Hypertension, Diabetes &

Kidney diseases
Chapters 19, 20, and 21
Chapter 19
Coronary Heart Disease and Hypertension
 Lesson 19.2: Hypertension
 Hypertension (i.e., chronically elevated blood pressure) may be
classified as primary or secondary hypertension.

 Hypertension damages the endothelium of blood vessels. It is also

the main cause of strokes.

 Early education is critical for the prevention of cardiovascular

disease.

 Most cardiovascular risk factors are associated with nutrition and can
be reduced by changing food habits and lifestyles.
 Essential Hypertension
 Incidence and nature of essential (primary) hypertension
➢ an inherent form of high blood pressure with no specific identifiable
cause; it is considered to be familial (90% of cases are primary)
➢ 30% of American adults have high blood pressure (hypertension)
➢ Specific cause is unknown
➢ Risk factors: family history, obesity, smoking, age, ethnicity, physical
inactivity, alcohol consumption, sodium intake, chronic stress
➢ Older African Americans women more susceptible to developing (44.2%).

• Secondary hypertension is the result of a known cause; symptom or

side effect of another primary condition.
➢ Hypertension called the “silent killer”, because no signs indicate its
presence
 Hypertensive Blood Pressure Levels
 Normal: systolic <120 mm Hg; diastolic <80 mm Hg

 Prehypertension: focus on lifestyle modifications

➢ 120 to 139 systolic or 80 to 89 diastolic

 Stage 1 hypertension: diet therapy and drugs as needed

➢ 140 to 159 systolic or 90 to 99 diastolic for persons age 18 to 59
➢ >150 systolic or 90 to 99 diastolic for persons 60 and older

 Stage 2 hypertension: diet therapy and vigorous drug therapy

➢ >160 systolic or >100 diastolic
 Principles of Medical Nutrition Therapy for Hypertension
 Weight management: lose excess body fat and maintain healthy weight
 Physical activity: moderate to vigorous-intensity aerobic activity 3-4 times/week
for average of 40 min per time
 DASH diet (Dietary Approaches to Stop Hypertension): : lower blood pressure
through diet. On average, decrease systolic blood pressure 6 to 11 mm Hg.
 Sodium control: limit sodium to 1500 to 2400 mg/day
➢ Direct correlation between sodium intake and blood pressure (high sodium
intake leads to high blood pressure), even in patients with resistant
hypertension (less NaCl → reduce hypertension)
 Additional lifestyle factors: limit alcohol, stop smoking, increase aerobic activity,
use stress management techniques.
 Excessive alcohol drinking increases heart rate. This puts pressure on vessel
walls. 3-5 drinks a day over a long period can cause high blood pressure.
Aging directly relates to an increase in risk. Men tend to see their blood pressure go up in
their 50s. Women's blood pressure tends to increase in their 60s.
Blood pressure readings measure the force of blood pushing against blood vessel (artery) walls as
your heart pumps blood. They can change when you are dehydrated, nervous, or stressed. They can
also change when you sleep, and when you wake up. They also change when you are active. Blood
pressure goes up as you get older. It is also related to your body size.
 Education and Prevention
 Food planning and purchasing
➢ Control energy intake, Read labels
➢ Eat fresh foods/fruits/vegetables with limited processed foods
 Food preparation
➢ Use less salt and fat (saturated and trans). Salt cause fluid buildup in the body
➢ Use seasonings instead (herbs, spices, lemon, onion, garlic, etc.) can use
lemon juice to season foods
➢ Less animal products in smaller portions
 Person-centered approach
➢ Personal desires, ethnic diets, economic restrictions, and food habits
➢ A healthy adult get a first blood pressure check at age 18 then every year.
 Education Principles
 Start early
➢ Prevention begins in childhood, especially with children in high-risk families

 Focus on high-risk groups

➢ Direct education to people and families with risk of heart disease and
hypertension

 Use variety of resources

➢ National organizations, community programs, registered dietitians
Chapter 20
Diabetes Mellitus
Key Concept
• Diabetes mellitus is a metabolic disorder of glucose metabolism
with many causes and forms.

• Blood glucose monitoring is a critical practice for effective glycemic

control.

