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Transcript
The Diabetes and Kidney Care (DKC) Food Guide was developed by Registered Dietitians at Orillia Soldiers’
Memorial Hospital (OSMH); the Diabetes Education Centre and the Regional Kidney Care Program Simcoe/Muskoka.
Authors
Sarah Bouchard, RD
Nancy Hunter, RD
Linda Ross Stringer, RD, CDE
OSMH, Regional Kidney Care Program Simcoe/Muskoka
OSMH, Regional Kidney Care Program Simcoe/Muskoka
OSMH, Diabetes Education Centre
We would like to thank Trish Duke, RD for her initial inspiration, Ada Malmstrom for administrative assistance, and the
many renal dietitians and diabetes educators throughout North Simcoe Muskoka who participated in the formal review
and evaluation of the DKC Food Guide. A special thank you to Holly Brown, RD, CDE who graciously donated her funds
raised from the Sun City Swim to assist with the initial printing of the DKC Food Guide poster.
The DKC Food Guide consists of a Poster, a Food List and the Educator’s Guide.
 The Poster is intended for use by the person with diabetes and chronic kidney disease (CKD) in conjunction
with a dietitian specialized in diabetes management and/or CKD.
 The Food List provides nutrient data on the key nutrients as well as a Glycemic Index (GI) ranking, if
available, and is intended for use by the healthcare professional as well as the person with diabetes and
CKD.
 The Educator’s Guide describes diabetes and CKD, the key nutrients, how to work with the DKC Food
Guide, as well as special issues related to diabetes and CKD. It is intended for use by healthcare
professionals. Further more inclusive comprehensive information is available elsewhere, however the
information provided in the DKC Food Guide gives a working knowledge of the basics in assisting people
who have both diabetes and kidney disease.
The Food List and the Educator’s Guide are available at the OSMH Internet www.osmh.on.ca
For further information contact OSMH; Diabetes Education Centre or the Kidney Care Program
Telephone (705)325-2201
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
1
Introduction
Chronic Kidney Disease (CKD) is one of the most common complications of type 1 and type 2 diabetes. The Canadian
Diabetes Association (CDA) claims that diabetes is the leading cause of kidney disease in Canada and that people with CKD
should be considered at high risk for cardiovascular disease (CVD). The Diabetes and Kidney Care (DKC) Food Guide
was developed to assist people learn about the key nutrients, foods and meal planning to manage both diabetes and CKD, to
help prevent the progression of kidney disease and to prevent CVD. The DKC Food Guide is intended for use from Stage 3
to 5 of CKD and may be individualized based on treatment for CKD (pre-dialysis, conservative treatment, peritoneal or
hemodialysis, or kidney transplant) and diabetes (diet managed, oral antihyperglycemic agents and/or insulin), laboratory test
results and goals of treatment. It was designed to provide a continuity of information from the CDA’s meal planning guide
Beyond the Basics (BTB). This will help transition the patient from meal planning information to manage diabetes to meal
planning for both diabetes and CKD. As with the BTB, the DKC Food Guide will help people make healthy food choices to
reduce their risk of CVD.
Diabetes and Chronic Kidney Disease
According to the CDA 2013 Clinical Practice Guidelines (CPG), a variety of forms of kidney disease can be seen in people
with diabetes; diabetic nephropathy, ischemic damage related to vascular disease and hypertension, as well as other renal
diseases that are unrelated to diabetes. Note the CDA describes classic diabetic nephropathy as a progressive increase of
proteinuria in people with longstanding diabetes followed by declining function that eventually can lead to end stage renal
disease (ESRD). In order to identify people with classic diabetic nephropathy as well as renal disease unrelated to diabetes
the CDA 2013 CPG recommends screening for kidney disease with an assessment of urinary albumin excretion (random
urine albumin-to-creatinine ratio (ACR)) as well as a measurement of the overall level of kidney function through an estimation
of the glomerular filtration rate (GFR) (Table 1). Refer to Table 2 for potential causes for transient albuminuria; Table 3 for
stages of diabetic nephropathy by level of urinary albumin level; and Table 4 for stages of CKD of all types.
TABLE 1: Recommended screening for CKD in people with diabetes (based on CDA 2013 CPG)
Type of Diabetes
Frequency
Type 1 diabetes
Annually in post pubertal individuals
with diabetes > 5 years
Type 2 diabetes
At diagnosis and annually
Pre-gestational/pre-existing
type 1 or type 2 diabetes
Preconception
During each trimester
Method
Random urine ACR and
Serum creatinine for eGFR
Random urine ACR and
Serum creatinine for eGFR
Random urine ACR and
Serum creatinine for eGFR
Random urine ACR and
***Serum creatinine
*
Screen annually when no transient causes of albuminuria or low eGFR are present, and when acute kidney injury or non-diabetic kidney
disease is not suspected
** eGFR <60 mL/min or ACR 2.0-20.0 mg/mmol repeat serum creatinine for eGFR in 3 months and 2x repeat random urine ACR over next 3
months
*** Serum creatinine and not eGFR should be used during pregnancy as eGFR will underestimate GFR in pregnancy
TABLE 2: Conditions that can cause transient albuminuria (CDA 2013 CPG)







Recent major exercise
Urinary tract infection
Febrile illness
Decompensated congestive heart failure
Menstruation
Acute severe elevation in blood glucose
Acute severe elevation in blood pressure
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
2
TABLE 3: Stages of diabetic nephropathy by level of urinary albumin level (CDA 2013 CPG)
24 hour urine
Stage of nephropathy
Urine dipstick
Urine ACR
collection for albumin
for protein
(mg/mmol)
(mg/day)
Normal
Negative
<2
<30
Microalbuminuria
Negative
2-20
30-300
Overt nephropathy
Positive
>20
>300
>67
>1000
Values are for urinary albumin, not total urinary protein, which will be higher than urinary albumin levels. ACR results may be elevated with
conditions other than diabetic nephropathy
TABLE 4: Stages of chronic kidney disease of all types (CDA 2013 CPG)
Stage
Qualitative Description
Renal Function (mL/min/1.73m²)
1
Kidney damage, normal GFR
>90
2
Kidney damage, mildly decreased GFR
60-89
3
Moderately decreased GFR
30-59
4
Severely decreased GFR
15-29
5
End-stage renal disease
<15 (or dialysis)
Progression of Kidney Disease:
The following can help to slow the progression of kidney disease:
1. Intensive glycemic control; based on the recommended targets in the CDA 2013 CPG:
Test
Target
A1C—Glycated hemoglobin
<7.0* **
Fasting or pre-prandial plasma glucose
4.0-7.0 mmol/L
2-hour post-prandial plasma glucose
5.0-10.0 mmol/L (5.0-8.0 if A1C target is not being met)
*
Consider A1C of <6.5% in some patients with type 2 diabetes to further lower the risk of nephropathy and retinopathy, but
this must be balanced against the risk of hypoglycemia
** Consider A1C of 7.1-8.5% if: limited life expectancy, high level of functional dependency, extensive coronary artery disease
at high risk of ischemic events, multiple co-morbidities, history of recurrent severe hypoglycemia, hypoglycemia
unawareness and longstanding diabetes for whom it is difficult to achieve an A1C <7.0% despite effective doses of multiple
antihyperglycemic agents, including intensified basal-bolus insulin therapy
Note the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Diabetes
Guideline: 2012 Update guideline regarding the management of hyperglycemia and general diabetes care in CKD:
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
3
a) Recommend a target hemoglobin A1C of < 7.0% to prevent or delay the progression of the micro vascular
complications of diabetes,
b) Recommend not treating to an A1C target of < 7% in patients at risk of hypoglycemia, including those treated with
insulin or sulfonylurea’s and/or have advanced CKD, and
c) Suggest that target A1C be extended above 7% in individuals with co-morbidities or limited life expectancy and risk of
hypoglycemia.
2. Although the patient on long-term dialysis therapy no longer needs to achieve good glycemic control to prevent the
deterioration of kidney function good control may prevent or slow the progression of retinopathy, neuropathy and
possibly macro vascular disease.
3. Optimal blood pressure control: less than 130/80 mm Hg (CDA 2013 CPG).
4. Medications that disrupt the renin-angiotensin-aldosterone system (RAAS); angiotensin-converting enzymes (ACE)
inhibitors and angiotensin receptor blockers (ARB). Refer to Appendix 7.
Note the NKF KDOQI Diabetes Guideline: 2012 Update guideline regarding the management of albuminuria in normotensive
patients with diabetes:
a) Recommend not using an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB)
for the primary prevention of diabetes related kidney disease in normotensive normoalbuminuric patients with
diabetes, and
b) Suggest using an ACE-I or an ARB in normotensive patients with diabetes and albuminuria levels >30 mg/g who are
at high risk of diabetes related kidney disease or its progression.
