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Nutritional management for people with diabetes has traditionally focused on blood glucose control.
Key studies that evaluated reduction or alteration of dietary protein are summarized in Table 42. At the other end of the spectrum, high-protein diets are a particular concern in patients with diabetes because they increase albuminuria and may accelerate loss of kidney function.
Evidence of biological activity of dietary fats and carbohydrates indicates that an exclusive focus on protein is too limiting with regard to broad effects on health in people with diabetes and CKD. People with diabetes and CKD should receive intervention from a specialty-trained registered dietitian that includes individualized management of multiple nutritional aspects.
The Institute of Medicine established guidelines for intake of omega-3 fatty acids, which recognize significant variances in physiologicalpotency between different omega-3 fatty acids. Studies of dietary protein interventions in diabetes and CKD are relatively few, short term, completed in small numbers of participants, and have limited documentation of DKD.
The Renal Dietitians Dietetic Practice Group of the American Dietetic Association recommends nutritional assessment and intervention at the diagnosis of CKD and quarterly thereafter.477Considering that diabetes further complicates CKD care, frequency of assessment may be adjusted based on the needs of individual patients. However, dietary protein intake at all stages of CKD appears to have an important impact in this population.
Reduction in albuminuria and stabilization of kidney function have been reported with dietary protein intake at the RDA level. Glomerular hyperfiltration and increased intraglomerular pressure are well-recognized mechanisms of kidney damage induced by excess dietary protein. When protein intake is limited, caloric distribution of the other macronutrients must be addressed.
Recommendations for fatty acids usually combine polyunsaturated fatty acids together without differentiating between categories.
The management of diabetes and CKD involves multiple nutrients (macronutrients and micronutrients), including protein, carbohydrate, fat, sodium, potassium, and phosphate, among many others.
Meta-Analysis Demonstrating Reduced Risk of Progression of DKD (Loss of Kidney Function or Increased Albuminuria) by Treatment with Low-Protein Diets. Recommendations for phosphorus and potassium are the same for CKD with and without diabetes.

Effect of Reduced Dietary Protein Intake on CKD Stage 5 and Death in Type 1 Diabetes and CKD Stage 2 (inferred) at baseline. In addition, both the qualitative (eg, beef, chicken, or soy sources) and quantitative definition of a low-protein diet differ tremendously among studies. A registered dietitian who is knowledgeable of both conditions should perform nutritional assessments and interventions. In recent studies of people with prehypertension or untreated stage 1 hypertension, higher protein intake from either soy or predominantly vegetable sources reduced blood pressure in short-term (6 to 12 weeks) feeding studies.200, 201 Along with the DASH trials, these data suggest that predominantly nonmeat protein may have a beneficial effect on blood pressure.
Few studies have examined the effects of fatty acid intake or supplements on markers of kidney disease and risk factors in patients with diabetes (Table 41).468-472 Moreover, these studies were short term and performed in small numbers of people, precluding firm conclusions.
The dietary protein recommendation should be based on idealized body weight because obesity, which is highly prevalent in the diabetes and CKD population, otherwise would lead to overestimating the dietary protein recommendation.
Phosphorus binders may be needed in patients with advanced CKD because of the emphasis on whole grains and dairy products. The Work Group is not aware of studies indicating disadvantages from this amount of EPA or DHA.
Substantial differences in amounts and types of fat and carbohydrate also have not been acknowledged adequately.
In addition, diets recommended by health care professionals often are viewed as unpalatable and unattractive. Obtaining accurate dietary histories often is challenging because of the subjective nature of reporting and difficulty with recall. These patients (85% to 89% during the course of the study) also received ACE inhibitors and had similar control of blood pressure and other risk factors irrespective of diet group assignment, indicating that reducing dietary protein provided benefits beyond established medical therapies.181 Benefits of limiting dietary protein intake are more evident in type 1 than type 2 diabetes, but fewer studies have been done in the latter population. Nevertheless, the available evidence suggests that increased intake of omega-3 and monounsaturated fatty acids may be considered because of potentially favorable effects on progression of CKD (Table 41). However, some concerns exist related to the potential for unacceptable levels of mercury or other contaminants. This type of variability is a potential explanation for the inconsistent results observed between studies evaluating the effect of protein intake on kidney outcomes.
Culinary approaches to enhance appeal of nutrient-appropriate foods should be encouraged, along with methods to make food preparation easy and inexpensive.

For some key nutrients in the regimen recommended for diabetes and CKD, such as sodium and protein (estimated by urinary urea nitrogen excretion), 24-hour urine studies are useful to assess intake and guide counseling.
To address dietary recommendations for people with diabetes and CKD stages 1 to 4, studies evaluating interventions that reduced or altered sources of dietary protein and other nutrients were reviewed (Table 37 to Table 41). Based on the available evidence (Table 37 and Table 38), the Work Group concluded that limiting dietary protein will slow the decrease in kidney function and progression of albuminuria, and it may prevent CKD stage 5. Therefore, a DASH-type diet that emphasizes sources of protein other than red meat may be a reasonable alternative to a lower total protein intake in people with hypertension, diabetes, and CKD stages 1 to 2. Fatty acid intake can be modified easily by substituting canola oil, a blend that includes both omega-3 and monounsaturated fats, for vegetable oils. Nevertheless, in the opinion of the Work Group, these recommendations may be considered for the diabetes and CKD population. An example of a meal plan that meets the nutritional goals of this guideline is provided in Appendix 1.
Close monitoring of patients who follow a dietary protein restriction is important to ensure adequate, but not excessive, protein intake.
Several brands of salad dressings and butter replacement products made from canola oil are available in most grocery stores. A professional chef designed the menu and accompanying recipes in collaboration with registered dietitians experienced with diabetes and CKD. Regardless of the level of protein intake, 50% to 75% of the protein should be of high biological value, derived predominantly from lean poultry, fish, and soy- and vegetable-based proteins.
To reduce intake of saturated fat, consumption of red meats should be reduced, and low-fat or nonfat dairy products should be used. In the view of the Work Group, these types of creative approaches facilitate interest and feasibility for lifestyle modification in diabetes and CKD.

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