From the Director’s Chair 
Diabetic and Renal Diet: Never the Two Shall Meet?
Prescription for Health: Medications to Control Diabetes
Activity and Diabetes: Exercise Can Help You Manage Your Diabetes
Laughter Brings Sunshine into the Home
Other News
Eat Right With Phil

From the Director’s Chair: Diabetes – What You Can Do to Prevent Complications as a Dialysis Patient

Paul Kellerman, MD

In a previous issue, I wrote about diabetes and vascular health, stressing the importance of controlling blood sugars to prevent atherosclerosis (hardening of the arteries), since diabetics are at higher risk for atherosclerosis. I not only described how high blood sugars contribute to atherosclerosis of your large blood vessels, but also of your tiny blood vessels, resulting in nerve damage and skin ulcers.

Approximately half of our dialysis patients are diabetic, and the kidney failure was a direct result of the diabetes. As a diabetic, particularly one with kidney failure, you have two enemies – atherosclerosis, and infection. Because of lack of sugar control, you will have acceleration of atherosclerosis as described in a previous issue of Pathways, which can lead to strokes, heart attacks, and poor circulation to the legs. But because of both diabetes and the kidney failure, you are doubly predisposed to infections. When there is poor blood flow to a part of the body  that makes infection even more likely, and makes it much harder to heal infections.

So how can you live well as a diabetic on dialysis?  Here is a list of things you can do to slow hardening of the arteries and prevent infections.

• Control your blood sugars with your primary physician. You should be measuring your blood sugars frequently (typically 4 times per day – before meals and bedtime). The hemoglobin A1C, a test that averages your sugars over 3 months, should be less than 7%.
• Control your blood pressure – this takes working with your kidney doctor, as blood pressure may be controlled with dialysis or with medications.
• Control your lipids (cholesterol and other blood fats) – we measure this yearly and you should ask your nephrologist or primary doctor if you need treatment. This is treated with medications, such as “statins”.
• If you have neuropathy (numbness, tingling in limbs), be careful not to bruise yourself which can lead to a foot ulcer.

Inspect your feet daily for ulcers, or if your vision is poor, have a family member inspect your feet. If abnormal, report this immediately to your doctor.

• If you have a catheter, if possible, have a fistula placed and get the catheter out as soon as possible.  Talk to your kidney doctor.
• Get your yearly flu shots, and all other scheduled immunizations.
• If you notice cramping of your calves with walking, report this immediately to your doctor, as this may be a sign of poor circulation.

Although many things are not able to be controlled by you, such as the kidney failure, you still have great control over your diabetes, by how well you monitor yourself, what you eat, and making sure you take your medications appropriately. You also are your own best advocate, so work with your primary physician and nephrologists to slow hardening of the arteries and prevent infection.

Diabetic and Renal Diet: Never the Two Shall Meet?

Fran Kittell, RD

Trying to combine the diabetic diet with the renal diet? Impossible? WELL! If it’s any consolation, you’re NOT ALONE! The number one cause of kidney disease is diabetes. So there’s a good chance the person sitting next to you is also attempting the same.

It can be very daunting attempting to combine the two diets. The worst-case scenario would be giving up and just not eating at all. There is a lot of research that says if you quit eating this can ultimately affect your overall outcome on dialysis. Maintaining nutritional health, while on dialysis and whether you have diabetes or not, could keep you out of the hospital. Becoming nutritionally sick affects your immune system. You would not be able to fight bugs as well if you were nutritionally unwell, ultimately fighting infections.

If there were one key to answering all of this, it really would be moderation. This sounds trite, but it’s really true. And if you don’t know what that means, going mod, and then ask your dietitian! Use that resource! Not everyone has such a resource so readily available!

In the box are two meals. One is a meal for the person with diabetes on dialysis. The other meal is for the person with diabetes. *NOTICE ANY DIFFERENCE?

The diabetic diet should not vary greatly than the renal diet. Granted the person with diabetes should not be eating hard candy, cake and sweetened sodas/syrups, but ideally these foods are not high in the list of recommended foods for the person without diabetes for the simple reason these foods are not rich in nutritional value. In excess they are not good for anyone.

Of course for you with diabetes you would have less room for error, thus the blood sugar check. Something else to keep in mind for those of you needing to watch your blood glucose, insulin should be adjusted around your usual carbohydrate intake as much as possible rather than carbohydrates adjusted to meet insulin regimens. Think about this. This enables you to have greater margin for error. Plus it may be of some benefit to eat anyone of the above mentioned foods in combination with a meal with other foods to help slow down the absorption of the sugar.

But would you think a dietitian would be recommending regular soda to one without diabetes? NO! Regular soda has little to no nutritional value. It only adds empty calories. This would not be suggested for you whether you are fighting diabetes or not. And instead of canned fruit what about an apple for each along with some fruit juice and/or ½ cup skim milk or even water? Either of these foods could be recommended with a person who does/does not have diabetes.