5. Lifestyle; smoking cessation, regular physical activity, alcohol consumption in moderation if person consumes
alcohol, a healthy diet and stress management.
6. Other micro vascular and macro vascular complications common with diabetes and CKD include; CVD, retinopathy,
neuropathy, ulcers and amputations. Therefore, the control of blood lipid levels and the screening and treatment of
retinopathy and foot care, as per the CDA 2013 CPG is important.
The KDOQI Diabetes Guideline: 2012 Update addresses the management of dyslipidemia in diabetes and CKD (a
multifactorial approach that includes medicines, proper nutrition, and physical activity) with recommendations
regarding the use of low-density lipoprotein cholesterol (LDL-C) lowering medicines:
a) Recommend using LDL-C lowering medicine, such as statins or statin/ezetimibe combination, to reduce risk
of major atherosclerotic events in patients with diabetes and CKD, including those who have received a
kidney transplant.
b) Recommend not initiating statin therapy in patients with diabetes who are treated by dialysis.
Key Nutrients
The nutritional management of diabetes and CKD needs to be individualized based on; medical history, management of
diabetes (diet, oral antihyperglycemic agents and/or insulin therapy), stage of CKD, treatment for end-stage kidney disease
(conservative, peritoneal or hemo-dialysis, or kidney transplant), the results of laboratory tests as well as individual
preferences, culture, stage of life, etc.
The key nutrients in the nutritional management of diabetes and CKD include: carbohydrate, protein, fat, potassium,
phosphorus, sodium and fluid.
For reference, Table 5 details a summary of the nutrition recommendations based on the CDA 2013 CPG; Table 6 is a
summary of nutrient recommendations for adults with CKD, adapted from The Essential Guide for Renal Dietitians-3rd Edition
2010 including 2011 revisions and based on the NKF KDOQI 2007 Guidelines for Nutrients for stage 1 to 5 of CKD; and
Table 7 details the Dietary Reference Intake (DRI) for sodium.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
4
TABLE 5: Summary of nutritional considerations for people with diabetes (adapted from CDA 2013 CPG)
Nutrient
Recommendation
 Follow ‘Eating Well with Canada’s Food Guide’ in order to meet nutritional needs; consume a variety of foods
from the 4 food groups (vegetables and fruits; grain products; milk and alternatives; meat and alternatives)
 In overweight or obese people with diabetes, a nutritionally balanced, calorie-reduced diet should be followed
to achieve and maintain a lower, healthier body weight
 An intensive lifestyle intervention program combining dietary modification and increased physical activity may
be used to achieve weight loss and improvements in glycemic control and cardiovascular risk factors
 People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic
control
 People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality or
should maintain consistency in carbohydrate quantity and quality
Carbohydrate
 Minimum intake is not less than 130 g/day to provide glucose to the brain
 45 to 60 % of energy (calories)
 Sugar alcohols (erythritol, isomalt, lactilol, maltitol, mannitol, sorbitol, xylitol) are approved for use; < 10 g/day
does not appear to result in adverse effects
 Acesulfame potassium, aspartame, cyclamate, neotame, saccharin, steviol, glycosides, sucralose, tagatose
and thaumatin have been approved by Health Canada for use as either table-top sweeteners or food
additives, or for use in chewing gum. Health Canada has set acceptable daily intake (ADI) values
 Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help
optimize glycemic control
 Include 25 to 50 g/day of dietary fibre
 Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a
maximum of 10% of total daily energy intake, provided adequate control of blood glucose and lipids is
maintained
Protein
 1 to 1.5 g per kg body weight per day, representing 15 to 20 % of total energy intake
 In people with diabetes and CKD consider the recommended dietary allowance (RDA) of 0.8 g per kilogram
body weight per day
Fats
 20 to 35 % of energy (calories)
 Saturated fats < 7 % of total daily energy intake and trans fatty acids arising from industrial hydrogenation
should be kept to a minimum
 Favour fats rich in monounsaturated fatty acids (e.g. olive oil, canola oil) with up to 20% of total calories
 Polyunsaturated fats, such as plant oils (e.g. canola, walnut, flax, salba) and long-chain omega-3 fatty acids
(e.g. fatty fish) should be included in the diet up to 10% of total energy intake
Other
 Alternative dietary patterns may be used in people with type 2 diabetes to improve glycemic control:
o Mediterranean-style dietary pattern
o Vegan or vegetarian dietary pattern
o Incorporation of dietary pulses (e.g. beans, peas, chickpeas, lentils)
o Dietary Approaches to Stop Hypertension (DASH) dietary pattern
Vitamin and
 Routine vitamin and mineral supplementation is generally not recommended. Supplementation with 400 IU
mineral
vitamin D is recommended for people >50 years of age. Supplementation with folic acid (0.4 to 1.0 mg) is
supplementation
recommended for women who could become pregnant
 The need for further vitamin and mineral supplements needs to be assessed on an individual basis
Alcohol
 People using insulin or insulin secretagogues should be aware of the risk of delayed hypoglycemia resulting
from alcohol consumed with or after the previous evening’s meal and should be advised on preventive actions
such as carbohydrate intake and/or insulin dose adjustments and increased blood glucose monitoring
 Limit intake to <2 standard drinks per day and <10 drinks per week for women and <3 standard drinks per day
or <15 drinks per week for men
General
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
5
TABLE 6: Summary of nutrient recommendations for adults with CKD
Nutrient
Protein
(g/kg/day)
Sodium
1.2
1.2 – 1.3
<60 yrs.
35
35
35
1st 6-8 weeks 1.3 - 1.5
Long-term 1.0
Sufficient to maintain
optimal weight
> 60yrs.
30 – 35
30
30
Individualized
(mmol/day)
65-100 (more for salt losers)
44-130
88-130
Individualized
(mg/day)
1000-3000
(mmol/day)
1500-2300
Individualized, restrict only if
indicated by lab values
Low K diet is generally < 60
Moderate K diet is 60-90
High K diet is >90
50-80
2000-3000
Individualized
Unrestricted unless
indicated by lab values.
Low K diet is usually < 60
Moderate K diet is 60-90 Individualized
High K diet is >90
(mg/day)
Individualized
2000-3120
Individualized
(mmol/day)
25-32 (GFR <60)
25-32**
25-32**
(mg/day)
775-992
775-992
Individualized
Individualized depending
on PET test
Usually not restricted
Potassium
Phosphorus
Transplant
.8 – 1.0
> 50 % HBV
Energy
(kcal/kg/day)
Stage 5
Hemodialysis
Peritoneal Dialysis
Stages 1-4
Individualized
Fluid (ml/day)
Usually not restricted
775-992
Individualized:
1000 ml plus urine output
Total Fat (% of energy)
Saturated Fat
(% of energy)
Polyunsaturated Fat
(% of energy)
Monounsaturated Fat
(% of energy)
25-35
30
30
30
<7
Up to 10
Up to 10
<7
Up to 10
Up to 10
Up to 10
Up to 10
Up to 20
Up to 20
Up to 20
Up to 20
Carbohydrates
Remainder of non-protein calories
Total Fibre (g)
20-30
20-25
20-30
Calcium (mg/day)
1000-1500
<2000 with a maximum of 1500 from binders
1000-1500
Magnesium (mg/day)
200-300
200-300
300-400
Iron (mg/day)
10-18
Zinc (mg/day)
15
15
15
9-12
Thiamin (mg/day)
1.1-1.2
1.1-1.2
1.5-2.0
1.1-1.2
Riboflavin (mg/day)
1.1-1.3
1.1-1.3
1.1-1.3
1.1-1.3
Niacin (mg/day)
14-16
14-16
14-16
14-16
Pyridoxine (mg/day)
5
10
10
1.3-1.7
B12 (mcg/day)
2.4
2.4
2.4
2.4
Vitamin C (mg/day)
75-90
60-100
60-100
75-90
Folic Acid (mg/day)
1
1
1
0.4
200-300
Individualized: oral/IV
Vitamin A (RE/day)
No supplements
Vitamin D (mcg/day)
5-15
Vitamin E (mg/day)
15
Vitamin K
Individualized
800-1000
No regular supplements
15
25-30
15
5-15
15
No supplements
Adapted from Essential Guide for Renal Dietitians-3rd Edition 2010 including 2011 revisions: based on the NKF-KDOQI Guidelines.
** These are the current recommendations for phosphorus intake. The editors of the Essential Guide for Renal Dietitians note that in order to provide adequate
protein intake it may be necessary to allow up to 39 mmol/kg phosphorus/day.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
6
TABLE 7: Dietary Reference Intakes (DRI) for sodium (2006 Institute of Medicine)
Adequate Intake
Upper Limit
Age
(mg/day)
(mg/day)
19 - 31
1500
2300
31 - 50
1500
2300
51 - 70
1300
2300
71 and over
1200
2300
The macronutrients, carbohydrate, protein and fat, need to be balanced to optimize glycemic control, kidney function,
weight management and to prevent CVD.
