1. New Nutritional Diet Approach for CKD Patients
Thai Dietetic Association 2560
New Nutritional Diet Approach for CKD Patients
I would like to talk about a new dietary cure for patients with chronic kidney disease, or CKD.
Kayoko Adachi
REJ Clinical Nutrition Association

2. Comparison of BMI between Thai and Japanese People
I. Comparison of BMI between Thai and Japanese males and females (*)
Sex
Lean
Medium build
Moderately obese
Obese
(<18.5)
( )
( )
30 or more
Thai M
9.8
58.2
24.8
7.2
Jap. M
6.0
66.2
23.9
4.0
Thai F
12.7
69.7
14.0
3.6
Jap. F
10.7
68.7
16.9
*Thai National Health Examination Survey 2014
*The 2014 National Health and Nutrition Survey
II. Comparison of BMI between Thai and Japanese males and females by age group
　◆ Thai males 　　　　　　　　　　　　　　　　　　　　　 <Unit: %> 　　◆Thai females　　　　　　　　　　　　　　　　<Unit: %> 　　　　　　　　　　　　　　　
Age (yrs.)
Lean
Medium build
Moderately obese
Obese
(<18.5)
( )
( )
30 or more
15-29
17.8
56.4
16.6
9.2
30-44
4.2
56.3
28.3
11.3
45-59
5.7
56.5
29.8
8.0
60-69
9.4
59.7
25.7
5.3
70-79
14.0
61.9
21.2
2.9
80 or older
23.9
64.8
10.1
1.2
Age (yrs.)
Lean
Medium build
Moderately obese
Obese
(<18.5)
( )
( )
30 or more
15-29
19.3
77.1
2.9
0.7
30-44
15.6
68.6
11.0
4.8
45-59
10.9
72.1
13.0
4.0
60-69
9.1
66.9
20.5
3.5
70-79
8.9
66.4
21.0
3.7
80 or older
23.6
54.8
17.7
3.9
Here is a comparison of BMI by gender between Thai and Japanese people.
As shown in I at the top, the rate of obesity with a BMI of 30 or over is as high as 7% of Thai males, and the rate of intermediate obesity (BMI of 25 or over but less than 30) is slightly higher compared with Japanese males. The rate of intermediate obesity is slightly lower in Thai females than in Japanese females: there are more lean women in Thailand.
Looking by generation, the rate of BMI of 25 or over already starts to increase at the age of 15 in Thailand, as shown in the middle. The rate increases further in males aged from 30 to 59, which is the prime of life: about 40% of them are classified as obese. This provides a warning, because the risk of diabetes rises as BMI increases. On the other hand, notably, there are more lean (BMI of less than 18.5) people in males aged 70 and older in Thailand. About 24% of the population aged 80 and older is lean in both males and females. This means that they are suffering from malnutrition. Being underweight can lead to immunological deterioration, reduced muscle mass, and cognitive function decline, and can even result in increased mortality. In Japan, the Ministry of Health, Labour and Welfare recommends that people aged 70 and older should be slightly plump, with a BMI from 22.5 to 24.9, to prolong healthy life expectancy.
It is necessary to advise elderly people to prevent weight loss.
◆ Japanese males 　　　　　　 　　　　　　　　　　 <<Unit: %> ◆ Japanese females <Unit: %> ％＞　　　　　　　　　　　　　　　
Age (yrs.)
Lean
Medium build
Moderately obese
Obese
(<18.5)
( )
( )
30 or more
15-29
18.6
65.5
11.7
4.2
30-44
5.0
67.8
21.7
5.6
45-59
2.8
66.2
24.7
6.2
60-69
3.1
62.6
28.5
5.9
70-79
3.9
64.9
28.2
3.0
80 or older
69.3
23.3
2.4
9.5
68.1
22.0
0.4
Age (yrs.)
Lean
Medium build
Moderately obese
Obese
(<18.5)
( )
( )
30 or more
15-29
18.1
74.1
5.4
2.4
30-44
15.6
68.6
11.0
4.8
45-59
10.9
72.1
13.0
4.0
60-69
7.6
68.7
20.2
3.5
70-79
9.1
66.9
20.5
80 or older
8.3
67.9
20.0
3.7
10.0
63.3
23.0

