according to a recently released ' the korean diabetes research report 2012 ' by korean diabetes association , one out of ten adults has diabetes disease , two out of ten have the impaired fasting glucose which is stage of diabetes , and three out of ten adults are threatened by high blood glucose . in addition , the aging society proceeds quickly , thereby the number of diabetes patients are predicted about 6 million in 2050 , approximately a 2-fold increase compared to the current number of diabetes patients .
also , the incidence of acute and chronic complications associated with diabetes is expected to increase .
especially diabetic nephropathy occurs more frequently among the patients suffered from diabetes for a long time .
also , it is a complication that has a large impact on patient 's quality of life . a balanced diet was recommended for diabetes mellitus patient as a key component of diet therapy . on the other hand , food intake increases burden to kidney function in diabetic nephropathy patients .
therefore , the patient who proceeded to diabetic nephropathy needs nutrition education to properly manage the disease and to increase the quality of life . .
diabetic nephropathy occurs in 20% to 40% of patients with diabetes , and is a most likely causes of end - stage renal disease reported worldwide .
continuous microalbuminuria ( 30 - 299 mg / day ) appears in the early stages of diabetic nephropathy with type 1 diabetes , and it is an indicator of nephropathy onset and the development of cardiovascular disease . a patient who had a progression from microalbuminuria to macroalbuminuria ( 300 mg / day ) has a high risk of developing end - stage renal disease in few years . according to a recent study , the deterioration of renal function could be delayed by proactive management at the initial diagnosis point , therefore , it is important to implement a personalized diet customized to individuals as soon as possible . in this case report , the nutrition education for one patient with diabetic nephropathy is discussed .
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 . the 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 .
the 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 ) ( table 2 ) .
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 ) .
- 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 ] ) - potassium : 2,000 mg / d this patient revealed problematic dietary habits including excessive carbohydrate intake , excessive protein intake , and excessive potassium intake ( table 3 ) .
after analysing etiology , lack of knowledge and absence of education experience were selected as main causes . therefore nutrition education for diabetic nephropathy
the 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 .
the 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 .
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 .
the 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 .
the results of nutrition education after 3 months are shown in table 4 - 6 .
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 . after receiving the nutrition education for three months , the patient 's energy intake was reduced by 500 kcal compared to three months ago .
this article is a case report of a patient with chronic kidney disease caused by diabetic nephropathy .
because this patient had never received any nutrition education , the patient 's food and nutrition related knowledges was poor .
as a result , the patient had problems including excessive intakes of carbohydrate , protein , and potassium , which was problematic for disease management . to solve this problem ,
three months after the education , the patient 's blood profile data was collected from electronic medical records ( emr ) , and the patient 's dietary intake data was collected through direct interviews .
after intervention , carbohydrate intake did not conform exactly to recommendation , but protein intake and limitation of high - potassium foods were fairly well complied .
excessive carbohydrate intake should be avoided as far as possible owing to its blood glucose control issues . to slow the progression of kidney complications ,
protein intake should be limited to 0.8 - 1 g / kg ibw / d for those with microalbuminuria , and should be limited to 0.8 g / kg ibw / d for those with macroalbuminuria , and should be limited to 0.6 - 0.8 g / kg ibw / d for those with end - stage renal disease .
adequate fat intake is necessary to prevent malnutrition , because a lack of caloric intake can induce the restricted protein and carbohydrate intake .
dyslipidemia is one of the most common complication in patients with diabetic nephropathy and is correlated with disease progression .
this patient needs to be screened for microalbuminuria to prevent the progression of diabetic nephropathy , and dyslipidemia should be treated to reduce cardiovascular mortality .
the consumption of oils with saturated fatty acids and meat should be limited , and stir - fried vegetables and vegetable oil should be consumed in moderation . for strict blood pressure control ,
potassium is involved in the contraction and relaxation of muscles in the human body and is an essential electrolyte . however , when kidney function decreases , excess potassium can not be easily excreted and is accumulated in the body , creating a burden . therefore , potassium intake should be limited in chronic kidney disease or in the case of hyperkalemia .
therefore , the intake of coarse grains and vegetables should be limited , and should be soaked in water for more than 2 hours , and then blanched in boiling water before cooking .
phosphorus in combination with calcium is found in bones and teeth . in reduced renal function ,
the amount of phosphorus that is emitted through the kidneys decreases and the blood levels of phosphorus increase .
therefore , drug therapy is required in chronic kidney disease stages and the intake of foods that contain high levels of phosphorus should be reduced .
a diabetic diet entails consumption of a healthy and balanced diet . whereas a chronic kidney disease or diabetic nephropathy diet should be designed to delay the progression of kidney disease , uremia due to renal dysfunction , hypertension , edema , hyperkalemia , hyperlipidemia and to control blood glucose along with the regulation of sodium , protein , and potassium levels .
thus compared to the diabetic diet , the diabetic nephropathy diet is a little more complicated and restrictive .
however , a personalized diet plan and continuous monitoring are required in diabetic nephropathy patien according to the patient 's stage of disease .
 in recent years , several studies have reported that the prevalence of diabetes mellitus is increasing every year , and also the acute and chronic complications accompanying this disease are increasing . 
 diabetic nephropathy is one of chronic complications of diabetes mellitus , and food intake which is burden to kidney function should be limited . 
 at the same time , diet restriction could deteriorate quality of life of patient with diabetic nephropathy . according to the results of previous studies , 
 the aggressive management is important for delaying of the progression to diabetic nephropathy . 
 also , the implementation of a personalized diet customized to individuals is an effective tool for preservation of kidney function . 
 this is a case report of a patient with diabetic nephropathy who was introduced to a proper diet through nutrition education to prevent malnutrition , uremia and to maintain blood glucose levels . 
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