetables, such as berries, pears, apples, green peas and green beans, as well as popcorn and cracked-wheat bread can be recommended to boost bre intake. Those unable to achieve bre goals through the diet can add natural tasteless bre supplements (e.g. Bene bre) to their meals or uids (6) . In terms of the glycemic index (GI), low GI foods should be encouraged until a restriction in dietary potassium limits their use. At that time, a stepwise approach to restrictions would be recommended. Limiting high- potassium, highly processed convenience foods, such as potato chips, chocolate and granola bars, and re ned breakfast cereals should be recommended. Most fruits and vegetables are low on the GI index but range in potassium content. The second step toward managing postprandial glucose while following a potassium- restricted diet would be to select fruits and vegetables that have lower potassium levels (see list above). Milk products, although generally low on the glycemia index, should be encouraged initially in amounts to meet the recommendations of the Canada Food Guide; however, as CKD progresses, recommended intakes may need to be further reduced and calcium and vitamin D supplements considered. Modi cation of the intake of grains and starches would be the nal step toward reducing potassium intake while main- taining targets in postprandial glucose. Grains lower on the GI index include parboiled rice, al dente pasta, cracked wheat and sourdough breads.

Sweeteners

1500

mg of sodium per day for those younger than 50 years of age;

1300

mg for those between 50 and 70 years of age; and no more

Nutritive and non-nutritive sweeteners (NNS) are considered

than 1200 mg for those over the age of 70 (25) . Restricting sodium intake to the recommended levels is often dif cult to achieve in practice, especially for those younger and more active individuals requiring larger caloric intakes. Nutrition counselling should focus on processed and prepackaged foods (including canned soups and deli meats), meals taken outside of the home and bread products that have high sodium content. The Dietary Approaches to Stop Hypertension (DASH) diet is a dietary pattern commonly recommended, along with a sodium

safe for use by people with diabetes and CKD when consumed in the acceptable intake ranges outlined by Health Canada. NNS, including acesulfame K, aspartame, stevia, sucralose and saccharin, are excreted unchanged in either urine or feces and as such do not have any impact on serum potassium levels (29) . Use of NNS may be of importance for those with CKD and diabetes to manage the overall glycemic load. This is especially important in situations where the necessity for dietary potassium restrictions has led to the use of foods lower in bre or higher on the GI. Use of NNS to

D. Whitham / Can J Diabetes 38 (2014) 344 e 348

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sweeten foods or for use in baking and low-sugar jams, jellies and yogurts may be appropriate and safe substitutions.

Proteins

The protein needs of people with diabetes are the same as those of the general population. Most adults consume, on average, between 1.0 and 1.4 g/kg BW/day (12) . In type 2 diabetes, meals containing protein may assist with blood glucose management by enhancing insulin release (27,29,30) and promoting satiety. Excessive dietary protein, however, causes hyper ltration and the accumulation of uremic toxins (24) and dietary acids that may be detrimental to the progression of CKD. Although the adverse effects of excessive protein intakes are clear, the bene ts of protein-restricted diets in CKD have long been debated. This is the result primarily of the relatively poor quality of the studies and the reliance on surrogate endpoints, particularly albuminuria. Much of the data suggesting the bene ts of protein restriction came from studies conducted prior to the use of RAAS blockade agents (31 e33) . A number of meta-analyses and a Cochrane review have been completed in attempt to summarize the available data. Based on 12 studies, the Cochrane review concluded that there was a small but nonsigni cant effect of low-protein diets on slowing diabetic nephropathy (34) . Pan and colleagues conducted a systematic review and meta- analysis of randomized controlled trials evaluating lower protein diets in people with diabetes, and the primary outcome was the rate of change of the GFR instead of the risk marker proteinuria (35) . The actual intake in the low-protein diets averaged 0.91 g/kg BW/day as compared to a usual intake range of 1.27 g/kg BW/day. Overall, the review found no improvement in kidney function, as estimated by GFR, between low protein intake and usual intake. The authors did conclude, however, that a signi cant decrease in proteinuria was observed in those who ingested the lower protein diet. Reductions in proteinuria have also been seen in other studies involving dietary protein intakes at the recommended dietary allowance (RDA) level (6) . In a more recent study, a protein- controlled diet limited to 0.89 g/kg BW/day was shown to reduce the risk for progression to end stage renal disease with more pronounced bene ts in individuals with diabetes (36) . Of particular interest is that this study was conducted in people with type 1 diabetes who were treated with an angiotensin-converting enzyme inhibitor, indicating that the effect of controlling protein intake closer to the RDA in early stages of CKD in diabetes may be additive to current treatment recommendations. In the only large-scale randomized controlled trial to date, the Modication of Diet in Renal Disease (MDRD) Study (33) , a lack of effectiveness of protein- restricted diets (de ned as less than the RDA of 0.8 g/kg BW/day) was found. Based on this information, the CDA (12) recommends that in people with CKD, intakes should be targeted to the RDA of 0.8 g/kg BW/day. Both the Academy of Nutrition and Dietetics (AND) (19) and the Kidney Disease Outcomes Quality Initiative (KDOQI) (6) guidelines also recommend intakes in the 0.8 to 0.9 g/kg BW/day range for those with CKD and diabetes. Counselling to avoid under- consumption or excessive consumption of protein is recom- mended. Excessive intakes are generally de ned as a diet that contains 20% or more total calories derived from protein. The 2012 KDIGO (24) guidelines recommend that protein intake should be maintained at 0.8 g/kg BW/day with avoidance of intakes above 1.3 g/kg BW/day for those individuals at risk for progression. Upon review of the evidence, the KDIGO working group concluded that in CKD with diabetes, there was no convincing evidence that long- term low protein intakes ( < 0.8 g/kg BW/day) were bene cial in slowing the progression of CKD.