• It can lead to serious health problems. These include:

➢ Eye problems, Nerve damage, Gum disease, Heart disease,
Stroke, Kidney damage, Lower-limb amputations
 About Diabetes
• 11.7% of the Americans population have diabetes.
• Diabetes is the sixth leading cause of death from disease in the U.S.
• People with diabetes either do not produce insulin or cannot
effectively use it.
• Diabetes is characterized by hyperglycemia.

• With professional guidance and support, individuals with diabetes

can remain in a state of good health and reduce the risk of long-
term complications by consistently practicing sound diet and lifestyle
habits.
 Word Origins
• Diabetes from Greek “to pass through”
• Mellitus from Latin for “honey”
• Insulin from Latin for “island”
• Islets of Langerhans—clusters of pancreatic cells named for
discoverer
Islands (cells):
60% Beta
30% alpha
10% delta
Insulin is the major hormone that controls the level of blood glucose. It accomplishes this
through the following metabolic actions:
• Helping to transport circulating glucose into cells
• Stimulating glycogenesis
• Stimulating lipogenesis
• Inhibiting lipolysis and protein degradation
• Promoting the uptake of amino acids by skeletal muscles, thereby increasing protein
synthesis
• Permitting cells to burn glucose for constant energy as needed

Glucagon is a hormone that acts in an opposite manner to that of insulin to balance the
overall blood glucose level control. It can rapidly break down stored glycogen in the liver
through glycogenolysis in response to hypoglycemia. So protect the brain and other tissues
during sleep or fasting.

Somatostatin (also produced by the hypothalamus) inhibits the secretion of insulin,

glucagon, and other gastrointestinal hormones.
 Type 1 Diabetes Mellitus
• Accounts for 5% to 10% of cases
• Previously called insulin-dependent or juvenile-onset diabetes
• Severe, unstable form.
• For some individuals, the rate of destruction is slower, and
symptoms may not appear until adulthood.
• Caused by autoimmune destruction of pancreatic cells
• Can occur at any age.
• Patients requires exogenous insulin for survival.
 Type 2 Diabetes Mellitus
• Accounts for 90% to 95% of cases
• Previously called adult-onset or non-insulin-dependent diabetes
• Initial onset usually after age 40
• Now being diagnosed in children
• Strong genetic link (90 genetic loci identified).
• Prevalent in older, obese people
• Caused by insulin resistance or defect or not enough.
• Usually treated with diet, exercise, no need for exogenous insulin.
 Risk Factors for Type 2 Diabetes Mellitus
• Family history of diabetes
• Age 45 years or older
• Overweight
• Not physically active
• Race/ethnicity (African American, Hispanic American (Latino),
Native American, Asian American, Pacific Islander ex: Hawaii)
• History of gestational diabetes
• Woman who has delivered infant weighing more than 9 pounds
• Identified impaired glucose tolerance.
 Impaired Glucose Tolerance
• Individuals whose fasting blood glucose level is higher than normal
(>100 mg/dL) but less than the level for the clinical diagnosis of
diabetes (≥126 mg/ dL) are defined as impaired glucose tolerance
(IGT).

• Which is also known as prediabetes.2

• IGT is a strong risk factor for the future development of type 2
diabetes.

• Overweight individuals with IGT can significantly reduce their risk for
developing diabetes by increasing physical activity and by losing 5%
to 10% of body weight.
 Gestational Diabetes
• Temporary form of disease occurring in pregnancy (in 7%).
• Presents complications for mother and fetus/infant ex: death and
macrosomia (abnormally large infant).
• Must be carefully monitored & controlled. Should follow a tightly
managed program of diet & exercise and to self-test measurements
of blood glucose, blood pressure, urinary protein, or insulin therapy

• Other types/causes of diabetes:

• Drugs and toxins: Steroid medicines like prednisone can raise blood
sugar. This diabetic condition can be reversed when you no longer
take the medicine. nicotinic acid (vit B3), Vacor (rat poison), etc.
• Genetic defect of the beta cells, acute pancreatitis, gallstones, cystic
fibrosis, alcoholism, viral infection.
 Symptoms of Hyperglycemia / Diabetes
• Initial signs
▪ Increased thirst (polydipsia)
▪ Increased urination (polyuria)
▪ Increased hunger (polyphagia)
▪ Unusual weight loss (type 1)