Protein is important to maintain muscle tissue and weight, to fight infections and heal wounds, however excess dietary
protein may increase albuminuria and accelerate the loss of kidney function. It can also cause urea (a waste product of
protein metabolism) to build up in the blood and cause side effects, such as tiredness, nausea, headaches and a bad taste in
the mouth. KDOQI guidelines from studies have shown a reduction in albuminuria and stabilization of kidney function (GFR
or creatinine-based measurements) with dietary protein intake at the Recommended Dietary Allowance (RDA) of 0.8 g/kg
body weight. Restricting dietary protein to less than 0.8 g/kg/day is controversial and is left to the discretion of the dietitian.
Protein requirements need to be adjusted in stage 5, based on treatment modality and laboratory test results.



Dietary protein recommendations should be based on idealized body weight.
50 to 75% of the protein should be of high biological value (HBV).
o Equation: Weight (kg) X protein guideline for stage 1 to 5 in g protein/kg body weight X % HBV goal
o Example: 50 kg person on dialysis (stage 5) with a target of 66% HBV protein
50 kg X 1.2 g/kg/day X 66%/100% = 39.6 g high biological value protein/day
If dietary protein is limited, adequate caloric intake must be maintained by increasing the calories from carbohydrates
and/or fats.
Potassium is a mineral that helps the nerves and muscles work well. It plays an important role in maintaining the heartbeat.
If the kidneys are not working properly the potassium level in the blood can go either too high or too low. Excessive serum
potassium can stop the heart. Foods, beverages and certain medications (antihypertensive and diuretics) can affect blood
potassium levels. Refer to Appendix 7 for a list of antihypertensive medication.
Dietary potassium requirements need to be individualized for stage 1 to 5 depending on treatment modality and medications,
and based on potassium laboratory test results. There is no benefit to restricting dietary potassium unless the blood levels
are high.
Phosphorus (phosphate) is a mineral that affects bone health. Blood phosphate levels will rise as kidney function
deteriorates. This may cause itchy skin or painful joints, loss of calcium from the bones and damaged blood vessels. The
nephrologist may order phosphate binders to be taken with food (usual timing to be taken with the first bite of food or midway
during the meal/snack). Commonly prescribed names for phosphate binders include; Calcium Carbonate, Oscal, Fosrenol,
Renagel, Tums, Tums XS, etc. If serum phosphate levels rise, a phosphorus restricted diet will be required.
Note that phosphorus absorbed from ‘natural-unprocessed’ foods are ~40-60% absorbed by the body, whereas inorganic
phosphorus additives added to foods/beverages are >90% absorbed by the body.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
7
Note regarding a potassium and phosphorus restriction: The nutrition recommendations from the CDA 2013 CPG
includes following Eating Well with Canada’s Food Guide (consuming a variety of foods from the 4 food groups; vegetables
and fruits; grain products; milk and alternatives; meat and alternatives), choosing low-GI CHO foods and 25-50 g fibre/day.
Although lower GI and higher fibre foods may decrease postprandial hyperglycemia and are associated with a decreased risk
of cardiovascular disease they may be higher in potassium and/or phosphorus. Therefore, due to the potential beneficial
affect on glycemic, and perhaps lipid management it is important to base a potassium and phosphorus restriction on
laboratory test results.
Sodium affects body fluids and blood pressure. Most people with diabetes and CKD require a sodium restriction to manage
or prevent hypertension and fluid retention. Refer to Table 7 for the DRI’s for sodium. Note the 2013 Canadian Hypertension
Education Program recommends the adequate intake (AI) target for the prevention and treatment of hypertension; 1500 mg
for adults age 50 years or less, 1300 mg if age 51 to 70 years and 1200 mg if age is greater than 70 years. However,
according to the CDA 2013 CPG “although advice to the general population over 1 year of age is to achieve a sodium intake
that meets the adequate intake (AI) target of 1000 to 1500 mg/day (depending on age, sex, pregnancy and lactation), there is
recent concern from prospective cohort studies that low sodium intakes may be associated with increased mortality in people
with type 1 and type 2 diabetes”.
Fluid requirements need to be individualized. A fluid restriction may be required if the kidney function decreases and the
kidneys are unable to produce as much urine, resulting in fluid overload and swelling of the legs, hands and face, high blood
pressure, and /or shortness of breath. However, limiting fluids unnecessarily may cause damage to the kidneys.
Working with the Diabetes and Kidney Care Food Guide
1. Nutrient Analysis: The values for the nutrients (carbohydrate, fibre, fat, protein, phosphorus, potassium and sodium)
were obtained from the Canadian Nutrient File (CNF) or if not available, either the United States Department of
Agriculture (USDA) food database or an alternate source. The Glycemic Index (GI) information was obtained from
Glycaemic Index Testing, Inc., the Glycemic Index Foundation and/or Foster-Powell K; Brand Miller J. International
Tables of Glycemic Index (refer to References).
2. Serving Sizes: The DKC Food Guide uses household measures for serving sizes.
Imperial
1 teaspoon (tsp)
1 tablespoon (tbsp)
¼ cup
1/3 cup
½ cup
=
=
=
=
=
Metric
5 mililitres (mL)
15 mL
60 mL
75 mL
125 mL
Imperial
cup
¾ cup
1 cup
1 ounce (oz)
2/3
Metric
=
=
=
=
150 mL
175 mL
250 mL
30 grams (g) by weight
3. Key Nutrients: The key nutrients (carbohydrate, fat, protein, phosphorus, potassium, sodium and fluid) important in the
management of diabetes and CKD are described on the front page of the DKC Food Guide. The back page offers tips to
limit the sodium and fluid, a caution to avoid salt substitutes and sodium reduced products that include potassium, tips for
reading labels and tips for reducing phosphorus and potassium. The inside spread of the poster is divided into food
groups based on specific criteria (refer to Table 8 for a summary of the key nutrient criteria for each of the food groups).
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
8
Foods are grouped into ‘Carbohydrate Containing Food’ and ‘Food That Contains Few or No Carbohydrates in the serving
size listed’
Carbohydrate Containing Food
Food that Contains Few or No Carbohydrates
in the serving size listed
 Grains & Starches,
 Fruits,
 Milk & Alternatives, and
 Other Choices
1 serving or 1 carbohydrate choice has approximately
15 grams of available carbohydrate (criteria used is
11-20 grams carbohydrate)
Available carbohydrate = Total carbohydrate - fibre





Vegetables,
Some Fruits,
Meat & Alternatives,
Fats, and
Extras
The criteria for the carbohydrate content;
 Vegetables = < 5 grams
 Some Fruits = < 6 grams
 Meat & Alternatives = Trace
 Fats = Trace
 Extras = < 5 grams
The food group heading will indicate if the choices are:

Lower in phosphorus, potassium and/or sodium

Higher in phosphorus, potassium and/or sodium

Higher in potassium – Lower in phosphorus and sodium
or
4. Continuity of Information for Diabetes Management: The DKC Food Guide is designed to provide a continuity of
information from the CDA’s Beyond the Basics (BTB). Similarities between the two systems are;
 Foods are grouped based on whether they contain carbohydrate or contain few or no carbohydrate.
 One serving from a Carbohydrate Containing food group is approximately 15 grams (range 11-20 grams) of available
carbohydrate, and is considered 1 carbohydrate choice.
 The criteria for the carbohydrate content of the Vegetables and Extras food group is < 5 grams available
carbohydrate.
 The names of the food groups are the same.
Differences between the CDA-BTB and the DKC Food Guide:



Although most of the foods listed on the DKC poster are the same as the BTB poster there are some differences.
Foods included in the DKC poster were based on the potassium, phosphorus and sodium content as well as the
carbohydrate content.
Wherever possible, nutrient information for the DKC Food Guide was obtained from the Canadian Nutrient File first
and then obtained from the USDA Nutrient Database or another source (as indicated in the DKC Food List reference)
if not available.
The serving size of foods listed on the DKC poster are similar to the BTB with a few exceptions:
o Certain foods have a different serving size based on the reference used, ie the Canadian Nutrient File.
o Fruits that meet the criteria for the Some Fruits group were removed from the Fruits group and are included
in the Some Fruits group in a serving size that provides approximately 6 grams or less of available
carbohydrate.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
9







o The actual serving size of specific cereals is listed.
o As different manufacturers have varying recipes for their products some products listed are advised to Check
Nutrition Facts for more accurate nutrition information and serving size.
o The BTB does not list a serving size for the choices in the Vegetables group. A serving size is listed for the
Vegetables group in the DKC Food Guide due to the potassium and/or phosphorus content.
o The BTB classifies parsnips, peas and winter squash in the Vegetables category and further advises that if
parsnips, peas and winter squash are eaten in a quantity of 1 cup they should be counted as 1 carbohydrate
choice.
