Diabetes mellitus, affecting over 450 million people globally with projections exceeding 700 million by 2045, frequently leads to chronic kidney disease (CKD). Up to 40% of diabetes cases are complicated by CKD, evidenced by persistent kidney function abnormalities such as elevated urine albumin excretion or reduced estimated glomerular filtration rate (eGFR). Individuals with both diabetes and CKD face heightened risks of CKD progression, cardiovascular disease (CVD), and mortality. Managing these risks involves a comprehensive approach encompassing lifestyle adjustments, risk factor management, and appropriate pharmacotherapy.
The Interplay Between Diabetes and Kidney Disease
Approximately 1 in 3 adults with diabetes has chronic kidney disease (CKD). Diabetes and high blood pressure are the main causes for CKD. Because the symptoms of CKD are often mild and go undetected, it’s critical to understand the risk factors and take necessary steps to protect your health.
The Cornerstone of Management: Structured Education and Dietary Adjustments
Structured education in diabetes self-management is highly recommended for individuals with diabetes and CKD. This form of education can significantly improve long-term clinical outcomes and overall quality of life.
Balanced Diet Composition
Dietary advice should emphasize a balanced, healthy diet rich in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts, while limiting processed meats, refined carbohydrates, and sweetened beverages. Remember, a diabetes diet is a healthy-eating plan that helps control blood sugar. A diabetes diet simply means eating the healthiest foods in moderate amounts and sticking to regular mealtimes. It's a healthy-eating plan that's naturally rich in nutrients and low in fat and calories. Key elements are fruits, vegetables and whole grains.
Individualized Nutritional Adjustments
Nutritional recommendations may need adjustments based on individual conditions, such as hyperkalemia, and personal or cultural preferences.
Read also: Managing Stage 3 Kidney Disease with Diet
Protein Intake
Daily dietary protein intake should be maintained at 0.8 g per kg, a recommendation for all adults. Neither higher- nor lower-protein diets are generally advised. However, individuals on dialysis require a higher daily protein intake of 1.0 to 1.2 g per kg to counter muscle catabolism. More protein than you need makes your kidneys work harder and may make CKD worse. But too little isn't healthy either. Both animal and plant foods have protein. Plant-based proteins have been shown to reduce health complications and support kidney health. Including a variety of protein sources in your eating plan will help you get essential amino acids
Physical Activity
Lower levels of physical activity are common and associated with worse clinical outcomes. It’s best to break up longer periods of sitting with some short, fun, and simple mini exercise breaks every thirty minutes. Fewer people are outside in the mornings, making it a great time for a relaxing workout and to start your day off right.
Pharmaceutical Interventions
For individuals with type 2 diabetes and CKD with an eGFR of 30 mL per minute per 1.73 m2 or higher, a combination of metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors is often recommended as a first-line medical treatment due to their effectiveness in improving glycemic control outcomes.
Metformin
Metformin is considered safe for patients with an eGFR above 45 mL per minute per 1.73 m2, unless there is a high risk of acute kidney injury.
SGLT2 Inhibitors
SGLT2 inhibitor use may cause a reversible decline in eGFR, which typically doesn't necessitate stopping the medication. The SGLT2 inhibitor can be continued with an eGFR below 30 mL per minute per 1.73 m2 if the patient tolerates it well and dialysis is not imminent. It's important to note that SGLT2 inhibitor use is associated with genital mycotic infections and rare diabetic ketoacidosis. The major recommendation that SGLT2 inhibitors be first-line therapy for diabetes with CKD requires scrutiny. All authors receive funding from companies that market SGLT2 inhibitors, and one receives funding from all four.
Read also: A Review of the Mediterranean Diet in Kidney Disease
GLP-1 Receptor Agonists
In patients with type 2 diabetes who have not achieved their glycemic goals despite using metformin and an SGLT2 inhibitor, or who are unable to use these medications, treatment with a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist is recommended. Some GLP-1 receptor agonists have shown beneficial effects in reducing cardiovascular events. GLP-1 receptor agonist trials are safe with an eGFR as low as 15 mL per minute per 1.73 m2, where they appear to reduce albuminuria and preserve eGFR. However, they should not be prescribed with dipeptidyl peptidase-4 inhibitors.
A1C Monitoring
A1C measurements are imprecise among people treated with dialysis but reasonably accurate with an eGFR of 30 mL per minute per 1.73 m2 or greater.