3. Number of Patients with Diabetes and Hypertension in Thailand
There are over 3,000,000 people with diabetes and over 10,000,000 people with hypertension in Thailand. Of them, 9,000,000 people are unaware that they have these diseases. The number of sufferers has risen fourfold in the last 15 years. The Ministry of Public Health intends to take immediate action (Thai Health Society Meeting on September 15, 2006).
The rate of diabetic patients accounts for 8% of the adult population, or more than 4,000,000 people (International Diabetes Federation (IDF), 2015).
According to a report published by the Thai Health Society in 2006, nationwide medical check-ups detected over 3,000,000 diabetic patients and over 10,000,000 hypertensive people in Thailand. At a meeting of the society, it was revealed that as many as 9,000,000 people, accounting for about 60%, were unaware that they have these diseases. The number of patients has risen fourfold in the last 15 years. The Ministry of Public Health intends to take immediate action.
The rate of diabetic patients accounted for 8% of the adult population in This may be associated with high BMI.

4. 29.6 kg per year, 80 g per day (Thai Ministry of Public Health, 2013)
International Comparison of Annual Sugar Consumption per Head
29.6 kg per year, 80 g per day (Thai Ministry of Public Health, 2013)
This figure shows an international comparison of the annual sugar consumption per head. The International Sugar Organization (ISO) announced that the sugar consumption was 42 kg in Thailand (in 2013?). The sugar intake has increased since 1956, reaching 29.6 kg per year and 80 g per day in Thai people consume about three times more sugar than the global average. In Japan, the annual sugar intake has gradually decreased, and people have started to avoid consuming a lot of sugar. The annual intake is 17.3 kg, and daily consumption is 47 g. This may be because Japanese people are focusing on preventing diabetes and obesity.
Notes:
1: Calendar-year-based figures after conversion into amount of unrefined sugar
2: Including sugar used for industrial use and others
ISO: International Sugar Organization

5. 2015 Diabetes Death Rate Ranking by Prefecture (per 100,000 people)
The dietetic association of each prefecture should take action.
Japan is divided into municipalities called prefectures. The rates of lifestyle-related diseases such as diabetes and mortality by prefecture are published every day. The dietetic associations in each prefecture cannot ignore these figures.
In 2013, Kagawa, Tokushima and Okinawa were the three worst prefectures. Okinawa raised its ranking to No. 16 among 47 prefectures in This may be a result of the efforts of dieticians and administrations in this prefecture.

6. 2025 Issues Regarding Medical Expenses
The annual medical expenses for the latter-stage elderly are about 920,000 yen, which is three times more than the average.
In 2025, the entire baby-boomer generation (born from 1947 to 1949), Japan’s largest demographic group, will become latter-stage elderly, or 75 years old and over.
How we should handle the issues from the viewpoint of a sustainable universal healthcare system?
Medical expenses and nursing costs will rise sharply.
Japan is currently facing a serious issue: whether the country can continue operating its healthcare system as universal care after 2025.
There is concern about the sustainability of the universal healthcare system. In 2025, the entire baby boomer generation (born from 1947 to 1949), Japan’s largest demographic group, will be 75 years old or over, that is, the latter-stage elderly. This means that they will have multiple diseases and may require nursing care. This is the 2025 issue that Japan needs to solve.
Annual medical expenses are approximately 920,000 yen per person in the latter-stage elderly population: about three times more than the national average (about 300,000 yen). The amount of medical benefits in social security is expected to increase to as much as 70 trillion yen in 2025, while nursing care costs will also go up radically.
Outpatient-based hemodialysis costs about 4,800,000 yen per patient, and continuous ambulatory peritoneal dialysis (CAPD) costs 3,600,000 to 6,000,000 yen per patient. These costs are higher than the average annual income of private citizens of 3,600,000 yen: dialysis is expensive. Dialysis treatment is one of the factors that endanger the universal healthcare system, while the public subsidization scheme helps patients financially.
Diabetes and kidney diseases stemming from diabetes are lifestyle-related diseases. The progress of such conditions can be delayed by improving the diet and/or lifestyle. Accordingly, as national registered dietitians, we can play a major role in this area.
Dialysis costs about 4,800,000 yen for outpatient-based hemodialysis and about 3,600,000 to 6,000,000 yen for continuous ambulatory peritoneal dialysis (CAPD) per patient per year (average annual income of private citizens: 3,600,000 yen).
Improve daily diet and lifestyle to extend healthy life expectancy and reduce medical expenses.