The DKC Food Guide lists parsnips, peas and winter squash in the Vegetables group in a specific portion
due to the potassium, phosphorus and/or sodium content.
o The BTB lists the legumes in the Meat & Alternatives group and advises that if eaten in the quantity of 1 cup
they should be counted as 1 carbohydrate choice. The DKC Food Guide includes legumes and canned
beans in the Meat & Alternatives group and in the Grains & Starches group and the ½ cup serving size was
maintained due to the potassium, phosphorus and carbohydrate content.
o The serving size for nuts and seeds is not shown on the poster as nuts vary in quantity/5 g fat serving size.
Check either the Nutrition Facts or the DKC Food List for nutrition information.
Grapefruit; ‘Check with Pharmacist’ is advised to discuss potential interactions between grapefruit and certain
medications.
Starfruit was included in the Fruits food group with an X through it and the wording ‘Do Not Eat’. Studies indicate that
starfruit may be neurotoxic to individuals with CKD. Refer to References.
The Some Fruits food group was developed in the DKC Food Guide to accommodate the lower potassium fruits that
if eaten in the serving size listed provide approximately 6 grams or less of available carbohydrate. This food group is
located with the Food That Contains Few or No Carbohydrates and was created to allow fruits that if eaten in
amounts equal to 1 carbohydrate choice would have exceeded the potassium criteria.
Rice beverage and almond beverage are not included in the Milk & Alternatives group as they are both lower
phosphorus, potassium and sodium choices:
o Rice beverage is placed in the Other Choices: Lower in phosphorus, potassium and sodium food group.
o Almond beverage is placed in the Extras: Lower in phosphorus, potassium and sodium food group as it
contains less than 5 g available carbohydrate per serving (1 cup for unsweetened and ½ cup for sweetened).
The Extras food group is included in the inside spread of the DKC Food Guide poster. The criteria for the Extras
group is based on the carbohydrate content as well as the potassium, phosphorus and sodium.
The BTB divides food in each of the food groups into food to ‘choose more often’ or food to ‘choose less often’. The
criteria is based on fibre, glycemic index and fat. Whereas the DKC Food Guide divides foods in each of the food
groups based on the potassium, phosphorus and sodium content.
A food may be on the DKC poster twice depending on how the item is offered: raw or cooked. Again placement is
dictated by the potassium, phosphorus and/or sodium content. I.e. 1 cup of raw spinach is considered a Vegetable—
Lower in phosphorus, potassium and sodium choice, whereas a ½ cup cooked spinach is considered a Vegetable—
Higher in potassium – Lower in phosphorus and sodium choice.
5. Blood Glucose Management: The DKC Food Guide is designed to help people achieve their target blood glucose
levels. The following meal planning approaches may be used:
 The Meal Plan matrix can be completed by the dietitian, indicating the number of recommended servings from each
of the food groups for meals and snacks. This approach will assist with carbohydrate consistency. The matrix
includes all of the food groups except the Extras group. The matrix can also be used to individualize the CKD
requirements for each patient.
 The DKC Food Guide can be used as a tool to help with carbohydrate counting; as an approach to help with
carbohydrate consistency; or to match rapid-acting insulin to the amount of carbohydrate eaten.
 The DKC Food Guide may be given to patients for a snapshot view of certain foods to choose over others.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
10
6. CKD Management: The DKC Food Guide is designed to be adaptable, based on the stage of CKD, treatment modality
for end-stage kidney disease and laboratory test results. Each of the food groups on the inside spread will indicate if the
food is Lower in phosphorus, potassium and sodium, Higher in phosphorus, potassium and/or sodium or Higher in
potassium — Lower in phosphorus and sodium. The back page provides information on sodium and fluid, a caution to
avoid salt substitutes and sodium reduced products that include potassium, tips for reading labels, as well as tips for
reducing potassium and phosphorus.
7. Recommendations for Key Nutrients: The back page includes a Daily Recommendations for Key Nutrients box which
includes calories, carbohydrates, fat, protein, phosphorus, potassium, sodium, and fluid. This allows the dietitian to
customize the targets for each individual as needed.
8. Label Reading: A sample Nutrition Facts table and directions on how to use the table are provided on the back page.
Directions on how to use the Ingredient List are also provided. The directions for use include;
 How to determine the available carbohydrate
 Tips to choose lower sodium products
 Advises that although potassium and phosphorus are not listed in the Nutrition Facts table the product might
include a significant amount of these nutrients. Information on referring to the Ingredient List for these nutrients is
given.
 How to use the % Daily Value
Useful Resources: Information on useful resources is provided in the Food List. This includes the Internet address for
the Canadian Diabetes Association, the Canadian Kidney Foundation and Dietitians of Canada. It also provides the Internet
address to obtain a copy of Health Canada’s Nutrient Value of Some Common Foods. This is a useful reference tool to assist
with carbohydrate counting, as well as to determine the key nutrient content of a product (carbohydrate, fibre, fat, protein,
phosphorus, potassium, sodium and fluid). The internet address is also provided to obtain more information on label reading
and some renal friendly recipes (Spice It Up).
Canadian Diabetes Association
www.diabetes.ca
Dietitians of Canada
www.dietitians.ca
The Kidney Foundation of Canada
www.kidney.ca
Spice It Up! Giving Zest to Your Renal Diet
www.myspiceitup.ca
Health Canada booklet: Nutrient Value of Some Common Foods
http://www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/nutrient_value-valeurs_nutritives-tc-tm-eng.php
Health Canada: Information on Food Labeling
www.hc-sc.ca/fn-an/label-etiquet/nutrition/index-eng.php
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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TABLE 8: Summary of nutrient criteria for the DKC Food Guide
Food
Group
Grains &
Starches
Available Potassium Phosphorus Sodium Protein
Fat
g
CHO g
mg
mg
Lower in phosphorus, potassium and sodium
11-20*
< 200*
< 70*
Higher in phosphorus, potassium and/or sodium
11-20*
> 200
> 70 or >
refined version
> 250
Variable Variable
Higher in potassium - Lower in phosphorus and sodium
11-20
> 200
< 70
< 250
Variable Variable
Lower in phosphorus, potassium and sodium
11-20
< 200
< 15*
Trace
0.5
Trace
Higher in potassium - Lower in phosphorus and sodium 11-20*
> 200
< 15*
Trace
0.5
Trace
Higher in phosphorus, potassium and/or sodium
11-20*
> 200
> 110
> 250
Variable Variable
Lower in phosphorus, potassium and sodium
11-20*
< 200
< 70*
< 250
Variable Variable
Higher in phosphorus, potassium and/or sodium
11-20
> 200
> 70
> 250
Variable Variable
Lower in phosphorus, potassium and sodium
< 5*
< 200*
< 40*
< 250
1
Trace
Higher in phosphorus, potassium and/or sodium
< 5*
> 200
> 40
> 250
1
Trace
Higher in potassium - Lower in phosphorus and sodium
< 5*
> 200
< 40*
< 250
1
Trace
< 6*
< 200
< 15*
Trace
0.5
Trace
Lower in phosphorus, potassium and sodium
Trace*
< 200 *
< 100 *
< 250
~7
5*
Higher in phosphorus, potassium and/or sodium
Trace*
> 200
> 100
> 250
~7
5*
Lower in phosphorus, potassium and sodium
Trace
< 10*
< 5*
< 55*
Variable
5*
Higher in phosphorus, potassium and/or sodium
Trace
> 10
>5
> 55
Variable
5*
Higher in potassium - Lower in phosphorus and sodium
Trace
> 10
< 5*
< 55
Variable
5
<5
< 200*
< 70
< 250
Variable Trace
Category
mg
g
< 250* Variable Variable
Fruits
Milk &
Alternatives
Other
Choices
Vegetables
Some Fruits Lower in phosphorus, potassium and sodium
Meat &
Alternatives
Fats
Extras
Lower in phosphorus, potassium and sodium
* Some exceptions may apply; check the DKC Food List for exceptions.
The reference used for potassium, phosphorus and sodium is the Manual of Clinical Dietetics Sixth Edition. Refer to References.
Refer to Appendix 1 for conversions used for phosphorus, potassium and sodium.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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Special Issues Related to Diabetes and Chronic Kidney Disease
1. Glycated Hemoglobin (A1C): The A1C measurement is often inaccurate in CKD. Factors that may contribute to falsely
decreased values include; a reduced red blood cell lifespan, transfusions and hemolysis. Falsely increased values may
occur due to carbamylation of the hemoglobin and acidosis.