The key is sugars and sucrose-containing foods may be included as part of the total carbohydrate in the meal plan. For best blood sugar results, sugars should be distributed throughout the day and mixed with other foods, mixed fuel, like protein and fats such as meat, milk and cheese. Food intake should be consistent.

It can be hard to sit back to look at the picture as a whole, getting entangled with the details. Keep checking your blood sugars ideally up to four times daily. If not doing this, at least once a day is better than nothing. If you think you can “feel” your sugars without checking them; THINK AGAIN. So many variables affect blood sugars, such as exercise, fitness, stress, illness, kidney disease. How your body deals with the fuel ultimately affects your blood sugars from day to day. And sugar unawareness can creep up on you without you knowing it. How you deal with the above meal can vary from day to day.

As one person WITH DIABETES on the unit has said, “You just have to do it”. “Do what you can do”. It is NOT a “can’t do situation”, but LIMIT. “A little is a lot”. Hmmm, back to that idea of moderation. Heard that before?

Whenever in doubt, again use your resources and ask your dietitian for help. These two diets, diabetic and renal, DO meet more often than not. Statistics indicate these two diets will keep meeting. Plus statistics indicate you are not alone. You are not the only one trying to keep blood sugars, and those pesky electrolytes, such as potassium, phosphorus and sodium, in line. This will not be achieved overnight. If you feel you have “gone wrong”, or have not used moderation, or not exercised one day, start with a clean slate the next day. There is always another day.

Prescription for Health: Medications to Control Diabetes

Kim Holdener, Pharm.D.

There are two types of diabetes. Type 1 diabetes (formerly known as insulin dependent or juvenile diabetes) is due to a dysfunction of the cells in the pancreas that produce insulin. People with Type 1 diabetes do not make enough insulin and need to take insulin injections. Type 2 diabetes (formerly known as insulin independent or adult onset diabetes) is due to a lack of sensitivity to insulin and impaired production of insulin. People with Type 2 diabetes may treat their diabetes by their diet, oral medications, insulin or a combination of these things.

Diabetes is very common in people on dialysis because it is the most common cause of kidney disease. Control of blood sugar (also called blood glucose)  can be affected by kidney disease because insulin is partly removed from the body by the kidneys. When a person’s kidney dysfunction becomes advanced, it is not uncommon for insulin needs to decrease. This is because insulin hangs around in the body longer. Sometimes people with diabetes who have previously needed insulin therapy no longer require insulin after starting dialysis or, more commonly, still need insulin but at smaller doses.

There are many different medications used to treat diabetes. A few of the more commonly used medications will be discussed in this article. The most frequently prescribed oral medications used for Type 2 diabetes are in a class of drugs that work by increasing insulin secretion from the pancreas. The drugs in this class that are most commonly used are:

• Glyburide (DiaBeta, Micronase)
• Glipizide (Gluctorol, Glucotrol XL)
• Glimepiride (Amaryl)

These medications can be taken with or without food, but are more effective when taken 30 minutes prior to a meal. Glipizide and glimepiride are better for use in patients with kidney disease because glyburide can accumulate in the body when the kidneys do not work well.

Metformin (Glucophage) is another commonly used medication for Type 2 diabetes. This medication can not be used in patients with kidney dysfunction because it can accumulate and cause a rare but very serious problem called lactic acidosis. Lactic acidosis can be fatal, therefore, no one with kidney disease should be taking metformin.

The third most common class of oral diabetes medications is a class that improves insulin sensitivity in the body. They help the body to respond more effectively to the insulin that is already there. This class of drugs includes:

• Pioglitazone (Actos)
• Rosiglitazone (Avandia)

It may take several weeks to see the full effect of these medications. One side effect of these medications that may be bothersome in people with kidney disease is fluid retention that can cause swelling. This may be more of a problem in people who have kidney disease but are not yet on dialysis.

Insulin is used by all people with Type 1 diabetes and many people with Type 2 diabetes. There are several different types of insulin. Some are short-acting and are intended for use with meals to lower the peaks in blood sugar levels that occur when eating.

These insulins are:

• Regular insulin (Humulin R, Novolin R)
• Insulin lispro (Humalog)
• Insulin aspart (Novolog)

Insulin lispro and aspart act quicker than regular insulin. There are also several insulins that have a longer duration of activity. The longer acting insulins are used to control blood sugar levels throughout the day. Some of these insulins are:

• Insulin isophane or NPH (Humulin N, Novolin N)
• Insulin glargine (Lantus)
• Insulin detemir (Levemir)

With all of these choices of medications to treat diabetes, plus many

others not discussed in this article, it can be confusing to know which medication is the right one for you. It is important to discuss your diabetes care with your doctor to decide the right treatment regimen for you. It is important to have a doctor who specifically sees you to manage your diabetes or to have a primary care doctor who is able to do so. Meeting with a dietician, pharmacist and/or diabetes nurse educator can also be very helpful.

