Day 11: Carbohydrates, Blood Sugar, and Numbers to Watch
We know carbohydrates have a direct effect on blood sugar and indirect effect on triglyceride levels. Those who cannot process sugar efficiently like people with diabetes end up with too much in the blood vessel. This can cause damage. Many would also develop hypertension or high blood pressure.
Some become diabetic because they were born with an auto-immune disease that makes their pancreas unable to produce insulin. These are people with type 1 diabetes mellitus (DM). Those who develop type 2 DM have genetic predisposition or have acquired belly fat that makes them insulin resistant. The latter can be prevented by lifestyle changes. But how do you know if you’re at risk for diabetes or actually have diabetes? And what’s so important about knowing this?
Let me tell you a story. Two stories, actually. I’ve shared these stories on my blog but it’s worth re-telling.
In 2009, I met Nina, a 40-year-old businesswoman, whose life turned upside down in a flick of a finger. "How could this be? Renal failure? I wish I had known sooner. I could have prevented it. My doctor didn't tell me until it was too late,” she said, as her eyes welled with tears. “I didn't understand it...the protein in the urine...because of my hypertension. Why didn't I get tested for this before? Now, I have to do this forever?" She pointed at the dialysis machine beside her, regarding it as a foe rather than a friend.
For Robin, a 28-year-old single mother, her dream of finishing college was swept away from the staggering news of renal failure. "I had no idea that my kidneys were getting damaged." She has juvenile diabetes mellitus and didn't have an inkling that renal failure is one of its potential consequences. "I felt bloated. I thought I just gained weight. And then my swollen legs... then the shortness of breath. My doctor told me that I had fluid in my lungs and needed to undergo dialysis immediately. Then they put this on my neck." She pointed at the central venous catheter for dialysis access jutting out in an awkward position below her right jaw. "I don't like my friends to see me like this. And my 3-year-old daughter... she'd be scared." Her voice cracked as she struggled to control her emotion.
I've worked for two years as an acute hemodialysis nurse and it wasn't uncommon for me to hear patients lament that had they known they were at risk for end-stage renal disease (ESRD), requiring dialysis or kidney transplantation, they would have taken better care of themselves.
Diabetes and hypertension still remain as the major causes of ESRD. According to the 2018 Annual U.S. Renal Data System, diabetes ranks first as the primary cause of ESRD for 44% of new patients and 29% had a primary diagnosis of hypertension. For most of these patients, renal failure never entered their consciousness until it slapped them in the face. And most had to deal with hemodialysis, which required a lifestyle overhaul. Dialysis sessions run three to four times a week, lasting three to four hours each visit.
The demands on the family resources and the many food and fluid restrictions for the patients make adhering to this new lifestyle a major challenge. The first year of hemodialysis treatment can prove to be a nightmare. Infection of vascular catheter access, blood toxicity, and heart and lung congestion bring the patients back to the hospital time and again.
I have also worked with patients on peritoneal dialysis, a type of dialysis that they can do on their own at home using a PD catheter in their abdomen into their peritoneal cavity. Most do it at night for 9-10 hours using a PD cycler, a small machine that is programmed to instill, dwell, and drain the PD solution in multiple cycles. It is less draining to the body and with less fluid and dietary restrictions. Most patients have better outcomes when transplanted. But many still feel overwhelmed by the lifestyle changes, although I’ve seen a few who have breezed through the process and get transplanted in less than a year.
Unknown to most hypertensive and diabetic patients, chronic kidney disease starts to threaten their kidneys from the moment of diagnosis. But the disease progression from CKD to ESRD may take months or years to happen depending on how they control their blood sugar or blood pressure.
So, don't get caught off guard like Robin and Nina.
You can detect subtle signs and symptoms of worsening CKD and impending ESRD with regular screening and follow-up.
How do you monitor your kidney's health?
There are the markers that will reveal kidney function:
A nephrologist (doctor specializing in kidney diseases) can calculate your glomerular filtration rate and the extent of kidney damage to tailor the recommendations accordingly.
Have these markers tested at least once a year.
The plan of management for early stages of CKD focuses on slowing down the disease progression.
How?
Strict control of blood pressure and blood sugar
Why?
Very low or very high blood pressure will affect blood supply to the kidneys.
High blood sugar damages the small blood vessels found in the eyes, kidney, and nerves.
Your BP goal if you have kidney disease and:
Normal blood pressure is less than 120/80.
PRE-HYPERTENSIVE (Stage 1 hypertension) level is between 120/80 to less than 140/90.