ACE Inhibitors and ARBs
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended to slow kidney disease progression in people with albuminuria and hypertension. An ACE inhibitor or ARB should be titrated to the maximal tolerated dosage, with monitoring of blood pressure, serum potassium, and serum creatinine within two to four weeks of dosing changes. Medications should be reduced or discontinued for symptomatic hypotension, uncontrolled hyperkalemia, creatinine increase of greater than 30%, or acute kidney injury. Combination therapy with ACE inhibitors and ARBs may be harmful and should be avoided. Women prescribed an ACE inhibitor or an ARB should be offered contraceptive advice because of adverse fetal and neonatal effects, especially during the second and third trimesters.
Aspirin
Aspirin is recommended for the secondary prevention of CVD.
Practical Dietary Guidelines for Kidney Diabetes
Living with chronic kidney disease (CKD) and diabetes can be challenging, but one key aspect of managing these conditions is having a diabetes- and kidney-friendly eating plan.
Read also: Nutrition and stage 2 CKD
Foods to Emphasize
Eating foods that have vitamins, minerals, and other nutrients and are minimally processed will help you reach your health goals. Foods like whole grains, vegetables, fruits, lean poultry, seafood, plant proteins, heart-healthy fats, and low-fat dairy have lots of nutrients with fewer calories. Eating these types of food will help you keep your kidneys healthy, manage diabetes, and lower your risk for other health problems. Your health care team will let you know if you need to limit your intake of certain foods to keep your nutrient levels within normal limits.
Sodium Restriction
Eat less salt/sodium. Over time, your kidneys lose the ability to control your sodium-water balance. Less sodium in your diet will help lower blood pressure. Focus on fresh, homemade food to better control the amount of sodium in your food. Eat only small amounts of restaurant food and packaged food, which usually have lots of sodium. In a week or two, you'll get used to less salt in your food. Add flavor with herbs, spices, mustard, and flavored vinegars. But don't use salt substitutes unless your doctor or dietitian says you can.
Potassium, Phosphorus, and Protein
Depending on your kidney disease stage, you may also need to reduce the potassium, phosphorus, and protein in your diet.
Herbal Supplements and Vitamins
Herbal supplements aren't safe if you have kidney disease. Some can hurt your kidneys and even make kidney disease worse. Some vitamins can cause kidney problems too and should also be avoided.
Sample Food Choices
Below are just a few examples of foods a person with both diabetes and CKD can eat. Here's one way your CKD diet and diabetes diet can work together. If you drink orange juice to treat low blood sugar, switch to kidney-friendly apple or grape juice.
Late-Stage CKD and Dialysis
Your nutrition needs will change with late-stage CKD. If you're on dialysis, you may need to eat more, especially more protein. Dialysis filters your blood like kidneys do, but it doesn't work as well as healthy kidneys. Fluid can build up in your body between treatments. You may need to limit how much fluid you drink. Your blood sugar levels can actually get better with late-stage CKD. This may happen because of changes in how your body uses insulin. But when you're on dialysis, your blood sugar can increase. This is because the fluid used to filter your blood is high in glucose (sugar).
Regular Check-ins
CKD and diabetes both change over time, and so will your diet. Be sure to check in with your dietitian as recommended.
A Practical Meal Planning Approach
One effective tool for planning meals is the diabetes- and kidney-friendly meal planner, which helps you plan meals with balanced portions for a nourishing eating pan. Here’s how to use it.
The 9-Inch Plate Method
- Half Your Plate with Non-Starchy Vegetables: Fill half your plate with non-starchy vegetables. For those with CKD who need to limit their intake of phosphorus and potassium, choose options that have essential vitamins, minerals, and fiber. Examples include: Broccoli, Cauliflower, Spinach, Asparagus, Bell peppers, Green beans
- One Quarter of Your Plate with Starchy Vegetables and Grains: In one fourth of your plate, add starchy vegetables or grains. Starchy vegetables and grains will affect your blood glucose most but provide you with energy and nutrients. Choose whole grains when you can to be able to get more fiber in your meals. Examples include: Quinoa, Brown rice, Whole wheat bread, Barley, Corn
- One Quarter of Your Plate with Lean Protein: The last one fourth of the plate, add proteins. Choose lean animal-based and plant-based proteins for lower calories and fats. Eating the right amount of protein in your meals is part of managing CKD. By eating the right amount of protein, you can help keep your kidneys from working too hard after meals. Examples of lean proteins include: Lentils, Beans, Tofu, Lean, skinless poultry (such as chicken or turkey breast), Fish and shellfish, Eggs
Heart-Healthy Fats
Eating heart-healthy fats and limiting saturated fats helps with kidney and heart health. Aim to include omega-3 fatty acids and monounsaturated fats in your meals. Examples of healthy fats include: Olive oil, Avocados or avocado oil, Canola oil, Nuts, Seeds, Fatty fish like salmon, mackerel, and albacore tuna
Focus on Fluids
While water should be your first choice to drink, you can also drink no-calorie options. Some examples are flavored water, unsweetened coffee, unsweetened tea, or zero-calorie clear (not dark) carbonated drinks.
