By Rita Dimmitt, RD, LDN, CSR

Diabetes Mellitus (diabetes) can eventually impact your kidney function. You need to manage your diabetes to improve your quality of life and maintain an active lifestyle.

What are the differences between type I and type II diabetes?

There are two types of diabetes:

• Type I is more common in the young, and is related to an autoimmune destruction of the insulin secreting beta cells in the pancreas. Type I diabetes requires insulin treatment within the first year after onset of diabetes.
• Type II diabetes is the more common type and is related to insulin resistance or inability to produce enough insulin. In the past, type II diabetes was thought to be in older individuals. However, the onset of obesity has led to more diagnoses of type II diabetes in obese children. Type II diabetics often use oral medication and progress to insulin or a combination of oral medication and insulin for better control.

Why does it seem as though everyone in my family has diabetes and some have chronic kidney disease?

Family history may be a risk factor in the development of diabetes. Certain races, particularly Native American, Hispanic (Mexican-American) and African-American have a higher rate of diabetes. They also tend to have a much higher risk of type II diabetes leading to chronic kidney disease (CKD).

What are the symptoms of diabetes?

Diabetes is characterized by hyperglycemia, an excess of sugar in the blood, or high blood glucose causing excessive thirst, urination or unexplained weight loss.

How can I control my diabetes and prevent complications?

Self Monitoring of Blood Glucose (SMBG) is the most helpful indicator of your level of control. The American Diabetes Association (ADA) recommends that glucose levels should be maintained as follows:

• Glucose levels before meals, 90-130 mg/dl.
• Glucose levels two hours after meals, less than 180 mg/dl.
• A1C less than seven percent (reflects an average glucose over the past two to three months).

Do I need a special diet for diabetes?

Dietary interventions and lifestyle changes can improve the quality of life with diabetes:

• Protein should not be restricted. A normal amount of protein from the Recommended Dietary Intake (RDI) of 0.8 g/kg/d is typical. However, Americans consume excessive amounts of protein. For example, a person who weighs 155 pounds, needs only four to five ounces of meat a day.
• Use fats in moderation to prevent weight gain, which can contribute to more insulin resistance. Better sources are monounsaturated fat from olive oil or canola oil. Limit cholesterol to maintain serum cholesterol less than 200 mg/dl.  
• Carbohydrates are referred to as sugars, starch and fiber. People with type II diabetes should include a variety of carbohydrate foods, such as grains, breads, pasta, fruit, vegetables or low-fat milk. In general, a meal should contain 60 to 70 percent of its calories from carbohydrates.
• A registered dietitian can help you achieve these goals.

What about medications to control diabetes?

Medication regimen depends on your type of diabetes:

• Type I diabetics on the same daily dose of insulin may benefit from day-to-day consistency in the amount of carbohydrate eaten.
• Type I diabetics with tight control may benefit from counting carbohydrates at each meal and dosing the short acting insulin according to the carbohydrate load. 
• Type II diabetics typically use oral medications initially, and make lifestyle changes to reduce weight and calorie intake, to better control glucose levels.

As I lose kidney function, I have more hypoglycemia (low blood sugar). Why?

Insulin is not excreted as well, and insulin needs decrease as the kidney disease progresses requiring the blood sugar levels to be checked more regularly. You may require rapid correction of hypoglycemia or low glucose (sugar) levels with glucose or carbohydrate containing foods. 

What are the symptoms of hypoglycemia (low blood sugar)?

Common hypoglycemic symptoms are sweating, shakiness, irritability or confusion.

How do I treat hypoglycemia with kidney disease?

Remember the rule of 15 and 15:

• Consume 15 grams of carbohydrate, immediately.
• Recheck your blood sugar in 15 minutes.

If glucose levels are still low, treat again with a carbohydrate source and recheck glucose as before. Eat a meal within an hour to prevent hypoglycemia recurrence. Discuss these hypoglycemic reactions with your physician and dietitian to adjust the food intake or decrease the medication dosage.

What would provide 15 grams of carbohydrate?

In the past, orange juice was the treatment for hypoglycemia. However, if your kidneys are not functioning normally, you may not filter out the potassium as well. Low potassium alternatives are:

• glucose tablets, chewed
• glucose gel
• 1/2 cup apple juice
• 1/3 cup grape juice
• 1 tablespoon sugar
• 5 Lifesavers® candy, chewed
• 1/2 cup regular soda

Are there other causes of high potassium?

Most diabetics benefit from the protective effects of angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blockers (ARB) medications to treat blood pressure. ACE inhibitors decrease your blood pressure by opening or dilating blood vessels. ARBs work by blocking the hormone that causes blood vessels to narrow. However, serum potassium can rise with these medications. You would need to limit the fruits and vegetables that are higher in potassium, for example: oranges, bananas, potatoes, tomatoes and dried beans. A registered dietitian can assist you with choosing safe amounts of these foods or alternative low potassium choices.

Rita Dimmitt, RD, LDN, CSR has been a renal dietitian for 27 years, working with transplant, hemodialysis, peritoneal dialysis and chronic kidney disease patients. She currently works for  Vanderbilt Dialysis Clinic in Nashville, TN.

References:

1. Diabetes Care 27:S79-S83, 2004.
2. Handbook of Nutrition and the Kidney, Mitch and Klahr 4th Edition.
3. Handbook of Dialysis, Daugirdas, Blake and Ing, 3rd Edition.

The information contained herein is intended for educational purposes only. It is not intended and should not be construed as the delivery of medical care. Persons requiring diagnosis or treatment, or those with specific questions, are urged to contact their local healthcare provider for appropriate care.

This article originally appeared in the June/July 2004 issue of Kidney Beginnings: The Magazine, Vol. 3, No. 2.

Back