• Other symptoms: blurred vision, dehydration, dry skin, skin

irritation or infection, Drowsiness, Nausea, and general weakness
 Symptoms of Diabetes
Laboratory Test Results
▪ Glycosuria (sugar in urine)
• Hyperglycemia (elevated blood sugar): HbA1c ≥6.5% represents
blood glucose levels over a 3-month period, Fasting plasma glucose
level of ≥126 mg/dL.
▪ Abnormal oral glucose tolerance tests
• Progressive Results
▪ Water, electrolyte imbalance
▪ Ketoacidosis (excess production of ketones)
▪ Coma
 Hypoglycemia
• Hypoglycemia (i.e., a blood glucose level of less than 70 mg/dL).
• It may occur from too much insulin or oral hypoglycemic agents that
act by stimulating the islet cells in the pancreas to secrete more
insulin.

• Hypoglycemia can also occur if a person with diabetes delays a

meal or snack, does not eat enough carbohydrate, or exercises too
much without sufficient food.
 Key Concepts
• A consistent, sound diet is the keystone of diabetes care and
control.

• Good self-care skills practiced daily enable a person with diabetes

to remain healthy and reduce risks for complications.

• A personalized care plan, balancing food intake, exercise, and

insulin regulation, is essential to successful diabetes management.
 Criteria for Diagnosis of Diabetes Mellitus
• Symptoms of diabetes plus casual (any time) plasma glucose
concentration greater than or equal to 200 mg/dl

• Fasting plasma glucose greater than or equal to 126 mg/dl

• Two-hour plasma glucose greater than or equal to 200 mg/dl during

an oral glucose tolerance test
 Management of Diabetes

• Early detection (Community screening programs by Glucose

tolerance test).
➢ Glycemic control: exogenous insulin injections Table 20.4, oral
hypoglycemic agents;), diet, exercise, and monitoring
➢ Prevention of complications
• Goals of Care
➢ Maintaining optimal nutrition
➢ Avoiding symptoms & Preventing complications as Retinopathy &
Nephropathy (damage to the small blood vessels in the retina &
kidney, respectively) & hypertension (71% of diabetic adults).
 Management of Diabetes

• Elements of therapy plan:

➢ Diet

➢ Exercise: makes your cells more sensitive to insulin. Your muscles

use more blood sugar during exercise. This lowers your blood sugar
levels. And that cuts your body’s need for insulin.

➢ Ensuring adequate insulin activity

➢ Controlling stress
 Diet Therapy
• Weight reduction (type 2)
• Sufficient energy intake
• Balance of energy intake and output
• Balance of carbohydrate, fat, protein
 Core Focus: Glycemic Control
• Nutrition therapy
▪ Total energy balance
▪ Nutrient balance
▪ Food distribution balance
• Personal diet
▪ Total kcalories of energy balance
▪ Ratio of carbohydrate, fat, protein
▪ Daily food distribution pattern
 Energy Balance
• Carbohydrate
▪ Should provide 60% of energy intake
▪ Starch and sugar—complex and simple carbohydrates
▪ Fiber
▪ Sugar substitutes—nutritive and nonnutritive
• Protein
▪ About 15% to 20% of total energy
• Fat
▪ No more than 25% to 30% of kcalories
 Food Distribution Balance
• Eat even amounts of food at regular intervals.
• Maintain even blood glucose supply.
• Snacks may be needed.
• Adjust eating according to activity level and stress.
• Regulate glycemic response according to physical
activity/exercise.
 Diet Management
• Develop plan to meet individual needs.
• Consult clinical dietician.
• Use the food exchange system.
▪ Foods grouped into “exchange lists”
▪ Foods selected to meet energy needs, balance ratio of nutrients
• Limit processed foods.
• Limit alcohol; plan carefully.
• Avoid hypoglycemia.
 Person-Centered Self-Care
• Persons with diabetes need essential skills/knowledge.
▪ Understand nature of diabetes
▪ Nutrition—develop sound food plan
▪ Insulin—know type, duration of action, combinations
▪ Monitor glucose levels
▪ Control emergencies, illness
▪ Identification bracelet
 Chapter 21
Kidney Disease/stones
 Key Concepts

• Kidney disease interferes with the normal

capacity of nephrons to filter waste products of
body metabolism.

