Diet for Diabetes and Chronic Kidney Disease: Tips for Educators

Diet for Diabetes and Chronic Kidney Disease: Tips for Educators

Introduction
When diabetic nephropathy is diagnosed, the goal is to retain kidney function for
as long as possible. To help maintain kidney function, and delay the progression
of kidney disease, optimal blood glucose and blood pressure control are
cornerstones of treatment (1). When a person is diagnosed with chronic kidney
disease (CKD), a referral to a nephrologist should be initiated, and management
by a renal medical care team advocated.

The “Diabetes and Kidney Disease – Kidney Care” section, in Chapter 13 of the
Beyond the Basics (BTB) Resource, provides an outline about kidney disease in
people with diabetes, with an emphasis on prevention. The purpose of this
document is to provide guidelines for adapting the BTB for people with diabetes
and kidney disease. It can help registered dietitians’ (RD) counsel people with
diabetes about their diet for both diabetes and kidney disease. This information
can be used in the interim time period before they are able to see a nephrologist
and/or dietitian specializing in kidney disease.

Diet counselling by a RD needs to be individualized based on many factors
including: kidney function, lifestyle, culture, religion, financial status, other
comorbid conditions, treatment goals and biochemical parameters (2). The diet
may have to be modified for sodium, protein, potassium and/or phosphorus.
Estimating Kidney Function
The 2003 CDA Clinical Practice Guidelines recommend estimating kidney
function using serum creatinine to calculate creatinine clearance (CrCl) with the
Cockcroft-Gault equation (1). Glomerular filtration rate (GFR) may also be used
to estimate kidney function using the Modified Diet in Renal Disease (MDRD)
study equation. Kidney function is often classified into five stages using CrCl or
GFR. A value less than 60mL/min for longer than 3 months is considered
chronic kidney disease (CKD). (3)
Stages of Kidney Disease
See Appendix 1 for Cockcroft-Gault and MDRD GFR study calculations.
CrCl or GFR in ml/minute
Kidney function
Stage
Greater than or equal to 90
Normal
1
89 – 60
Mild decrease
2
59 – 30
Moderate decrease
3
29 - 15
Severe decrease
4
Minimal function. Dialysis or
less than 15
5
transplantation may be required.




Page 1 of 9

---

Sodium
Most people with diabetes and CKD require a sodium restriction to achieve
optimal blood pressure control and prevent fluid retention. “Shake the salt habit”,
located on page 131 of the Beyond the Basics Resource, is a tool that can be
used to educate people regarding lowering the sodium in their diet.

Dietary Approaches to Stop Hypertension (DASH)
The DASH diet has been promoted for the treatment of hypertension in people
with diabetes (4). When kidney function is normal, or mildly decreased, the
DASH diet may be used in the presence of normal serum potassium levels (5).
Due to its higher protein, potassium and phosphorus content, it is not
recommended for people with moderately or severely decreased kidney function
(CrCl < 60 mL/min). For more information regarding the DASH diet see the
resource list.
Protein
Restricting dietary protein (0.6 – 0.75 g/kg/d) for people with CKD is controversial
due to the intensive counselling and monitoring required to prevent malnutrition.
Most renal dietitians aim for the Dietary Reference Intakes (DRI) of 0.8 g/kg/d
with at least 50% coming from high biological value protein sources (6, 7). For
people with nephrotic syndrome, up to 1.0 g/kg/d may be used (7). A controlled
protein diet also helps to control potassium and phosphate content in the diet.
Diet Counselling Guidelines:
1) Choose fresh or fresh frozen meats, poultry, pork and fish most often.
Limit salty products like bacon and deli meat.
2) Limit servings to the size of the palm of your hand.
3) The protein sources listed below are high in potassium and/or
phosphorus. If the person’s serum potassium or phosphate is elevated
suggest limiting to one Meat and Alternative choice per day of either:
a. Legumes (dried beans, peas, lentils)
b. Cheese
c. Peanut butter

Vegetarian diet counselling in CKD
Due to the higher potassium content of various vegetarian protein sources a
more individualized diet pattern may be required to prevent protein malnutrition
and hyperkalemia. The diet recommendations should be based on the person’s
food preferences, culture and beliefs.
Potassium
The antihypertensive medications angiotensin-converting enzyme (ACE)
inhibitors and angiotensin receptor blockers (ARB), are preferred agents for
treatment of diabetic nephropathy (1,5). Hyperkalemia is a common side effect.
People with diabetes who are started on one or both types of the above