7. Number of Patients with End-stage Renal Failure Worldwide (Dialysis)
◆ The number patients with end-stage kidney disease (ESKD*1) requiring dialysis and/or transplantation has continued to increase notably worldwide (increased about five times in the 20 years from 1990 to 2010: 2,100,000).
　　　　　　　　　 ESKD*１：End-Stage Kidney Disease
(Tens of thousands)
World
Number of patients on maintenance dialysis/logarithmic scale
U.S.A.
This shows the number of patients with end-stage renal failure and those under dialysis around the world. Unfortunately, the number of patients with end-stage renal failure under dialysis or requiring transplantation was 2,100,000, increasing fivefold in the 20 years from 1990 to There has been a remarkable increase globally.
This may be interpreted as more countries having become able to provide dialysis with national insurance, or that medical check-ups have helped earlier detection. However, it is necessary to take measures in Japan as well, because the increase in the number of patients can boost medical expenses. I believe that the early start of a dietary cure will save people and countries.
Japan
*: Predicted value
(Year)
Fig.1: Number of patients with ESKD worldwide
Cited from Lysaght MJ. J Am Soc Nephrol 2002: 13:S37-S40 with modification. Cited from An overview of dialysis treatment in Japan (as of Dec. 31, 2010) edited by the Japanese Society for Dialysis Therapy.

8. What is CKD?
◆CKD has drawn attention as a precursor of end-stage kidney disease (ESKD).
◆Definition of CKD
　・Findings showing renal diseases such as urine protein*1
　　　　　　or
　・Three continuous months or more of decreased renal function [glomerular filtration rate (GFR*2): less than 60 ml/min/1.73 m2]
*1: Abnormalities in urine, renal disorder confirmed by imaging/blood test/pathological test, in particular, urine protein is important
*2: GFR: Glomerular Filtration Rate
As you may know, chronic kidney disease (CKD) is defined as a condition of continued findings of renal diseases such as the presence of urine protein*1 or renal hypofunction [glomerular filtration rate (GFR*2) of less than 60ml/min/1.73m2] for at least three months.
If a patient gradually commences a dietary cure at this stage, it may be easier and a patient may become accustomed to it more easily than by making a sudden start.

9. CKD Staging and Number of Patients in Japan
◆The number of adult patients with CKD in Japan is 13,300,000 (12.7%).
◆The number of patients requiring a protein intake restriction diet is 10,980,000 (10.4%) in the patients from CKD Stages 3 to 5.*
Number of patients with CKD (%) (20 years and over) and dietary cure standards in Japan
GFR
(mL/min/1.73m2)
Urine protein
－ to ±
1+ or higher
Estimated number of patients
Dietary cure standard G1
≧90
28,030,000
610,000 (0.6%)
In the case of hypertension/plethora
◆Limitation of salt intake: 3 g or more but less than 6 g G2
60-89
61,870,000
1,710,000 (1.7%)
G3a
45-59
8,860,000 (8.6%)
580,000 (0.6%)
9,440,000 (9.2%)
◆Protein intake restriction:
　 g/kg
G3b
30-44
1,060,000 (1.0%)
240,000 (0.2%)
1,300,000 (1.2%) G4
15-29
100,000 (0.1%)
90,000 (0.1%)
190,000 (0.2%) G5
<15
10,000 (0.01%)
40,000 (0.03%)
50,000 (0.04%)
This shows the number of patients by CKD stages and the standards for a dietary cure.
According to a survey by the Ministry of Health, Labour and Welfare in 2011, CKD patients account for 12.7% of the total adult population, and the rate of CKD patients requiring protein restriction is as high as 10.4% of the total adult population.
Patients should commence a protein restriction diet at Stage G3 CKD and higher. For Stage G3b or higher, potassium intake should be restricted if hyperkalemia is present.
: CKD patients
(The 2011 MHLW study group concerning early detection, prophylaxis, treatment standardization, and development prevention of CKD)