Making some lifestyle changes especially in diet and exercise can help in bringing it back to normal.
Your Blood Sugar Goal if you are a diabetic:
Daily blood sugar monitoring tracks the adequacy of your medication and food intake. A blood test called HbA1C can detect poor blood sugar control for the past three months.
The desirable level is <7% or an eAG of <154 mg/dL for diabetics.
Get tested every 3-6 months.
To meet that goal, your daily blood sugar should be well monitored and controlled.
Here are typical targets, which may vary according individual medical needs:
PRE-DIABETES:
You may be at risk for diabetes if your fasting blood sugar is between 100 - 125 mg/dL and your HbA1C is between 5.7 - 6.4%
NORMAL HbA1C level is less than 5.7% and normal blood sugar is less than 100 mg/dL.
If CKD progresses into kidney failure, you will need a permanent vascular access such as a graft or fistula (typically on your arm).
These are less prone to infection.
In more than 15 years, the rate of infectious and cardiovascular events in the first year was high because majority of the newly diagnoses patients with ESRD come in without prior detection of CKD. This indicates the need for better monitoring of renal function among diabetics and hypertensives with emphasis on prevention.
In general, the following are recommended to delay if not prevent end-stage renal disease:
A nephrologist should monitor a CKD patient receiving any of these.
Don't feel helpless when it comes to your health. There are many resources available to you. These are just a few of them:
Find one that resonates best with you and stick to a lifestyle change program. With greater awareness, you will be able to participate in your health care and prevention of disease complications. You will become more prepared should chronic kidney disease set in and give you more options other than hemodialysis to maintain a favorable lifestyle.
Some become diabetic because they were born with an auto-immune disease that makes their pancreas unable to produce insulin. These are people with type 1 diabetes mellitus (DM). Those who develop type 2 DM have genetic predisposition or have acquired belly fat that makes them insulin resistant. The latter can be prevented by lifestyle changes. But how do you know if you’re at risk for diabetes or actually have diabetes? And what’s so important about knowing this?
Let me tell you a story. Two stories, actually. I’ve shared these stories on my blog but it’s worth re-telling.
In 2009, I met Nina, a 40-year-old businesswoman, whose life turned upside down in a flick of a finger. "How could this be? Renal failure? I wish I had known sooner. I could have prevented it. My doctor didn't tell me until it was too late,” she said, as her eyes welled with tears. “I didn't understand it...the protein in the urine...because of my hypertension. Why didn't I get tested for this before? Now, I have to do this forever?" She pointed at the dialysis machine beside her, regarding it as a foe rather than a friend.
For Robin, a 28-year-old single mother, her dream of finishing college was swept away from the staggering news of renal failure. "I had no idea that my kidneys were getting damaged." She has juvenile diabetes mellitus and didn't have an inkling that renal failure is one of its potential consequences. "I felt bloated. I thought I just gained weight. And then my swollen legs... then the shortness of breath. My doctor told me that I had fluid in my lungs and needed to undergo dialysis immediately. Then they put this on my neck." She pointed at the central venous catheter for dialysis access jutting out in an awkward position below her right jaw. "I don't like my friends to see me like this. And my 3-year-old daughter... she'd be scared." Her voice cracked as she struggled to control her emotion.
I've worked for two years as an acute hemodialysis nurse and it wasn't uncommon for me to hear patients lament that had they known they were at risk for end-stage renal disease (ESRD), requiring dialysis or kidney transplantation, they would have taken better care of themselves.
Diabetes and hypertension still remain as the major causes of ESRD. According to the 2018 Annual U.S. Renal Data System, diabetes ranks first as the primary cause of ESRD for 44% of new patients and 29% had a primary diagnosis of hypertension. For most of these patients, renal failure never entered their consciousness until it slapped them in the face. And most had to deal with hemodialysis, which required a lifestyle overhaul. Dialysis sessions run three to four times a week, lasting three to four hours each visit.
The demands on the family resources and the many food and fluid restrictions for the patients make adhering to this new lifestyle a major challenge. The first year of hemodialysis treatment can prove to be a nightmare. Infection of vascular catheter access, blood toxicity, and heart and lung congestion bring the patients back to the hospital time and again.
I have also worked with patients on peritoneal dialysis, a type of dialysis that they can do on their own at home using a PD catheter in their abdomen into their peritoneal cavity. Most do it at night for 9-10 hours using a PD cycler, a small machine that is programmed to instill, dwell, and drain the PD solution in multiple cycles. It is less draining to the body and with less fluid and dietary restrictions. Most patients have better outcomes when transplanted. But many still feel overwhelmed by the lifestyle changes, although I’ve seen a few who have breezed through the process and get transplanted in less than a year.