Beyond quantity, the type of dietary protein may be important to renal outcomes. High-biologic value proteins, which include lean sources of sh, poultry, eggs, soy and legumes, should make up between 50% and 75% of the protein intake (6) . Diets that empha- size plant sources of protein (soy, legumes and nuts) may be higher in potassium and phosphorus. In the Dietary Approaches to Stop Hypertension (DASH) trials, despite a relatively high protein intake (1.4 g/kg BW/day), blood pressure was signi cantly reduced by the intake of mainly vegetable sources of protein (whole grains, low-fat dairy products) along with sh and chicken. The DASH diet trials were not the only studies to demonstrate that there may be some bene t to limiting red meat (24) . In the Nurses Health Study, the risk for end stage renal disease was greater in women who had higher intakes of animal meat (24) . Therefore, in people within stages 1 to 2 CKD, employing a patterned approach to intake, such as the DASH diet, may be bene cial in terms of promoting appropriate types of proteins and carbohydrates and ultimately may affect blood pressure, glycemia and proteinuria. A DASH pattern can be continued until such time as limitations in potas- sium or phosphorus intake are required or until the GFR falls below 30 mL/min/1.73m 2 . The practical implementation of achieving a protein-controlled diet through nutrition therapy requires speci c guidance by healthcare professionals and the avoidance of the word restriction . Speci c guidance related to achieving the RDA of 0.8 g/kg BW/day with a maximum of 1.3 g/kg BW/day would be bene cial, especially for those with a GFR < 30 mL/min/1.73m 2 . When translating protein requirements into protein servings, use of actual or ideal body weight is recommended. After using the formula of 0.8 g/kg BW/day, multiply by 0.5 to allow for at least 50% of protein to come from high biologic sources. Divide the result by 7 in order to determine the number of protein servings that would come from meats and alternatives.

Hypoglycemia and hyperglycemia

The risk for hypoglycemia, especially in those using insulin or insulin secretagogues, increases with declining renal function. In those with later stages of CKD, altered drug metabolism may affect the clearance of certain medications. Uremic factors, including gastroparesis, poor appetite, fatigue and taste changes, compound the risk. Furthermore, reduced kidney mass impairs renal gluco- neogenesis and can predispose an individual toward hypoglycemia. Treatment of hypoglycemia should follow CDA guidelines (12) , but care should be taken to avoid hyperkalemia (by using higher potassium treatment options such as orange juice) and uid over- load. Fast-acting carbohydrates that are suitable for those with renal impairment include dextrose tablets, hard candies, honey and non-cola regular pop instead of commonly recommended treatments such as juices or cola beverages. With declining renal function, uid control may become an issue. Adherence to uid restrictions may be more dif cult in situations of hyperglycemia. When a uid restriction is warranted, patients should be educated to maintain optimal glucose control and to control thirst with alternate strategies such as using lime and lemon wedges, ice chips and sugar-free gums or candies.

Summary

Living with either CKD or diabetes is a challenge. For patients with diabetic nephropathy, acceptance and adherence to the diet is often limited because the restrictions required by the renal diet may contradict previous dietary recommendations for diabetes. Poor adherence places patients at risk for acute complications, such as uid overload, hyperkalemia, hyperphosphatemia and malnu- trition, not to mention the potential worsening of CKD. Adherence is best achieved through collaboration with a registered dietitian to

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provide clear nutrition goals that balance both renal and diabetic needs while keeping electrolytes, protein, phosphorus and carbo- hydrates balanced. Patients should be educated about the overall goals of therapy and the requirements necessary within each stage of CKD. Nutrition care plans should aim to achieve blood glucose, blood pressure and lipid targets, as well as achieving ideal body weight, limiting sodium to between 1500 and 2000 mg, limiting protein to between 0.8 g/kg BW/day, with avoidance of intakes greater than 1.3 g/kg BW/day, and encouraging smoking cessation and exercise.

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