• Short-term kidney disease requires basic

nutrition support for healing rather than dietary
restriction.
 Kidney Disease

• 3.8 million Americans have some form of kidney

disease.
• More than 114,000 Americans are diagnosed with
endstage renal disease (ESRD) annually

• 42,000 persons die annually from such diseases.

 Dual Role of the Kidneys

• Kidneys make urine, through which they excrete most of the waste
products of metabolism.

• Kidneys control the concentrations of most constituents of body

fluids, especially blood.
• Kidneys filters ~120 mL fluids/minute. Next slide.
• Kidneys has endocrine functions:
➢ Produce renin hormone that activate aldosterone mechanism to
reabsorb Na & maintain water balance.
➢ Produce erythropoietin hormone that stimulate RBC production.
➢ Convert an intermediate inactive form of vitamin D into the active
vitamin D hormone in the tubules.
 Basic Structure and Function

• Structures
– Basic unit is the nephron
– 1 million nephron/kidney.
– Nephron: composed of glomerulus (initial filer)
& tubules (reabsorb nutrients to the blood,
controlled by aldosterone).
– CKD is defined as a GFR of <60 mL/min
• Major nephron functions
– Filtration of materials in blood
– Reabsorption of needed substances
– Secretion of hydrogen ions to maintain acid-base balance
– Excretion of waste materials
 Causes of Kidney Disease

• Infection and obstruction: bacterial urinary tract infection and

obstruction by kidney stones cause damage to kidney tissues.
• Damage from other diseases: diabetes & hypertension.
• Toxins: chemical pesticides, animal venom, heavy metals, some
drugs as NSAID, radiographic contrast dye, etc.
• Genetic defect: Cystic diseases & Congenital kidney abnormalities.
• Risk factors: Clinical and Sociodemographic factors. Next slide
Risk Factors and Causes of Kidney
Disease

• Sociodemographic factors
– Older age: >60 years
– Racial or ethnic minority status
– Exposure to certain chemical and environmental
conditions as smoking and alcohol.
– Low income or education
Risk Factors and Causes of Kidney
Disease, cont’d

• Clinical factors
– Poor glycemic control in diabetes
– Hypertension
– Autoimmune disease
– Systemic infections
– Urinary tract infections
– Urinary stones
– Obesity
 Acute Renal Failure

• Sudden due to a reason (injury, dehydration),

might be reversible.
• Clinical symptoms: Oliguria (less urination),
proteinurea, hematuria, loss of appetite,
nausea/vomiting, fatigue, edema, itchy skin
• Short-term dialysis may be needed
• May progress to chronic renal failure
 Medical Nutrition Therapy MNT

• Acute kidney failure (AKI)

– Goal is to improve or maintain nutritional status
– Parenteral nutrition therapy may be required
– Recommendations for protein intake have been debated
– Individualized therapy based on renal function (indicated by
glomerular filtration rate)
– Treating the underlying cause & preventing further kidney
damage from nutrient deficiencies.
– Correcting any fluid, electrolyte abnormalities.
 Medical Nutrition Therapy MNT for AKI

• Protein: 0.8 to 1.0 g/kg/day, dialysis: 1.2 to 1.5 g/kg, use high biologic
value sources as soy protein, grilled chicken.
• Energy intake: 25 to 35 kcal/kg
• Sodium & potassium: depend on the phase, hypertension, but should
replace diuretic losses (Na 1-2 g/day; K: 2 - 3 g/day each).
• Phosphate: Phosphorus: limit as needed : 8 to 15 mg of phosphorus per
kg of body weight.
• Maintain serum value levels of Ca within normal limits 1 - 1.5g/day.
• Vitamins and minerals: DRI.
• Fluid: in response to urine output (30ml / kg). Urine output + 500ml
 Chronic Kidney Failure

• Caused by progressive breakdown of renal tissue, which

impairs all renal functions
• Develops slowly
• No cure (other than kidney transplant)
• Clinical symptoms: Polyuria/oliguria/anuria, electrolyte
imbalances, nitrogen retention, anemia, hypertension,
azotemia, weakness, shortness of breath, fatigue, thirst,
appetite loss, bleeding, muscular twitching
Medical Nutrition Therapy Objectives

• Reduce protein breakdown

• Avoid dehydration or excess hydration
• Correct acidosis
• Correct electrolyte imbalances
• Control fluid and electrolyte losses
• Maintain optimal nutritional status
• Maintain appetite and morale
• Control complications of hypertension, bone pain, nervous system
involvement
• Slow rate of renal failure
 Medical Nutrition Therapy Principles

