Nutritional Intervention for a Patient with Diabetic Nephropathy
The patient was a 52-year-old woman who was diagnosed with type 2 diabetes mellitus approximately 6 years ago. The patient had been taking oral hypoglycemic agents (Glimepiride) and insulin (Glargine 18-20 IU before breakfast and 4 IU before bed) to control blood glucose level. The patient's 2 hrs postprandial blood level was normally maintained between 280-300 mg/dL, however, the level increased to 300-400 mg/dL, in recent 2-3 weeks and the patient was hospitalized to control high glucose level. In addition to that, the patient had been receiving medical treatment for hypertension and dyslipidemia, and regular blood tests and urine tests were performed to monitor significant changes. The patient had been diagnosed with renal failure and proteinuria one year ago, and at the time of this hospitalization, the patient was diagnosed with stage 4 chronic kidney disease, and was consulted for nutrition education of diabetic nephropathy.\nThe patient's height and weight were 158 cm and 81.4 kg, respectively, percent of ideal body weight was 155.5%, indicating she was severely obese. Biochemical values of the patient are shown in .\nThe patient preferred a salty soup and stew, and the actual amount of intake exceeded the recommendation. When eating out once a week, the patient often ate a hamburger or a noodle meal. The patient's diet history was analyzed by the 24-hr recall method using Can Pro 3.0 software (The Korean Nutrition Society, Seoul, South Korea) (). The patient consumed approximately 1,840 kcal/d with a protein intake of 67.5 g, and the energy ratio from carbohydrate, protein, and fat was 61.7%: 14.4%: 23.9%, respectively. The patient did not take any nutritional supplements, and did not drink alcohol, or smoke. The patient's physical activity was rated to mild level of a homemaker; she participated in weight training or bowling for 2 hrs (3 times a week). The patient had never received nutrition education.\nThe patient was prescribed the nutritional regimen as follows.\n- Energy: 1,600 kcal (30 kcal/kg x 52.4 kg ideal body weight [IBW]) - Protein: 40 g/d (0.8 g/kg × 52.4 kg [IBW]) - Sodium: 2,000 mg/d - Potassium: 2,000 mg/d\nThis patient revealed problematic dietary habits including excessive carbohydrate intake, excessive protein intake, and excessive potassium intake (). After analysing etiology, lack of knowledge and absence of education experience were selected as main causes. Therefore nutrition education for diabetic nephropathy was conducted.\nThe nutritional problems of "excessive carbohydrate intake" and "excessive protein intake" were managed by establishing adequate nutrition through a diet comprising 1,600 kcal of energy, and below 60 percent of energy from carbohydrate and 40 g of protein per day. Food models and a food exchange list were configured to provide nutritional training for the proper dietary intake. Compliance issues were also discussed during the education period.\nThe association of carbohydrate intake and blood glucose control was discussed in relation to the nutritional problem of "excessive carbohydrate intake". Also, recommended amount of rice intake was 2/3-3/4 bowls (2.3 exchanges), which is reduced from one bowl (3 exchanges) a meal. Usually, it was necessary to take a proper amount of fat for preventing malnutrition and lack of caloric intake arise when protein and carbohydrates were restricted. However the patient had dyslipidemia and limited intake of animal fat was recommended. In addition, the patient was provided with information on the importance of eating the low-salt diet and tips for how to eat the low-salt diet easily. The tips for how to eat the low-salt diet are as follows. 1) Apply of spicy and sour flavor seasoning like pepper or vinegar, instead of salt or fermented soybean paste. 2) Limit the intake of high-salt-containing foods, such as kimchi, and other salted and pickled foods, 3) Consume side dishes during meals without the addition of salt, 4) Grilled food rather than boiled was recommended and use the food's own flavor effectively when cooking, 5) When salting, focus on one kind of food.\nThe patient was instructed to limit their intake of high potassium-containing foods (grains, potatoes, sweet potatoes, corn, soybean, green vegetables, nuts, tomatoes, kiwi, banana, melon etc.). To reduce potassium intake, the intake of raw vegetables was recommended. It was also recommended to remove the shell before cooking, to use leaves rather than stem and to boil vegetables in water 4-5 times of their volumes.\nThe results of nutrition education after 3 months are shown in -. The patient's diet history during last 3 months was analyzed by the 24-hr recall method using Can Pro 3.0 software (The Korean Nutrition Society, Seoul, South Korea). The patient consumed approximately 1,300 kcal/d with a protein intake of 37.6 g, and the energy supply from carbohydrate, protein, and fat was 71.3%, 11.6%, and 17.1%, respectively.\nAfter receiving the nutrition education for three months, the patient's energy intake was reduced by 500 kcal compared to three months ago. Protein intake was about 30 g less compared to three months ago. Limited intake of high-potassium foods was relatively well kept.