2. Hypoglycemia is a potential complication of managing diabetes with insulin and/or certain oral antihyperglycemic agents.
People with diabetes and CKD (stage 3 to 5) are at a higher risk of hypoglycemia for several additional reasons, to
include:
 Decreased clearance of insulin and of some of the oral antihyperglycemic agents used to treat diabetes, and
 Impaired renal gluconeogenesis with reduced kidney mass.
Therefore, it is important that capillary blood glucose levels are monitored closely for low blood glucose levels, and the
dose(s) of insulin and/or oral antihyperglycemic agents are adjusted as needed to prevent hypoglycemia.
Treatment of hypoglycemia should be made with lower potassium (and if necessary lower phosphorus) sources of fastacting carbohydrate if possible. Refer to Appendix 2 for the Hypoglycemia and Chronic Kidney Disease pamphlet. This
pamphlet may be used as a patient handout.
3. Glucose content in Peritoneal Dialysis (PD) Solutions: PD solutions may contain glucose and therefore may affect
blood glucose levels.
4. Hyperglycemia and hyperkalemia: Hyperglycemia can cause elevated blood potassium levels. Therefore, achieving
target blood glucose levels can help prevent hyperkalemia.
5. Hyperglycemia and fluid intake: Increased thirst is one of the symptoms of hyperglycemia. Controlling blood glucose
levels can help to decrease thirst and control fluid intake. This is especially important if a person is on dialysis and/or
requires a fluid restriction.
6. Blood glucose monitoring in Peritoneal Dialysis (PD):
Test strips that use glucose dehydrogenase
pyroloquinolinequinone (GDH-PQQ) or glucose dye oxidoreductase (GDO) enzymatic assays can react with other sugars
such as maltose, galactose and zylose. Medical products that contain or are metabolized into maltose, galactose and
xylose (which include icodextrin peritoneal dialysis solution) may induce falsely elevated blood glucose results. The
falsely elevated blood glucose reading may lead to the administration of insulin, potentially resulting in hypoglycemia,
coma or death. Therefore, blood glucose meters utilizing a GDH-PQQ or GDO glucose test strip should be avoided in
patients requiring icodextrin-containing PD solution.
7. Oral antihyperglycemic agents: Some oral antihyperglycemic agents are contraindicated with reduced kidney function.
Refer to individual product monograms for reference and Appendix 3: Therapeutic Considerations for Renal Impairment
(CDA 2013 CPG).
8. Illness and certain medications: The CDA 2013 CPG advises that certain medications can either reduce kidney
function (angiotensin-converting enzyme inhibitor, angiotensin receptor blockers, direct rennin inhibitors, non-steroidal
anti-inflammatory drugs and diuretics) or have reduced clearance (metformin and sulfonylureas) during periods of
intercurrent illness and that they be discontinued, specifically with intravascular volume contraction due to reduced oral
intake or excessive losses due to vomiting or diarrhea. The CPG’s recommends consideration be given to providing a
sick day medication list that outlines the medications that should be held if a person becomes dehydrated for any reason.
Refer to Appendix 4 for the Sick Day Medication List from CDA 2013 CPG, Appendix 5 for the Sick Day Guidelines for
those with Type 1 Diabetes pamphlet and Appendix 6 for the Sick Day Guidelines for those with Type 2 Diabetes
pamphlet. These pamphlets may be used as patient handouts. Note sick days may be more common in the renal patient
prior to initiating or following initiation of dialysis.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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9. Pregnancy: Pregnancy planning is recommended for women with pre-existing diabetes. The CDA 2013 CPG
recommend screening for CKD prior to conception (refer to Table 1). Micro albuminuria and overt nephropathy are
associated with increased risk of maternal and fetal complications. The CPG also recommend that ACE inhibitors and
ARB’s be discontinued prior to conception or upon detection of pregnancy. Refer to CDA 2013 CPG Diabetes and
Pregnancy chapter for more information.
10. Antihypertensive medications: Hyperkalemia is a common side effect of ACE and ARB therapy. Therefore, based on
laboratory test results a dietary potassium restriction may be required. However, a higher potassium diet may be required
if a loop diuretic is started. Refer to Appendix 7: Antihypertensive Medications that may affect Blood Potassium Levels.
11. Salt substitutes and sodium-reduced products: Some salt substitutes and sodium-reduced products contain
potassium chloride (e.g. No Salt and Half Salt). These are not recommended if a potassium restriction is required.
Products that do not contain potassium chloride include; Mrs. Dash™; La Grill by Clubhouse™--No Added Salt
Seasonings; McCormick’s™-- Salt Free Seasonings. As manufacturers change their formulations without notice it may
be necessary to review the ingredient list/Nutrition Facts table from purchase to purchase.
12. Dietary Approaches to Stop Hypertension (DASH): The DASH diet has shown to have a beneficial affect on reducing
blood pressure in people with or without diabetes. The CDA 2013 CPG includes DASH as an alternative dietary pattern
suggested to assist people with type 2 diabetes to improve glycemic control. However, the DASH diet may not be
appropriate for people with stage 3 to 5 of CKD due to its higher protein, potassium and phosphorus content. Refer to
Resources for a reference for the DASH diet.
13. Vegetarian Diets: Alternative sources of protein are often higher in potassium. Therefore, it may be necessary to
individualize a vegetarian diet to prevent both malnutrition and hyperkalemia.
14. Glycemic Index (GI): Low GI foods are recommended for the beneficial glycemic affect. However, many low GI foods
are high in potassium and/or phosphorus. The following suggestions to reduce the GI are appropriate for people who
require a potassium and/or phosphorus restriction.
 Vinegar and/or lemon juice added to food will lower the GI
 Balanced meals and/or snacks (include a protein and/or fat with a carbohydrate) will lower the GI
 Foods that are less cooked or processed have a lower GI than foods that are more cooked or processed
 Low GI fruits include; apple, strawberries, peach, cherries, grapes and grapefruit
 Low GI grains include; white pasta (cooked al dente), converted or parboiled white rice, barley and millet. Medium GI
grains include; basmati rice and couscous
 Medium GI breads include; cracked wheat and sourdough bread
15. Nutrition Supplements: Refer to Appendix 8 for a nutrient analysis of nutrition supplements often recommended for
diabetes and/or CKD.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
14
REFERENCES
American Dietetic Association, Dietitians of Canada. (2000). Manual of Clinical Dietetics Sixth Edition, Renal Disease section;
449-499.
Canadian Diabetes Association. (2013). Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention
and Management of Diabetes in Canada. Retrieved April 19, 2013 from www.diabetes.ca.
Canadian Diabetes Association. (2010). Building Competency in Diabetes Education, Chapter 9, Chronic Kidney Disease:930. Available at www.diabetes.ca.
Canadian Diabetes Association. (2008). Beyond the Basics: Meal Planning for Healthy Eating, Diabetes Prevention &
Management. Available at www.diabetes.ca.
Canadian Hypertension Education Program (CHEP). (2013). Canadian recommendations for the management of
hypertension. Retrieved April 26, 2013 from www.hypertension.ca.
Canadian Nutrient File. Retrieved 2010 from www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng./hp.
Chang CH; Yeh JH (2004). Non-convulsive status epilepticus and consciousness disturbance after star fruit (Averrhoa
carambola) ingestion in a dialysis patient. Nephrology. Dec 9(6):362-5.
Dietitians of Canada. Food Photo graphics. Accessed 2013 from www.dietitians.ca.
Essential Guide for Renal Dietitians. 3rd Edition 2010-including 2011 revisions. Canadian Association of Nephrology
Dietitians (CAND) Retrieved January 2012 from www.renalrd.ca.
Food and Drug Administration: FDA public health notification: potentially fatal errors with GDH-P glucose monitoring
technology (article online). 2009. Retrieved May 21, 2010 from
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublichHealthNotifications?ucm176992.htm.
Foster-Powell K, Brand Miller J. (1995). International Tables of Glycemic Index. American Journal of Clinical Nutrition;
62:871S-893S.
Glycaemic Index Testing, Inc. Glycaemic Index Values of Some Canadian Foods. Retrieved 2010 from www.gitesting.com.
Glycemic Index Foundation. GI Data Base. Retrieved 2010 from www.glycemicindex.com.
Health Canada. (2008). Possible interference of icodextrin, intravenous immunoglobulins, galactose and d-xylose with certain
blood glucose meters – Notice to Hospitals. Retrieved June 16, 2010 from
http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2008/glvc_met_nth-aah-eng.php.
Institute of Medicine. (2006). Dietary Reference Intakes: The essential guide to nutrient requirements. Washington, DC:
National Academies Press.