• Provide enough protein therapy to maintain tissue integrity while

avoiding excess (0.6 to 0.8 g/kg/day)
• Reserve protein for tissue synthesis by ensuring adequate
carbohydrates and fats.
• Energy: 23 to 35 kcal/kg/day, Fat: <30%.
• Maintain adequate urine volume with water
• (Possibly) restrict Na 1-2 g/day), K: 40mg/Kg, phosphate 800 to 1000
mg/day, also restrict Ca to 2 g/day.
• Supplement diet with multivitamin: DRI for B complex and vit C.
• Fluid: sufficient to produce adequate urine (in none dialysis patients).
1L + daily urine output.
 Kidney Stones

• Basic cause is unknown

• Factors relating to urine (pH, concentration) or urinary
tract environment contribute to formation.
• Present in 7% of U.S. women and 10.6% of U.S. men
• Major stones are formed from one of three substances:
– Calcium
– Struvite (magnesium ammonium phosphate)
– Uric acid
Kidney Stones, cont’d
Risk Factors
 Calcium Stones

• 80% of kidney stones are composed of calcium oxalate or Ca-P.

• Almost half result from genetic predisposition
• Other causes
– Excess calcium in blood (hypercalcemia) or urine (hypercalciuria)
– Excess oxalate in urine (hyperoxaluria) uric acid in the urine
(hyperuricosuria)
– Low levels of citrate in urine (hypocitraturia)
– Infection
– Long-term high vit C (2000 mg/day) may cause kidney stones.
• Dietary calcium binds oxalates in the intestines, preventing
absorption and thus concentration of oxalates in the urine.
 Struvite Stones

• Composed of magnesium ammonium phosphate

• approximately 10% of all stones.
• Mainly caused by urinary tract infections rather than
specific nutrient
• No diet therapy is involved
• Usually removed surgically
 Uric Acid Stones

• Approximately 9% of kidney stones.

• Risk factors for uric acid stone:
➢formation are overly acidic urine (as in obesity,
type 2 diabetes, diarrhea).
➢excess urinary excretion of uric acid (gout)
➢and low urine volume
 Other Stones

• Cystine stones
– Caused by genetic in the renal reabsorption of the
amino acid cystine and methionine.
– Occur rarely
 Kidney Stones: Symptoms and
Treatment

• Clinical symptoms: Severe pain, other urinary symptoms,

general weakness, fever
• Several considerations for treatment
– Fluid intake to prevent accumulation of materials
– Dietary control of stone constituents
– Achievement of desired pH of urine with medication
– Use of binding agents to prevent absorption of stone elements
– Drug therapy in combination with diet therapy
 Nutrition Therapy:
Calcium Stones

• For calcium oxalate stone avoid oxalate rich-food.

• If stone is calcium phosphate, sources of phosphorus (e.g., meats,
legumes, nuts) are controlled
• Low-calcium diet (~400 mg/day) recommended for those with
supersaturation of calcium in the urine and who are not at risk for bone
loss
• Fluid intake increased
• Sodium intake decreased
• Fiber foods as wheat, bran which high in phytates increased to bind Ca in
the intestines & prevent their absorption so no stone formation
 Nutrition Therapy:
Uric Acid Stones
• Alkaline diets low in purines alter urine PH so lower uric acid
concentration. Alkaline urine favors the excretion of uric acid.
• Potassium citrate treatments may also be used to raise the urinary pH

• Low-purine diet is recommended:

• Avoid sources of purine as meats, Alcohol, sardines, Legumes,
mushrooms, spinach, asparagus, cauliflower, Poultry, etc.

• Maintain a healthy weight and alkalization of the urine through a

vegetarian-type diet with limited animal protein
 Medical Nutrition Therapy:
Cystine Stones

• Decreasing intake of animal foods high in cystine & methionine.

• Reducing sodium intake;
• Increasing the intake of vegetables high in organic anions
(Malate and citrate in apples, cherries, plums, etc).
• Diluting the urine, dringk 4 L water/day.

• In children, a regular diet to support growth is recommended

• Medical drug therapy is used to control infection or produce

more alkaline urine