10. Number of Patients with CKD in Thailand
◆The rate of patients with Stages 3 to 5 CKD is 8.45% of the adult population aged 15 and over (approx. 4,800,000). (Total population: 68,800,000; population aged 15 and over: 82.4%; source: CIA - The World Factbook)
The research paper says that patients with at least Stage 3 CKD accounted for 8.45% of the total adult population in Thailand in I therefore infer that there were at least 5,000,000 patients nationwide.
In 2016, the Thai Health Promotion Foundation reported that the number of CKD patients was 8,000,000. This means that it increased by 3,000,000 in twelve years.
The number of patients with Stage 5 CKD is 200,000.

11. Leading Primary Disease Introducing Dialysis - 1
◆Dialysis is introduced most frequently in diabetic nephropathy (43.7%) as a primary disease, followed by chronic glomerulonephritis and then nephrosclerosis.
Diabetic nephropathy
Chronic glomerulonephritis
Nephrosclerosis
Polycystic kidney
Chronic pyelonephritis
Rapidly progressive glomerulonephritis
SLE nephritis
Unknown
Diabetic nephropathy
Chronic glomerulonephritis
In Japan, the most common primary disease resulting in dialysis is diabetic nephropathy, which accounts for about 44%. This disease is the principal primary disease leading to dialysis in the U.S.A., Canada, and many countries in Europe and Oceania as well, while the rate is rising every year in Japan.
There are three problems with nephropathy caused by hyperglycemia. First, there are some cases with declined GFR while albuminuria is not present, although it has been regarded as a marker for early diagnosis. Second, a large amount of albuminuria (nephrotic syndrome) can be caused even with normal eGFR. Third, the prognosis is poor for the kidneys, cardiovascular organs and life if albuminuria is present. As a result, patients should always receive an accurate diagnosis and appropriate guidance regarding diet and nutrition from specialists.
Year
Changes in rates of patients on dialysis by leading primary diseases (the Statistical Survey Committee, the Japanese Society for Dialysis Therapy, 2015)

12. Leading Primary Disease Introducing Dialysis - 2
◆ As a cause of dialysis, diabetes affects an increasing number of people around the world. The diabetic population worldwide was 410,000,000 in It is expected to increase to 640,000,000 by 2040 (Asia-Pacific region: 210,000,000).
Source: Diabetes Atlas 7th Edition 2015
Europe
59,800,000 ▼
71,100,000
North America and Latin America
44,300,000
60,500,000
Middle East and North Africa 35,400,000
72,100,000
Africa
14,200,000
34,200,000
Southeast Asia
78,300,000
140,200,000
South and Central America
29,600,000
48,800,000
Asia-Pacific region
153,200,000
214,800,000
World diabetic population
2015: 415,000,000
2040: 642,000,000 or more
The number of diabetic patients is rising as the chief cause of dialysis. The number of diabetic patients was 415,000,000 in 2015: one in eleven adults. The number is expected to rise to 642,000,000 by The Asia-Pacific Region (Asia and Oceania) including Japan has the largest diabetic population in the world. The prevalence of diabetes is 153,200,000 (prevalence rate: 8.8%) in the West Pacific Ocean, which accounts for 37% of all diabetic patients worldwide. The number of patients is expected to reach 215,000,000 by Three countries in the region, namely China, Indonesia, and Japan, are ranked in the top ten in the global ranking: it is one of the issues that Japan must address.