Unknown to most hypertensive and diabetic patients, chronic kidney disease starts to threaten their kidneys from the moment of diagnosis. But the disease progression from CKD to ESRD may take months or years to happen depending on how they control their blood sugar or blood pressure.
So, don't get caught off guard like Robin and Nina.
You can detect subtle signs and symptoms of worsening CKD and impending ESRD with regular screening and follow-up.
How do you monitor your kidney's health?
There are the markers that will reveal kidney function:
- urine albumin (protein in your urine which is abnormal) and creatinine
- blood creatinine
A nephrologist (doctor specializing in kidney diseases) can calculate your glomerular filtration rate and the extent of kidney damage to tailor the recommendations accordingly.
Have these markers tested at least once a year.
The plan of management for early stages of CKD focuses on slowing down the disease progression.
How?
Strict control of blood pressure and blood sugar
Why?
Very low or very high blood pressure will affect blood supply to the kidneys.
High blood sugar damages the small blood vessels found in the eyes, kidney, and nerves.
Your BP goal if you have kidney disease and:
- If you are 60 years or older: Keep your BP < 150/90
- If you are younger (at least 18 years old) or 60 years or older but have diabetes or chronic kidney disease: Keep your BP < 140/90
Normal blood pressure is less than 120/80.
PRE-HYPERTENSIVE (Stage 1 hypertension) level is between 120/80 to less than 140/90.
Making some lifestyle changes especially in diet and exercise can help in bringing it back to normal.
Your Blood Sugar Goal if you are a diabetic:
Daily blood sugar monitoring tracks the adequacy of your medication and food intake. A blood test called HbA1C can detect poor blood sugar control for the past three months.
The desirable level is <7% or an eAG of <154 mg/dL for diabetics.
Get tested every 3-6 months.
To meet that goal, your daily blood sugar should be well monitored and controlled.
Here are typical targets, which may vary according individual medical needs:
- Before meals: 80 to 130 mg/dl.
- Two hours after the start of the meal: Less than 180 mg/dl.
PRE-DIABETES:
You may be at risk for diabetes if your fasting blood sugar is between 100 - 125 mg/dL and your HbA1C is between 5.7 - 6.4%
NORMAL HbA1C level is less than 5.7% and normal blood sugar is less than 100 mg/dL.
If CKD progresses into kidney failure, you will need a permanent vascular access such as a graft or fistula (typically on your arm).
These are less prone to infection.
In more than 15 years, the rate of infectious and cardiovascular events in the first year was high because majority of the newly diagnoses patients with ESRD come in without prior detection of CKD. This indicates the need for better monitoring of renal function among diabetics and hypertensives with emphasis on prevention.
In general, the following are recommended to delay if not prevent end-stage renal disease:
- Control your blood sugar through diet, exercise, hypoglycemic pills or insulin as prescribed, and regular monitoring of blood sugar.
- Control your blood pressure through diet, exercise, and intake of anti-hypertensive medications.
- Usually ACE-inhibitors (drugs ending in ---pril) or ARBs (drugs ending in ---tan) are given for renal protection. Daily monitoring of blood pressure should meet target goals.
- Consult a dietitian to help in meal planning. Eating too much protein in the early stages of chronic kidney disease is harmful to the kidneys and too much salt intake can increase blood pressure and cause swelling.
- Promptly report any signs and symptoms of urinary tract infection like frequency, burning or pain in urination, cloudy and smelly urine.
- Regularly monitor kidney function through blood and urine screening tests and referral to nephrologist when needed.
- Be cautious with use of drugs that can harm your kidneys like pain relievers (NSAIDs), antibiotics like aminoglycosides (gentamicin, tobramycin, amikacin, neomycin) and sulfa drugs (Bactrim, sulfasalazine), and IV contrast dye.
A nephrologist should monitor a CKD patient receiving any of these.
Don't feel helpless when it comes to your health. There are many resources available to you. These are just a few of them:
- Center for Disease Control and Prevention
- National Kidney Foundation
- National Kidney Disease Education Program
- National Institute of Diabetes and Digestive and Kidney Diseases
- American Diabetes Association
- American Heart Association
Find one that resonates best with you and stick to a lifestyle change program. With greater awareness, you will be able to participate in your health care and prevention of disease complications. You will become more prepared should chronic kidney disease set in and give you more options other than hemodialysis to maintain a favorable lifestyle.