Page 2 of 9

---

mentioned medications may require a dietary potassium restriction. If serum
potassium levels are greater than normal, a low potassium diet should be
prescribed. In some cases, a higher potassium diet may be required due to high
doses of loop diuretics (e.g. furosemide). See Appendix 2 for antihypertensive
therapies that affect blood potassium levels.
Diet Counselling Guidelines:
Before implementing a potassium restricted diet a thorough diet history should
be performed by a RD to identify major sources of potassium. To avoid
unnecessary diet restriction, counselling on a reduced potassium diet can be
done in two phases.
1) Initial instruction focusing on:
a) Choosing lower potassium fruit and vegetables, and their juices. (See
Table 1)
b) Avoiding salt substitutes containing potassium chloride (e.g. No Salt or
Half Salt) and avoiding sodium reduced products that use potassium
chloride. Recommend no added salt seasoning blends such as “Mrs.
Dash™” or “McCormick’s No Salt Added™”.
2) If serum potassium remains above normal levels:
a) Limit Milk and Alternatives to one choice (e.g. ≤ 8 ounces of milk) per day
or less.
b) Limit legumes (dried beans, peas, lentils) and peanut butter to one Meat
and Alternative choice (7 grams of dietary protein) per day. If the person is
vegetarian more may be allowed to meet protein needs.
c) Limit nuts to one Fat choice per day or less.
Table 1: Common Lower and Higher Potassium Fruits and Vegetables
(See Appendix 3 for a more expanded list including multicultural fruit and vegetables)

Lower Potassium
Higher Potassium
Fruit
Apples, Blueberries, canned
Avocado, Banana, Cantaloupe
(drained) fruit, Cranberries, Grapes, melon, Dried fruit, Honeydew
Mango, Peach (small), Pear,
melon, Kiwifruit, Nectarine, Orange,
Pineapple, Plum, Watermelon
Papaya
Vegetables Asparagus, Beans (green/yellow),
Beets, Brussels Sprouts,
Carrots (boiled), Cauliflower,
Mushrooms (cooked), Potato,
Celery, Corn, Cucumber, Eggplant,
Pumpkin, Spinach (cooked),
Lettuce, Onions, Peas (green or
Squash, Sweet Potato, Tomato
snow, boiled), Peppers
paste and sauces, Yams
Note: Various resources and renal programs use different milligram cut-off levels
to determine what foods are higher and lower in potassium. Therefore, low
potassium diet resources may vary. The above table was based on the National
Kidney Foundation (NKF) resource which uses a cut-off of 200 mg per (½ cup)
serving.






Page 3 of 9

---

Potassium and Blood Glucose
Hyperglycemia can cause elevated blood potassium levels. Encouraging optimal
blood glucose control can help prevent hyperkalemia.
Remind people to choose lower potassium sources of carbohydrates to treat
hypoglycemia. (Refer to the “Hypoglycemia and Chronic Kidney Disease”
resource.)
Phosphorus
Maintaining normal serum phosphate levels is important for preventing renal
bone disease and calcification of the soft tissue in people with CKD (8). Increase
in blood phosphate is not usually seen until the later stages of CKD. Referral to
a nephrologist is needed to optimize renal bone disease management through
prescription of phosphorus binding medications and vitamin D derivatives.
Counselling regarding a low phosphorus diet may often be delayed until the client
is seen by a multidisciplinary renal team (including a RD).
Diet Counselling Guidelines:
1) Counselling on the above guidelines for sodium, protein and potassium,
indirectly reduces phosphorus in the diet.
2) In the earlier stages of CKD continue to encourage the use of fibre rich
grains and cereals to promote optimal blood glucose control.
3) The following foods are a source of readily absorbed phosphorus and
should be discouraged due to the poor nutrient content:
a) Beverages that contain phosphoric acid (e.g. regular and diet cola’s) or
phosphates.
b) Beer
c) Chocolate
Glycemic Index (GI)
Many low glycemic index foods are higher in potassium and phosphorus. Below
are counselling guidelines that are appropriate for people with elevated
potassium or phosphate levels.
Diet Counselling Guidelines:
1) Lower the GI of foods by using lemon juice or vinegar to flavour foods.
2) Breads - cracked wheat or sourdough breads.
3) Fresh fruits - Apples, cherries, pears, plums and strawberries.
4) Grains - parboiled rice, barley and millet.
5) Balance meals with appropriate portions of protein and good sources of
mono- and poly-unsaturated fats.