13. Actual State and Medical Expenses for Diabetic Patients Around the World
● The age of onset ranges from 40 to 59. The number of patients is increasing in both developed and developing countries. ● The rates of sufferers who die from untreated hyperglycemia from among those who die from diabetes mellitus are 32.2% in males and 14.3% in females in developed countries. On the other hand, the corresponding rates are higher in developing countries where people have low incomes: 56.3% in males and 47.5% in females. ● One in two (46.5%) diabetic patients do not undergo medical checks, so they are not diagnosed with diabetes. Most cases with Type 2 diabetes mellitus are detected five to ten years after the onset. Many of them already have complications at the time of diagnosis. ● According to the survey undertaken in 2015, diabetes accounts for 12% (71 trillion yen or 673 billion dollars) of medical expenses in adults. The rate is trending upward. If there are any complications, medical expenses increase drastically. Accordingly, the prevention of diabetes and the prevention and improvement of complications will lead to the reduction of medical expenses.
The onset of diabetes tends to increase between the ages of 40 to 59 worldwide. This increase can be found in both developed and developing countries.
The rates of people dying from untreated hyperglycemia in deaths caused by diabetes are 32.2% in males and 14.3% in females in developed countries. In developing countries, the corresponding rates are as high as 56.3% in males and 47.5% in females.
● In addition, one in two diabetic patients or 46.5% had not undergone a medical check-up and were not diagnosed with diabetes. The problem is that many cases of Type 2 diabetes mellitus are detected five to ten years after development. This means that there are already complications by the time of detection, and retinopathy and/or renal hypofunction may occur.
● According to a survey undertaken in 2015, diabetes accounts for 12% (71 trillion yen or 673 billion dollars) of medical expenses in adults. The rate is trending upward. If there are any complications, medical expenses increase drastically. Accordingly, the prevention of diabetes and the prevention and improvement of complications will lead to the reduction of medical expenses.
In Japan, we should start by improving our lifestyle and daily diet.
World Health Day 2016: (World Health Organization, April 6, 2016) Global Report On Diabetes (World Health Organization) Cost of diabetes hits 825 billion dollars a year, according to new study (Imperial College London, April 6, 2016) Worldwide trends in diabetes since 1980: (Lancet, April 9, 2016)

14. Efforts in Japan
Background: Renal diseases have become increasingly prevalent, causing a significant impact on public health.
　　　↓　Measures by MHLW (the report by the meeting to consider future countermeasures to kidney diseases published in 2008)　
Countermeasures: Implement CKD awareness activity to the public and strengthen measures to prevent the development and progress of kidney diseases.
Report by the meeting to consider future countermeasures to kidney diseases
Education and promotion
Disseminate the importance of countermeasures to CKD and preventive methods.
Use all opportunities such as the media, Internet, and health guidance.
Cooperation system in healthcare
Promote cooperation between home doctors and specialized medical institutes.
Promote health and nutrition guidance.
Promote the establishment of a medical cooperation system in the community.
Upgrading of level of medical care
Prepare a CKD medical care guideline. Distribute it to home doctors.
Improve guidance and management skills.
Link with treatment of diabetes, CV diseases and others.
I will now explain the efforts being made in Japan.
In 2008, the Ministry of Health, Labour and Welfare established a study group to discuss measures regarding kidney diseases to raise awareness of CKD and enhance preventive measures in terms of the development and advancement of kidney diseases as countermeasures to patients with kidney diseases, whose number was rising year by year.
Activities were commenced based on 1) awareness activity, 2) enhancement of a system based on medical facilities cooperation, 3) upgrading of the level of medical services, 4) personnel development, and 5) promotion of research.
Cooperation between family doctors and nephrologists took place. Guidance on public health and nutrition was promoted. Public health nurses, nurses, and national registered dietitians were trained in providing technical public health guidance.
Personnel development
Train kidney specialists.
Improve the credentials of specialists and home doctors.
Train health guidance providers such as public health nurses, nurses and nutritionists.
Promotion of research
Research to establish evidence of medical care and on practice
Research to clarify pathology and develop therapies

15. Awareness Activity in Nationals March 10, 2011
Host:
Ministry of Health, Labour and Welfare
Sponsors: 10 organizations
The Japan Dietetic Association
Japanese Society of Nephrology
Japan Association of Chronic Kidney Diseases Initiative
The Kidney Foundation
Japan Association of Kidney Disease Patients
The Japan Society for Transplantation
Japanese Society for Clinical Renal Transplantation
Japan Medical Association
International Kidney Evaluation Association Japan
Kidney Support Association
*Twelve organizations in 2016, newly including:
The Japanese Society for Pediatric Nephrology
Japan Pharmaceutical Association
As an awareness activity among the general public, ten organizations held an annual symposium from 2011 with the Ministry of Health, Labour and Welfare as the hosting organization, including kidney-related organizations, the Japan Medical Association, and the Japan Dietetic Association. In 2016, the Japan Pharmaceutical Association joined them as one of the supporters. Today, twelve organizations are jointly involved in the awareness activity for prevention.