Juan P Frias: Christine G Lim; John M Ellison; Carol M Montandon. (2010). Review of Adverse Events Associated With False
Glucose Readings Measured by GDH-PQQ-Based Glucose Test Strips in the Presence of Interfering Sugars. Diabetes Care,
33,(4):728-729.
Kamyar Kalantar-Zadeh et al. (2010). Understanding Sources of Dietary Phosphorus in the Treatment of Patients with
Chronic Kidney Disease, Clinical Journal of the American Society of Nephrology 5:519–530.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
15
National Kidney Foundation. (2012). KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update. Retrieved
September 5, 2013 from http://www.kdoqi.org.
National Kidney Foundation. (2007). KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes
and Chronic Kidney Disease. Retrieved April 29 2010 from http://www.kdoqi.org.
Nitcharoenpong K; Chalermasanyakom P; Panvichan R; Kitiyakara C. (2006). Acute deterioration of renal function induced
by star fruit ingestion in a patient with chronic kidney disease. Journal of Nephrology. Sep-Oct; 19(5):682-6.
Reimer, R. The DASH diet: implications for people with diabetes. (2002) Canadian Journal Diabetes; 26(4):369-377.
United States Department of Agriculture (USDA) Food Database. Retrieved 2010 from
http://www.nal.usda.gov/fnic/foodcomp/search/.
Wang, YC: Liu BM; Supernaw RB; Lu YH; Lee PY. (2006). Management of star fruit-induced neurotoxicity and seizures in a
patient with chronic renal failure. Pharmacotherapy; Jan; 26(1):143-6.
Spices: Clubhouse www.clubhouse.ca McCormick’s www.mccormick.com Mrs. Dash www.mrsdash.com
RESOURCES
Canadian Diabetes Association. Available at www.diabetes.ca
 Beyond the Basics Meal Planning for Healthy Eating, Diabetes Prevention and Management
 For additional Nutrition Resources-diet and kidney disease:
http://www.diabetes.ca/for-professionals/resources/additional/
The Kidney Foundation of Canada. Available at www.kidney.ca
The following is a list of some of the brochures and Fact sheets available:
 Diabetes and Kidney Disease
 Nutrition and Chronic Kidney Disease
 Anemia and Chronic Kidney Disease
 Bone Disease & Chronic Kidney Disease
 High Blood Pressure and Your Kidneys
 Eating guidelines for diabetes and chronic kidney disease
 Phosphorus (phosphate) and chronic kidney disease
 Potassium and chronic kidney disease
 Potassium in multicultural fruits and vegetables
 Sodium (salt) and chronic kidney disease
 Some facts about E. Coli
National Institutes of Health. Available at www.nih.gov
 Your Guide to Lowering Your Blood Pressure with DASH. April 2006.
Canadian Hypertension Education Program (CHEP). Available at www.hypertension.ca
 Canadian recommendations for the management of hypertension 2013.
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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APPENDIX
APPENDIX 1: Conversion Factors used for Phosphorus, Potassium and Sodium
1 mmol of Phosphate = 31 mg of elemental Phosphorus
1 mmol of Potassium = 39 mg of elemental Potassium
1 mmol of Sodium = 23 mg of elemental Sodium
APPENDIX 2: Hypoglycemia and Chronic Kidney Disease Pamphlet – Available at www.osmh.on.ca
APPENDIX 3: Therapeutic Considerations for Renal Impairment (CDA 2013 CPG)
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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APPENDIX 4: Sick Day Medication List from CDA 2013 CPG
APPENDIX 5: Sick Day Guidelines for those with Type 1 Diabetes Pamphlet - Available at www.osmh.on.ca
APPENDIX 6: Sick Day Guidelines for those with Type 2 Diabetes Pamphlet - Available at www.osmh.on.ca
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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APPENDIX 7: Antihypertensive Therapies that may affect Blood Potassium Levels*
Renin-Angiotensin System Agents
May increase serum potassium levels
Diuretics
Chemical Name
Brand Name
Angiotensin Converting Enzyme (ACE) Inhibitors
Benazepril
Lotensin®
Captopril
Capoten®
Cilazapril
Inhibace®
Enalapril
Vasotec®
Enalaprilat
n/a
Fosinopril
Monopril®
Lisinopril
Prinivil®, Zestril®
Perindopril
Coversyl®
Quinapril
Accupril®
Ramipril
Altace®
Trandolapril
Mavik®
Angiotensin II Receptor Blockers (ARBs)
Azilsartan
Edarbi®
Candesartan
Atacand®
Eprosartan
Teveten®
Irbesartan
Avapro®
Losartan
Cozaar®
Olmesartan
Olmetec®
Telmisartan
Micardis®
Valsartan
Diovan®
Renin Inhibitors
Aliskiren
Rasilez®
Chemical Name
Brand Name
Loop—increases potassium excretion
May either increase potassium excretion or are potassium sparing
Bumetanide
Ethacrynate sodium
Ethacrynic acid
Furosemide
Burinex®
Sodium Edecrin®
Edecrin®
Lasix®
Potassium-sparing Diuretics
Amiloride
Spironolactone
Diuretic Combinations
Amiloride/HCT
Spironolactone/HCT
Triamterene/HCT
Thiazides & Related Agents
Chlorthalidone
Hydrochlorothiazide (HCT)
Indapamide
Metolazone
n/a
Aldactone®
n/a
Aldactazide
n/a
n/a
n/a
Lozide®
Zaroxolyn®
COMBINATIONS
Chemical Name
Brand Name
ARB/Calcium Channel Blocker Combinations
Amlodipine/telmisartan
Twynsta®
ACE Inhibitor/ Calcium Channel Blocker Combinations
Trandolapril/verapamil
Tarka®
Renin Inhibitor/Diuretic Combinations
Aliskiren/HCT
Rasilez HCT®
Beta Blocker/Diuretic Combinations
Chemical Name
Brand Name
ARB / Diuretic Combinations
Candesartan/HCT
Atacand Plus®
Eprosartan/HCT
Teveten Plus®
Irbesartan/HCT
Avalide®
Losartan/HCT
Hyzaar®
Olmesartan/HCT
Olmetec Plus®
Telmisartan/HCT
Micardis Plus®
Valsartan/HCT
Diovan-HCT®
ACE Inhibitor/ Diuretic Combinations
Cilazapril/HCT
Inhibace Plus®
Enalapril/HCT
Vaseretic®
Lisinopril/HCT
Prinzide®, Zestoretic®
Perindopril/indapamide
Coversyl Plus®
Quinapril/HCT
Accuretic®
Ramipril/HCT
Altace HCT®
May increase potassium excretion
Atenolol/chlorthalidone
Pindolol/HCT
Tenoretic®
Viskazide®
* From Canadian Pharmaceutical and Supplies 2013
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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APPENDIX 8: Nutrient Analysis of Nutrition Supplements
Supplement
Protein
CHO Available Fat Potassium Phosphorus Sodium
(Fibre) g CHO g
g
mg
mg
mg
Supplier
Size
Calories
Beneprotein powder
Nestle Nutrition
7g-1 scoop
25
6
0 (0)
0
0
35
n/a
15
Boost Diabetic
Nestle Nutrition 237ml-bottle
190
16
16 (2)
14
7
70
300
180
Glucerna *
Abbott Nutrition 237ml-bottle
225
11.3
26.7 (3.1)
23.6
8.2
375
275
250
Nepro Carb Steady
Abbott Nutrition 237ml-bottle
425
19.1
37.9 (0)
37.9
22.7
250
170
250
NovaSource Renal
Nestle Nutrition
237ml-tetra
475
21.6
43.8 (n/a)
43.8
23.7
225
198
225
Suplena
Abbott Nutrition
235ml-can
471
7
60 (0)
60
22.5
263
174
183
g
* Check label for different varieties.
Information retrieved April 2013
For the most current nutrient content please see the manufacturer’s product label
N/A – not available
Educator’s Guide for the Diabetes and Kidney Care Food Guide – OSMH - March 2014
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Help from others to treat severe hypoglycemia
If you have a severe hypoglycemic reaction and become unconscious or are
unable to swallow, you will require immediate assistance from family and/or
friends. They will need to:
• Contact Emergency (telephone 911); and, if possible
• Give glucagon by injection:
• 0.5 mg for children less than 5 years of age;
Hypoglycemia and Chronic
Kidney Disease
I N F O R M AT I O N B O O K L E T
• 0.5 to 1 mg for children 5 to 10 years of age; and
• 1 mg for everyone over the age of 10.
What is glucagon and how is it given?
Glucagon is a hormone made in your pancreas that quickly raises blood
glucose. It can be purchased over-the-counter at a pharmacy. Glucagon may
not work in the presence of alcohol or in those suffering from starvation,
chronic hypoglycemia, advanced liver disease or adrenal insufficiency.