Managing Diabetes Through Dietary Choices
Carbohydrate Management
The first step in managing diabetes is balancing your carbohydrates. Carbohydrates (or “carbs”) are foods that turn into sugar when you digest them. Any carbohydrate food will raise your blood sugar. Complex carbohydrates raise sugar more slowly (it takes your body longer to digest and absorb these), while simple carbohydrates can raise your sugar level more quickly. Along with more obvious sugars like candy and chocolate, many other foods contain carbs, like milk products, bread, cereal, fruit and some vegetables (corn and potatoes).
Portion Control
Portion control is the KEY! With proper portion control, you can enjoy a wide variety of foods, but still keep your dietitian happy, your body healthy, and your lab values under control. When counting carbohydrates, remember that one slice of bread or ½ cup of pasta is counted as one serving of carbs. Generally, people need 3-4 servings of carbs at a meal and 1-2 servings for a snack (you will also want to add protein and a little fat to each meal and snack. To make up for the extra fiber you may be missing by avoiding whole grains, try eating low potassium fruits and vegetables with the skin on. Listed here are some examples of carbohydrate servings for meals and snacks.
Navigating the Differences
About 1 in 3 American adults with diabetes also has chronic kidney disease (CKD). Figuring out what to eat can be a major challenge. Diabetes and CKD diets share many of the same foods, but there are some important differences. A healthy diabetes diet looks pretty much like a healthy diet for anyone. Eat lots of fruits, veggies, healthy fats, and lean protein. Eat less salt, sugar, and foods high in refined carbs (cookies, crackers, and soda, just to name a few). Your individual carb goal is based on your age, activity level, any medicines you take, and other factors. Following your meal plan will help keep blood sugar levels in your target range.
Additional Tips for Managing Diabetes
- Fruits: Kidney-friendly fruits like apples, grapes, peaches, and watermelon make a great snack anytime. Berries are especially beneficial for keeping diabetes in check because they are lower in sugar. Choose whole fruits to get the benefits of fiber and limit fruit juice to minimize sugar and potassium.
- Whole Grains: High-fiber carbs like whole grain bread, whole grain pasta, brown rice, and even unsalted popcorn can be smart choices in moderation. Eating high-fiber foods helps keep your blood sugar within a normal range and prevents spiking.
- Proteins: Balance your meals with fresh protein choices such as chicken, fish, and eggs. Limit processed foods like deli meats or sausages because they are usually high in sodium and phosphorus.
- Unsaturated Fats: Healthy fats like unsaturated fats can be good for you. Unsaturated fats typically come from plants and are found in vegetable oils, nuts, and peanut butter.
Kidney-Friendly Eating Plan: Key Considerations
When you have kidney disease, it is important to watch what you eat and drink because your kidneys cannot remove waste products as well as they should. A kidney-friendly eating plan can help you stay healthier and slow down damage to your kidneys. Everyone is different and has different nutritional needs. Work with a dietitian to create a kidney-friendly eating plan that is right for you.
What is a Kidney-Friendly Eating Plan?
A kidney-friendly eating plan is a way of eating that helps you stay healthy and can slow down damage to your kidneys. It includes foods that are easy on your kidneys and limits other foods and fluids so certain minerals in those foods, like potassium, do not build up to high levels in your body.
Creating Your Personalized Plan
Ask your doctor to refer you to a dietitian (someone with special training in food and nutrition to know which foods are right for people with kidney disease). You can talk to a dietitian about the foods you enjoy or any special requirements you have (for example, you are vegetarian or have food allergies) and they will help you create a kidney-friendly eating plan that is right for you and includes the foods you enjoy. Always talk to a dietitian before increasing or decreasing your daily intake of certain foods or nutrients.
Why is it Important?