16. Criteria for Referral to a Nephrologist by a Family Doctor
Introduction of the criteria for referral and the system in ) Advanced albuminuria: UP/CR: 0.50 g/g Cr or more: or 2+ or more 2) Both urine protein and hematuria are present: 1+ or more 3) eGFR: less than 50 mL/min/1.73 m² (For patients younger than 40: eGFR of < 60; for those aged 70 and over whose renal function is stable: eGFR of < 40)
The criteria for referral to a nephrologist by a family doctor were established under the leadership of the Japanese Society of Nephrology in 2009.
1) Advanced albuminuria, that is urine protein/Cr ratio: 0.50g/g Cr or more; or 2+ or more
2) Both urine protein and hematuria are present: 1+ or more
3) eGFR: less than 50 mL/min/1.73 m²; however, patients younger than 40 should be referred to a nephrologist even with eGFR of less than 60. For those aged 70 and over whose renal function is stable, eGFR of less than 40 is required.
These criteria are still effective.
Source: CKD Medical Care Guide 2012

17. Community Medical Facilities Cooperation and Strategic Research for Prevention of a Severe Condition of CKD (FROM-J)
Group comparison of renal function as a result of non-pharmaceutical intervention in FROM-J, the strategic study
Doubling of accumulated serum creatinine value
Halving of accumulated eGFR
Year
Year
Group A: standard intervention group; Group B: proactive intervention group
Changes in frequency of use of drugs in groups during the study period
There is a report on countermeasures against CKD comprising community medical facilities cooperation and strategic research for the prevention of severe CKD (FROM-J), which was conducted between 2008 and 2012 under the sponsorship of MHLW.
It was a prospective clinical study. Group A was a control group with intervention by the usual family doctors. Group B was a group handled with team-based non-pharmaceutical intervention including physicians and national registered dietitians and a community medical cooperation group involving nephrologists and family doctors.
The results show that renal hypofunction was suppressed in patients with Stage G3 CKD more effectively when they received guidance from a medical team than when only family doctors were involved. This was one of the efforts made by the Japan Dietetic Association.
However, the FROM-J intervention was not effective in Stages G4 and 5 CKD or advanced cases.
It is still very important to investigate efficacious therapies for advanced cases and establish evidence as our challenge.
No significant differences in use of drugs between groups

18. Certification examination National registered dietitian
Efforts of the Japan Dietetic Association National Registered Dietitian System Specializing in Pathology of and Nutrition for Kidney Diseases
In FY2015, the Association began to accredit experienced national registered dietitians with broad knowledge and skills regarding kidney diseases as national registered dietitians specializing in pathology of and nutrition for kidney diseases, jointly with other academic societies.
National registered dietitians specializing in pathology of and nutrition for kidney diseases
Certification examination
Field practice (three years’ training at facilities certified for practice) and case reporting (five cases)
Japanese Society of Nephrology/Japan Society of Metabolism and Clinical Nutrition
30 credits for lecture-based training: Technical knowledge and basic training relating to kidney diseases
Japanese Society of Nephrology/The Japanese Society for Dialysis Therapy/ Japan Society of Metabolism and Clinical Nutrition/The Japan Dietetic Association
Certified national registered dietitian in pathology and nutrition (Japan Society of Metabolism and Clinical Nutrition)
Certified national registered dietitian in clinical nutrition (lifelong education by the Japan Dietetic Association)
In 2015, the Japan Dietetic Association launched a system of national registered dietitians specializing in the pathology of and nutrition for kidney diseases because of the necessity of training on technical knowledge.
Our association sends efficient national registered dietitians with broad knowledge and skills in kidney disease into society to contribute to national health promotion while certifying them jointly with other academic societies.
In terms of the certification criteria, they should be:
1) national registered dietitians; 2) members of the Japan Dietetic Association and the Japan Society of Metabolism and Clinical Nutrition; and 3) certified national registered dietitians in clinical nutrition accredited by the Japan Dietetic Association or national registered dietitians specializing in the pathology of and nutrition for kidney diseases accredited by the Japan Society of Metabolism and Clinical Nutrition.
In addition to the above conditions, they need to take 30 credits of basic training (90 minutes per time, 30 classes), undertake three years’ practical training, submit a report on five cases, and take a certification test.
This has just been launched.
Masters course at graduate school (course relating to kidney diseases) and three years’ practical work
National registered dietitian 18