Activity and Diabetes: Exercise Can Help You Manage Your Diabetes

Physical fitness is an important, but often overlooked part of diabetes management. But what do you think of when you hear the word “fitness”? Do you visualize strenuous exercise routines, sports teams, going to the gym and maybe using weights or equipment?  

Those all help make people fit, and art activities many people enjoy. But a healthy exercise routine can be much simpler. Exercise is really any kind of physical activity that gets you up and moving. That includes taking a walk, using the stairs, even doing work around the house, yard or garden. Ideally, you should have 30 minutes of activity every day.

Physical activity can help you manage your diabetes because it burns your blood glucose for energy and helps your body better use insulin. And, activity has many other benefits. It can help keep your blood pressure and “bad” cholesterol down and your “good” cholesterol up. In fact, being active is crucial if you wan to reduce your risk for heart disease and stroke. It’s also an essential part of losing weight, or staying at a current, healthy weight. Exercise can keep your muscles and bones strong, give you better flexibility and even help you stay in a brighter mood!

Perhaps the hardest thing about exercise is finding the time. But those 30 minutes can be divided into three 10-minute chunks for the same good effect! Look for ways to get up and moving, even for 10 minutes at a time.

To learn more about what this article has to say about diabetes and the importance of exercise go to the OneTouchgold site.

Laughter Brings Sunshine into the Home

Penny Andrews, Chaplain

When we have an illness that challenges us, we have days that we just don't feel good.

So what do you do when you don't feel like laughing? Well, know that it’s okay! You don’t have to be happy all the time, but it’s not healthy to linger in sadness either. If your mood is low, take notice and ask yourself “why am I feeling this way and what can I do for myself to feel better?” Acknowledging our feelings helps us to understand ourselves and our needs better. This deeper understanding helps us to lead more fulfilling lives.

We all have days that 'test' us. If you have a chronic illness this can test you, and this in turn, affects your relationships with your loved ones and interferes with coping well. However, a good way to “pass the test” is to find your own answers.

I was speaking to a kidney patient not long ago, who knew she was in a slump, and she didn't want to stay there. So we explored what might help her out of it. She loved to write, so we talked about journaling a little every morning with some of her favorite music playing.

Research is showing that writing about your feelings is good for you. Often, you end your journaling in a different frame of mind, than you started with.

We also talked about having a DVD of her favorite comedy. For her, It was Everybody Loves Raymond, she thought she might get a DVD of a season of that show to turn on when she  needed a little change of perspective. Having that break-through laugh after a down time is like jumping into a pool on a hot summer's day. And then she talked about the people in her life who lift her spirits. She said she could always get in touch with them.

When you think about it, life really does have many things that deserve a good laugh. We don’t need to get hooked into feeling badly. Feelings are fleeting and with good strategies, we can lighten our mood.

Write your own “Lighten up List”, and have it on hand when you need it. lf you have access to a computer and you’d like to read more about ways to use humor as a stress buster and to bring sunshine into your home, go to www.LaughWays.com.

Wishing you many laughter-filled moments this season!

Other News

Nurses Week is May 6-12. We recognize and thank those who have devoted their careers to the caring of others: Sharon, Theresa, Cheryl, Karl, Maria, Carla, Kelly, Jackie, Dean, Kathy, Jean, Ramona, Lila, Kathleen, Carol, Jan S., Chris, Xinliu, Michelle, Karen, Dawn, Jan V. and Linda and Deb.

Administrative Assistants Day is April 23rd. Where would we all be without Tricia, Kris, Terri, Mary and Jacqui?  LOST that’s for sure!!

Other News! Congratulations to Robert Lueck, WDI Patient and 2008 winner of the patient survey drawing. Thanks to all patients who participated.

Special Thanks! To WDI patients, Phil for his recipe and Randy for proofing this edition of Pathways

Watch Out! WCRD Recipients: you will be receiving your packet to renew the program in the mail soon. If you need assistance, ask your social worker.

More Class Offerings:  Additional classes on “Living Well with Chronic Illness” will be offered throughout the spring. Ask your social worker if interested in learning more about it.

Eat Right With Phil: Phil’s Peppered Pork Loin

• 1-3 pound Pork Loin
• 1 of each Bell Pepper (Yellow, Orange, Red, Green)
• 4 cloves of Garlic, peeled and crushed
• 1 Medium Vidalia OnionBlack pepper              
• ¼ cup Olive Oil
• ½ cup Red Wine
• Sesame Oil
• Rosemary

Set oven at 270 degrees F. Remove veins and seeds from peppers, chop into quarters and place in a food processor with garlic, onion, black pepper and olive oil. Process the ingredients to medium-fine texture.

To prepare pork loin, cut 1 inch pockets along both sides and stuff peppers into slots, RESERVING ¾ CUP OF THE PEPPER MIXTURE. Sear pork loin in fry pan with sesame oil, then coat top with REMAINING pepper mixture top and add rosemary. Place pork loin in a roasting pan. Add red wine to the frying pan to deglaze and pour these juices over the pork loin. Roast in the oven for 4 hours. Enjoy!