Page 4 of 9

---

References:
1. Canadian Diabetes Association: 2003 Clinical Practice Guidelines for the
Prevention and Management of Diabetes in Canada.
2. National Kidney Foundation: K/DOQI CLINICAL Practice Guidelines for
Nutrition in Chronic Renal Failure. 2000.
3. National Kidney Foundation: K/DOQI CLINICAL Practice Guidelines for
Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002.
4. Reimer, R. “The DASH diet: implications for people with diabetes” Can J
Diabetes. 2002;26(4): 369-377.
5. National Kidney Foundation: K/DOQI CLINICAL Practice Guidelines on
Hypertension and Antihypertensive Agents in Chronic Kidney Disease. 2004.
6. Dietitians Special Interest Group of the EDTNA/ERCA: European Guidelines
for the Nutritional Care of Adult Renal Patients. October 2002.
http://www.associationhq.com/edtna/pdf/diet_dietguid.pdf
7. American Dietetic Association: A Clinical Guide to Nutrition Care in Kidney
Disease. 2004.
8. National Kidney Foundation: K/DOQI CLINICAL Practice Guidelines for Bone
Metabolism and Disease in Chronic Kidney Disease. 2003.

Resources:
National Institutes of Health: Your Guide to Lowering Your Blood Pressure with
DASH. April 2006.
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
2006 CHEP: Canadian recommendations for the management of hypertension
http://www.hypertension.ca/chep/recommendations2006/CHEP_2006_complete.pdf
Canadian Nutrient File (database), 2005
www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index_e.htmlAppendix



Page 5 of 9

---

Appendix 1 – Cockcroft-Gault and MDRD GFR calculations
Online version of these calculations are available at http://www.nephron.com
*Cockcroft-Gault equation (1):
Creatinine clearance (mL/min) = (140 – age in years) x actual weight (kg)

serum creatinine (µmol/L)
Multiply the result by 1.2 for men
Normal range is > 90 mL/min, > 1.5 mL/s

*MDRD GFR (abbreviated) equation (3):
Estimated GFR (mL/min/1.73 m2)
= 186 x (SCr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if African American)
= exp (5.228 – 1.154 x In(SCr) – 0.203 x In(Age) – (0.299 if female) + (0.192 if African American)

* Some clinical situations may produce an over or underestimation of kidney
function if estimated using the above equations (3). In these situations, a 24
hour urine clearance should be measured to estimate GFR. These situations
include:
Extremes of age and body size
Severe malnutrition or obesity
Disease of skeletal muscle
Paraplegia or quadriplegia
Vegetarian diet
Rapidly changing kidney function



Page 6 of 9

---

Appendix 2 - Antihypertensive therapies that affect blood
potassium levels
Renin-angiotensin system
Diuretics
inhibitors
Increases blood potassium
Loop (increases potassium excretion)
bumetanide Burinex
Generic Name
Trade Name
ethacrynic acid
Edecrin
Angiotensin-converting enzyme inhibitors
furosemide Lasix
(ACE-I)
Beta Blocker and Diuretic Combo
benazepril Lotensin
(increases potassium excretion)
captopril Capoten
pindolol/HCTZ Viskazide
cilazapril Inhibace
atenolol/ chlorthalidone
Tenoretic
enalapril Vasotec
Thiazide
fosinopril Monopril
(mildly increases potassium excretion)
lisinopril Prinivil,
Zestril
chlorthalidone
Apo-
perindopril Coversyl

Chlorthalidone,

Hygroton, Novo-
quinapril Accupril

Thalidone, Uridon
ramipril Altace
Apo-Hydro,
trandolapril Mavik
hydrochlorothiazide
Hydrodiuril, Novo-
Angiotensin Receptor Blockers (ARB)
(HCTZ)
Hydrazide
candesartan Atacand
indapamide Lozide
irbesartan Avapro
methyclothiazide Duretic
losartan Cozaar
metolazone** Zaroxolyn
telmisartan Micardis
Dyazide, Apo-
valsartan Diovan
triamterene/HCTZ
Triazide
eprosartan Teveten
amiloride/HCTZ Moduret

spironolactone/HCTZ Aldactazide
Potassium sparing
Combination therapies
(decreases potassium excretion)
amiloride
Midamor
ACE-I plus diuretic (HCTZ)
spironolactone
Aldactone,
enalapril / HCTZ
Vaseretic