Glucagon is given as an injection, just like insulin, and should be administered
by another person according to the instructions on the package. As glucagon
could cause nausea and vomiting you should not be left alone and you should
be placed lying on your left side. Once you regain consciousness and are able
to swallow, have 15 g of fast-acting carbohydrate (see inside page for chart)
followed by a snack containing 1 Carbohydrate choice (15 g carbohydrate) and
1 Meat & Alternatives choice (e.g. ½ sandwich or crackers and cheese).
Discuss the hypoglycemia event with your doctor or diabetes education team
as soon as possible.
Be prepared!
Discuss glucagon with your doctor and diabetes educators. Have an up-todate Emergency Glucagon Kit so that you are always prepared. Ensure your
family and/or friends have been trained on how to administer glucagon.
What you need to know about
hypoglycemia if you have diabetes and
chronic kidney disease.
If you manage your diabetes with insulin and/or medication you are at risk of
hypoglycemia, which is also known as low blood glucose. Hypoglycemia is
serious and should not be ignored!
This pamphlet explains hypoglycemia and how to treat it. Here are some
important tips:
• Know the symptoms, causes and how to prevent and treat hypoglycemia.
• Monitor your blood glucose using an accurate blood glucose meter (have
a lab/meter check annually).
• Carry your blood glucose meter, testing supplies and fast-acting
carbohydrate with you at all times.
• Wear medical identification.
• Discuss your diabetes management with your doctor or diabetes
education team if you have frequent episodes of hypoglycemia (more
than three in a week).
• Review the “Diabetes and Driving: Safety Guidelines” pamphlet if you take
insulin and/or diabetes medication that may cause hypoglycemia.
Developed by the Diabetes Education Team at the OSMH Diabetes Education Centre. Based on the 2013 Canadian Diabetes
Association Clinical Practice Guidelines. Revised July 2013.
Diabetes Education Centre
Orillia Adult Program: 705-325-7611
Gravenhurst Adult Program: 705-687-9515
Paediatric Program: 705-327-9152
What is hypoglycemia?
How should I treat my hypoglycemia?
Hypoglycemia, also called low blood glucose or low blood sugar, occurs
when blood glucose drops below normal levels. Hypoglycemia can happen
suddenly. It can be treated quickly and easily by eating or drinking a fastacting carbohydrate. However, hypoglycemia can also be severe and result in
confusion, coma or seizure if not treated immediately.
If your blood glucose (blood sugar) drops below 4 mmol/L, you need to treat it
promptly to bring your blood glucose (BG) level back above 4 mmol/L. Follow
these 4 steps to raise your BG promptly and prevent rebound hyperglycemia
(high blood glucose).
What are symptoms of hypoglycemia?
Hypoglycemia symptoms may include: dizziness, shakiness, sweating,
headaches, hunger, weakness, sleepiness, confusion, anxiety, nervousness, or
nausea. You may also have vision changes, numbness and tingling, difficulty
concentrating or speaking.
Others may notice that you are irritable, sweaty, pale, acting or speaking
strange, or having a restless sleep.
What could cause hypoglycemia?
• Eating less than usual and/or delayed meals and snacks;
• More exercise than usual;
• Taking too much insulin or diabetes medication;
1. Test your BG using your blood glucose meter.
2. If your BG is less than 4 mmol/L treat with fast-acting carbohydrate.
Fast-acting carbohydrate
Glucose tablets
Apple or cranberry juice,
regular lemonade or pop
BG 3 to 4 mmol/L
BG less than 3 mmol/L
15 g fast-acting
20 g fast-acting
carbohydrate
carbohydrate
15 g carbohydrate
20 g carbohydrate
Check label to determine amount
¾ cup (175 mL)
1 cup (250 mL)
Lifesavers (chew and
swallow) or jelly beans
6
8
Skittles
15
20
• Drinking alcohol;
Table sugar
3 tsp (15 mL)
4 tsp (20 mL)
• Recent weight loss; or
Pasteurized honey (do not
use for children under 12
months)
3 tsp (15 mL)
4 tsp (20 mL)
• Kidney or liver disease.
Severe hypoglycemia is more likely to occur if you:
• Have hypoglycemia unawareness;
• Have frequent episodes of hypoglycemia;
• Have had a recent significant reduction in your A1C (glycated
hemoglobin);
• Have an A1C within the normal range (less than 6%);
• Have had a prior episode(s) of severe hypoglycemia;
• Have had diabetes for a long time;
• Have autonomic neuropathy;
• Are less than 18 years of age; or
• Are pregnant (hypoglycemia unawareness is common at this time).
Note:
• Avoid cola (phosphorus) and orange juice (potassium).
• If you need to limit your fluid intake use candy or glucose tablets instead of fluids. If
you use juice or pop, include as part of your total fluid allowance for the day.
• If you take Acarbose (Gluco Bay) use only glucose tablets or pasteurized honey.
3. Wait 15 minutes. Re-test your BG. If your BG is less than 4 mmol/L re-treat
as described above. Although 15 minutes may feel like a very long time it
is important not to eat food that contains complex carbohydrate, protein
or fat (e.g. chocolate or snack bar) until your BG is above 4 mmol/L.
4. Once your BG is above 4 mmol/L have your usual meal or snack. If your
next meal is more than 1 hour away, or you are going to be active, eat a
snack containing 1 Carbohydrate choice (15 g carbohydrate) and 1 Meat
& Alternatives choice (e.g. ½ sandwich or crackers and cheese, or 1 snack
bar).
8. Talk to your pharmacist.
Be prepared and discuss your medication needs for sick days with a
pharmacist ahead of time. Also, ask for advice when purchasing over-thecounter medication. Try to select sugar-free cold remedies, lozenges and
cough syrup and products that do not include NSAID’s (common in pain
medication such as Advil and cold remedies). Also, review products that
contain acetaminophen with your doctor or pharmacist to make sure you
do not exceed the maximum daily dose.
Sick Day Guidelines for those
with Type 1 Diabetes
I N F O R M AT I O N B O O K L E T
9. Seek immediate medical assistance if:
• You are not well enough or able to follow these guidelines or are worried
about your symptoms;
• You have vomited and/or have had diarrhea 2 or more times in 4 hours;
• You are unable to eat or drink;
• You are showing signs of dehydration, like a very dry mouth, cracked lips,
dry skin or sunken eyes;
• After having extra fluids and insulin your blood glucose remains higher
than 14 mmol/L and/or blood ketones are higher than 1.5 mmol/L for
more than 4 hours; and/or
• You cannot keep your blood glucose above 4 mmol/L or you are having
a severe hypoglycemic reaction.
10.Prepare for tests and procedures.
Plan in advance. Carry an updated list of your medication and allergies.
You may need to adjust your insulin and/or diabetes medication before
and after the tests. In order to do this safely you must talk to your doctor
or pre-admission health professional to determine what medication to
take, not take, and when to restart.
It is important to know how to take care of yourself if you are ill, have an
infection or injury, or are under stress. You need to know that:
• Hypoglycemia (low blood glucose) can occur if you are not able to eat
or drink, or if you have symptoms of an illness, such as vomiting and/or
diarrhea.
• Hyperglycemia (high blood glucose) can occur in response to the body’s
release of stress hormones when you are ill or under stress. Other causes
include certain medications, such as steroids, a lack of insulin or missed
insulin dose, injection site issues or pump failure.
• Ketones are produced when the body burns fat for energy. This can
occur for a number of reasons: if you are not getting enough insulin and
when there is not enough carbohydrate for your body to use for energy.
• Diabetic Ketoacidosis (DKA) can occur as a result of hyperglycemia
and/or ketones. DKA is a life threatening condition and requires
immediate medical attention. The signs and symptoms of DKA include:
dehydration, nausea, vomiting, abdominal pain, shortness of breath, a
fruity breath, a decreased level of awareness, etc. Do not confuse these
symptoms with symptoms of the flu!
11.Update your immunizations.
To help prevent illness it is recommended that most people with
diabetes get their yearly flu shot and the pneumonia vaccine. Discuss
with your doctor whether you need to revaccinate. For children, discuss
immunization with your doctor.
Developed by the Diabetes Education Team at the OSMH Diabetes Education Centre. Adapted from materials developed by
the Canadian Diabetes Association (CDA) and based on the 2013 CDA Clinical Practice Guidelines. Revised July 2013.
Diabetes Education Centre
Orillia Adult Program: 705-325-7611
Gravenhurst Adult Program: 705-687-9515
Paediatric Program: 705-327-9152
Follow these sick day guidelines when you feel unwell or notice signs of an
illness or infection, are injured or under stress, or when your blood glucose is
above 14 mmol/L on 2 consecutive blood glucose tests. You should also see
your doctor to have the illness or infection diagnosed and treated.