A kidney-friendly eating plan helps you manage your kidney disease and slow down damage to your kidneys. It does this by preventing certain minerals from building up in your body, which is important because your kidneys do not work as well to remove waste products from your body. A kidney-friendly eating plan can also help prevent other serious health problems and controls high blood pressure and diabetes, which can prevent kidney disease from getting worse. It also ensures that you get the right balance of nutrients to help you: Have energy to do your daily tasks, Prevent infection, Build muscle, Stay at a healthy weight
Essential Components of a Kidney-Friendly Diet
Your kidney-friendly eating plan may change over time but will always give you the right amount of key nutrients. Protein: One of the nutrients that gives you energy. Your body needs protein to grow, build muscles, heal and stay healthy. Fat: Fat is another one of the nutrients that gives you energy. Your body needs fat to carry out many jobs, such as using vitamins from your food and keep your body at the right temperature. Carbohydrates or "carbs": Your body's main source of energy. Your body can more easily convert carbs into energy than protein and fat.
Key Steps to Follow
- Eat the Right Amount and Types of Protein: Having too little protein can cause your skin, hair and nails to be weak. But having too much protein can make your kidneys work harder and cause more damage. This happens because when your body uses protein, it makes waste products that your kidneys must filter. To stay healthy and help you feel your best, you may need to adjust how much protein you eat.
- Choose the Right Types of Fat: Fat gives you energy and helps you use some of the vitamins in your food. You need some fat in your eating plan to stay healthy. Too much fat can lead to weight gain and heart disease. Limit fat in your meal plan, and choose healthier fats when you can, such as olive oil.
- Choose Whole Grain Carbohydrates: Eating too many carbs can lead to weight gain. When you have kidney disease, it is best to choose whole grains and healthy carbs such as fruits and vegetables. Unhealthy carbs include sugar, honey, hard candies, soft drinks and other sugary drinks.
- Eat the Right Amount of Calories: Calories are like fuel and give your body energy. Calories come from the protein, fat and carbs in your food and fluid plan. How many calories you need depends on your age, gender, body size and activity level. You may need to adjust how many calories you eat to stay at a healthy weight.
- Choose and Prepare Foods with Less Sodium (Salt): Sodium (salt) is a mineral found in almost all foods. It has many important roles in the way your body works. The amount of sodium found naturally in foods is enough to keep a healthy level in your body. But eating packaged foods and adding salt to foods can lead to eating too much sodium.
Portion Control Strategies
Good portion control or watching how much you eat is important in a kidney-friendly eating plan, because you may need to limit how much of certain things you eat and drink. To help control your portion sizes: Read the nutrition label to learn the serving size and how much of each nutrient is in one serving. Many packages have more than one serving. For example, a 20-ounce bottle of soda is two-and-a-half servings. For foods that do not have nutrition labels, such as fruits and vegetables, ask your dietitian for a list of nutrition facts to measure the right portions. Eat slowly and stop eating when you are full. It takes about 20 minutes for your stomach to tell your brain that you are full. If you eat too quickly, you may eat more than you need. Avoid eating while doing something else, such as watching TV or driving. When you are distracted, you may not realize how much you have eaten.
Adjustments Based on CKD Stage
Yes, how strict your eating plan should be depends on your stage of kidney disease. When you are in the early stages of CKD (Stages 1 and 2), you will have less limits on what you can eat. As your kidney disease gets worse (Stages 3, 4 and 5), your doctor may recommend that you limit: Potassium: A mineral found in foods that your body needs to make your muscles work. Phosphorus: A mineral found in foods that works with calcium and vitamin D to keep your bones healthy. Fluids: Anything that turns to liquid at room temperature, not just water.
Managing Potassium Levels
When your kidneys are not working well, your potassium level may be too high or too low. Having too much or too little potassium can cause muscle cramps, problems with the way your heart beats and muscle weakness. If you have kidney disease, your doctor or dietitian may tell you to lower the amount of potassium in your eating plan.
Phosphorus Control
Healthy kidneys keep the right amount of phosphorus in your body. When your kidneys are not working well, phosphorus can build up in your blood. Too much phosphorus in your blood can lead to weak bones that break easily.
Fluid Restriction
When you have kidney disease, you may need to limit water and fluids. This is because damaged kidneys do not get rid of extra fluid as well as they should. Too much fluid in your body can cause high blood pressure, swelling and heart failure. To limit fluids, you will need to cut back on how much you drink and limit eating some foods that contain a lot of water, such as soups, ice cream, gelatin and many fruits and vegetables.
Vitamins and Supplements
Your doctor and dietitian can help you find vitamins that are right for you. To help you get the right amounts of vitamins and minerals, your dietitian may suggest you take: A special supplement made for people with kidney disease. A special kind of vitamin D, folic acid or iron pill, to help prevent some common side effects of kidney disease, such as bone disease and anemia. Regular multi-vitamins may not be healthy for you if you have kidney disease. Tell your doctor and dietitian about any vitamins, supplements or over-the-counter medicines you are taking.
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