Novospiroton
lisinopril / HCTZ
Prinzide
triamterene Dyrenium
lisinopril / HCTZ
Zestoretic
quinapril / HCTZ
Accuretic
** Metolazone produces a greater and more
Preterax or
rapid increase in potassium excretion than
perindopril/indapamide
Coversyl Plus
other thiazide diuretics.
cilazapril/HCTZ Inhibace
Plus
eprosartan/HCTZ Teveten
Plus
ARB plus diuretic (HCTZ)
candesartan / HCTZ
Atacand Plus
irbesartan / HCTZ
Avalide
Avalide
telmesartan / HCTZ
Micardis Plus
valsarten / HCTZ
Diovan HCT
losartan / HCTZ
Hyzaar




Page 7 of 9

---

Appendix 3 - Multicultural Fruit and Vegetables
East Indian Fruit and Vegetables
Lower Potassium Fruit
Higher Potassium Fruit
Ambada* Bamboo
Fruit
Passion Fruit
Boysenberries Coconut Phalsa*
Casaba Melon
Dates
Pomegranate
Clementine (Mandarin Orange)
Dried Green Mango
Sapota
Jambu* Figs
Seetaphal*
Loganberries
Green Plantain
Tamarind (Dried Amli*)
Loquat Guava
Tamatil o*
Lychees Jackfruit
Tangelo*
Passion Fruit
Korukkapalli (Amli*)

Rose apple
Musk Melon

Tangerine

Woodapple

Zizyphus

Lower Potassium Vegetables
Higher Potassium Vegetables
Bamboo Shoots
To Limit:
To Avoid:
Bottlegourd
Bittermelon, Bittergourd
Amaranth Tender
Cluster Beans
Chilies: green and red
Artichoke
Coriander Leaves
Marrow, Summer Squash
Beet Greens
Crookneck Squash*
Turnip
Bok Choy
Fenugreek Zucchini
Colocasia
Leaf
Kankoda

Cow pea pods
Mint
Drumsticks
Mustard leaves

Green mangoes
Pink Beans

Green banana
Ridge Gourd

Lotus Root
Snowpeas
Okra
Spaghetti Squash

Parsnips
Water Chestnuts, canned

Plantain
Rasam
Sambar*
Taro
Roots
* Indicates the Indian name
West Indian Fruit and Vegetables
Lower Potassium Fruit
Higher Potassium Fruit
Mammie apple
Ackee
Custard apple
Soursop
Passion fruit
Bread fruit
Guava
Sapodilla
Prickly pear
Carambala (Starfruit) Jackfruit
Sapote
Tangerine Coconut
Pawpaw
(Papaya)

Lower Potassium Vegetables
Higher Potassium Vegetables
Bamboo Shoots, canned
Cassava
Okra (Ochara)

Chocho (Chayote, Christophene)
Callaloo
Plantain

Collards
Dasheen roots & leaves
Tamarind

Mustard greens
Eddoe (Coca)
Yucca

Sago Green
banana


Watercress (crishes)



Notes:
1) Whenever possible, peel, chop in small pieces and boil vegetables in a large quantity of
water and drain before they are used in a curry.
2) Limit potato to a small amount as it is higher in potassium. Always pre-boil the potatoes.
Page 8 of 9

---

Chinese Fruit and Vegetables
Lower Potassium Fruit
Higher Potassium Fruit
Chinese Dates (Jujube)
Lychee
Durian
Jackfruit, canned and
Mandarin orange
Guava
drained
Kumquat Mangosteen
Jackfruit,
raw
Loquats Pear
(Asian)
Persimmon

Plantain

Pomegranate



Lower Potassium Vegetables
Higher Potassium Vegetables
Alfalfa sprouts
Jicama Artichoke
Bamboo shoots, canned
Jew’s Ear, soaked)
Beans: mung, yardlong
Bean sprouts
Judas Ear, soaked
Bok choy, cooked
Bitter melon
Mustard greens
Chinese broccoli (Gai lan)
Chayote
Suey Choy (Nappa)
Daikon radish
Coy Sum (Yao Choy)
Long qua (Squash)
Lotus root, cooked
Dandelion greens
Tung choy
Rutabaga
Hairy melon
Water chestnut,canned
Taro (Wu Tao)
Watercress






Page 9 of 9

---