1. Do not stop taking your insulin!
The stress hormones released in response to an illness, infection, injury or
stress can cause high blood glucose levels. You need to continue to take
your insulin, even if you have a poor appetite. You need more insulin for
hyperglycemia and extra insulin with ketones (0.6 mmol/L or higher).
2. You may need to hold certain medication.
If you have nausea, diarrhea or fever, or are vomiting or dehydrated, you
may need to stop taking certain medication until your symptoms go
away. These medications may include: Glucophage (Metformin), Gliclazide
(Diamicron), Glimepiride (Amaryl), Glyburide, certain blood pressure
medication (ACE inhibitors and ARB’s), certain pain medication, NSAID’s
(non-steroidal anti-inflammatory drugs), and diuretics (fluid pills).
Please review your medication needs for sick days with your doctor ahead
of time.
The medications I need to stop taking during an illness are:
Contact your doctor or local emergency service if you need help.
3. Test your blood glucose every two to four hours or more often if
needed.
• If you have low blood glucose, follow the hypoglycemia guidelines. You
may need to reduce your insulin to prevent further hypoglycemia.
• If you have high blood glucose, you need more insulin. Follow your
“Insulin Adjustment Scale”.
• Contact your doctor or diabetes educator if you need assistance.
4. Test your blood for ketones if your blood glucose is 14 mmol/L or
higher and/or if you are vomiting.
You need extra insulin if your ketones are 0.6 mmol/L or higher. Follow
your “Insulin Adjustment Guide for Ketones” to determine how much extra
insulin you need.
5. Have a Pump Emergency Plan (if you use an insulin pump).
Change infusion set if ketones are 0.6 mmol/L or higher. Keep a record of
your current pump settings and have a Multiple Daily Injection (MDI) backup plan for insulin delivery in case of pump failure or during emergency
situations such as surgery or a hospital stay.
6. Drink plenty of beverages to prevent dehydration.
You need about 1 cup of sugar-free beverages every hour (review your
fluid needs with your doctor if you have a fluid restriction). Water, broth
(low-sodium if you have a salt restriction), tea or herbal tea, as well as
sugar-free drinks or sugar-free beverage crystals such as Kool-Aid (made
with artificial sweetener) or Crystal Light are good choices.
7. Try to eat regularly.
If you can eat, follow your regular meal plan. If not, try to have a light snack
or beverage that contains carbohydrate. Aim to have 1 Carbohydrate
choice (15 grams of carbohydrate) every hour. For example:
Light Snack
1 slice of bread or toast
7 soda crackers
4 melba toast
¾ cup (200 mL) hot cereal
1 medium fruit
Beverage
½ cup (125 mL) juice
½ cup (125 mL) regular soft drink
1 cup (250 mL) milk
½ cup (125 mL) chocolate milk
1 bottle (237 mL) Glucerna
1 meal replacement bar (Glucerna)
1 bottle (237 mL) Boost Diabetic
1 cup (250 mL) chicken noodle soup
½ cup (125 mL) regular Jell-O
1 popsicle
1 cup (250 mL) regular sport drink
7. Seek immediate medical assistance if:
• You are not well enough or able to follow these guidelines or are worried
about your symptoms;
• You have vomited and/or have had diarrhea 1 or more times in 4 hours;
• You are unable to eat or drink;
• You are showing signs of dehydration, like a very dry mouth, cracked lips,
dry skin or sunken eyes;
Sick Day Guidelines for those
with Type 2 Diabetes
I N F O R M AT I O N B O O K L E T
• Your blood glucose has been higher than 20 mmol/L for more than 12
hours; and/or
• You cannot keep your blood glucose above 4 mmol/L or you are having
a severe hypoglycemic reaction.
8. Prepare for tests and procedures.
Plan in advance. Carry an updated list of your medication and allergies.
You may need to adjust your insulin and/or diabetes medication before
and after the tests. In order to do this safely you must talk to your doctor
or pre-admission health professional to determine what medication to
take, not take, and when to restart.
9. Update your immunizations.
To help prevent illness it is recommended that most people with
diabetes get their yearly flu shot and the pneumonia vaccine. Discuss
with your doctor whether you need to revaccinate. For children, discuss
immunization with your doctor.
Developed by the Diabetes Education Team at the OSMH Diabetes Education Centre. Adapted from materials developed by
the Canadian Diabetes Association (CDA) and based on the 2013 CDA Clinical Practice Guidelines. Revised July 2013.
It is important to know how to take care of yourself if you are ill, have an
infection or injury, or are under stress. You need to know that:
• Hypoglycemia (low blood glucose) can occur if you are not able to eat
or drink, or if you have symptoms of an illness, such as vomiting and/or
diarrhea.
• Hyperglycemia (high blood glucose) can occur in response to the body’s
release of stress hormones when you are ill or under stress. Other causes
include certain medications, such as steroids, a missed insulin dose, or
injection site issues.
• Hyperosmolar Hyperglycemic State (HHS) can occur as a result
of hyperglycemia. HHS is a life threatening condition and requires
immediate medical attention. Warning signs include: hyperglycemia,
dehydration, nausea, vomiting, a decreased level of awareness, weakness,
loss of vision, etc. Do not confuse these symptoms with symptoms of the
flu!
Diabetes Education Centre
Orillia Adult Program: 705-325-7611
Gravenhurst Adult Program: 705-687-9515
Paediatric Program: 705-327-9152
Follow these sick day guidelines when you feel unwell or notice signs of an
illness or infection, are injured or under stress, or when your blood glucose
is above 15 mmol/L on 2 consecutive blood glucose tests. You should also
contact your doctor to have your illness or infection diagnosed and treated.
1. Do not stop taking your diabetes medication and/or insulin!
The stress hormones released in response to an illness, infection, injury or
stress can cause high blood glucose levels. You may need more medication
and/or insulin. Even if you have a poor appetite you need to continue to
take your insulin and/or diabetes medication (please note: you may be
advised to stop taking certain diabetes medication).
2. You may need to hold certain medication.
If you have nausea, diarrhea or fever, or are vomiting or dehydrated, you
may need to stop taking certain medication until your symptoms go
away. These medications may include: Glucophage (Metformin), Gliclazide
(Diamicron), Glimepiride (Amaryl), Glyburide, certain blood pressure
medication (ACE inhibitors and ARB’s), certain pain medication, NSAID’s
(non-steroidal anti-inflammatory drugs), and diuretics (fluid pills).
Please review your medication needs for sick days with your doctor ahead
of time.
The medications I need to stop taking during an illness are:
• Contact your doctor or diabetes educator if you need assistance.
4. Drink plenty of beverages to prevent dehydration.
You need about 1 cup of sugar-free beverages every hour (review your
fluid needs with your doctor if you have a fluid restriction). Water, broth
(low-sodium if you have a salt restriction), tea or herbal tea, as well as
sugar-free drinks or sugar-free beverage crystals such as Kool-Aid (made
with artificial sweetener) or Crystal Light are good choices.
5. Try to eat regularly.
If you can eat, follow your regular meal plan. If not, try to have a light snack
or beverage that contains carbohydrate. Aim to have 1 Carbohydrate
choice (15 grams of carbohydrate) every hour. For example:
Light Snack
1 slice of bread or toast
7 soda crackers
4 melba toast
¾ cup (200 mL) hot cereal
1 medium fruit
1 meal replacement bar (Glucerna)
1 cup (250 mL) chicken noodle soup
½ cup (125 mL) regular Jell-O
1 popsicle
Beverage
½ cup (125 mL) juice
½ cup (125 mL) regular soft drink
1 cup (250 mL) milk
½ cup (125 mL) chocolate milk
1 bottle (237 mL) Glucerna
1 bottle (237 mL) Boost Diabetic
1 cup (250 mL) regular sport drink
6. Speak with your pharmacist.
Contact your doctor or local emergency service if you need help.
3. Test your blood glucose every two to four hours or more often if
needed.
• If you have low blood glucose, follow the hypoglycemia guidelines.
You may need to reduce your diabetes medication(s) and/or insulin to
prevent further hypoglycemia.
• If you have high blood glucose, you may need more diabetes
medication and/or insulin. If you use insulin follow your “Insulin
Adjustment Scale”.
Be prepared and discuss your medication needs for sick days with a
pharmacist ahead of time. Also, ask for advice when purchasing over-thecounter medication. Try to select sugar-free cold remedies, lozenges and
cough syrup and products that do not include NSAID’s (common in pain
medication such as Advil and cold remedies). Also, review products that
contain acetaminophen with your doctor or pharmacist to make sure you
do not exceed the maximum daily dose.