19. Rate of presence of albuminuria by CKD stage/age
Over 70% of CKD may be overlooked with a urine protein test alone.
In particular, it is important
By CKD stage
By age
As part of the promotion of research, we found that it was important to measure serum creatinine to detect CKD, particularly in the elderly, because 70% of the demand for healthcare in CKD may be overlooked if we only depend on the presence of albuminuria in the assessment of CKD cases by stage.

20. Changes in Number of Patients Undergoing Chronic Dialysis Until 2013
man
In 2013, the increase was less than that in the previous year
Increased by about 10,000 per year until around 2005
The number of patients under chronic dialysis rose by about 10,000 a year until 2005 or so. In 2013, however, the increase fell below that of the previous year.
It is uncertain, but this may be the fruit of the efforts made in Japan.
Year

21. Lifestyle/Diet Guidance Manual for CKD Countermeasures against CKD
◆ Countermeasures against CKD aim at suppressing the development and progress of end-stage renal failure and CVD.
◆ Dietary cure plays a very important role in the treatment of CKD from the early stages.
Dietary guidance
Better lifestyle
Blood pressure control
Countermeasures against CKD
Countermeasures against uremic toxins
Control of blood sugar
The purpose of action for CKD is to suppress the onset and advancement of end-stage renal failure and cardiovascular diseases.
To achieve this, dietary cure is extremely important. It is necessary to commence intervention with CKD in the initial stages for these nine items.
Countermeasures against potassium shift and acidosis
Lipid control
Countermeasures for bones and minerals
Anemia management
Extracted from the diet and lifestyle guidance manual for CKD (2015, Japanese Society of Nephrology)

22. Prevention of Development of CKD
1) Appropriately start and continue treatment of lifestyle-related diseases such as diabetes, hypertension, hyperlipidemia, and hyperuricemia. 2) Maintain an ideal body weight. 3) Alter lifestyle habits that can cause CKD (avoid excessive salt intake, heavy drinking, smoking, and habitual use of analgesics).
The Health Service Bureau of the Ministry of Health, Labour and Welfare advised that each medical insurer should review the characteristics of each group, consider the health issues found as a result of the reviews, and add test items such as serum creatinine as an additional examination item when a plan is made for the second-term special health check-ups that were commenced in FY2013.
The development of CKD can be prevented by 1) continuing the treatment of lifestyle-related diseases such as diabetes and hypertension; 2) maintaining an ideal body weight; and 3) correcting a lifestyle that can lead to CKD (e.g. excessive salt intake, heavy drinking, smoking, and habitual use of analgesics).

23. BMI and new onset of albuminuria
Odds of presence of albuminuria (1+) by level of BMI (multivariate logistic regression)
Lean people (with a low BMI) have a risk of albuminuria, as do obese people.
This presents the results of the research on the ideal body weight in patients with kidney diseases.
Looking at BMI and albuminuria, albuminuria is inclined to occur in both lean males with a BMI of 20.4 or less and obese males with a BMI of 25.5 or more on the left side. On the right side, albuminuria is found in both lean females with a BMI of 18.4 or less and obese females with a BMI of 26.5 or more. It would be necessary to provide guidance in the normal range of 18.5 or more but less than 25.
The two-year longitudinal observation also found a U-shaped curve in the relationship between BMI and the presence of albuminuria.

24. Dietary Cure for CKD
◆Salt intake is basically 3 g or more but less than 6 g/day.
◆Protein intake is to be reduced down to the effective amount for suppressing renal function deterioration ( g/kg/day).
◆The suggested energy amount ranges from 25 to 35 kcal/kg/day. Sufficient energy should be taken from carbohydrates and lipids.　　
◆The amino acid score for food as a whole should be close to 100.
　1) Replace staple foods (i.e. rice, bread and noodles) with starch products or protein-controlled foods (the amino acid score of refined rice is 65).
　2) Sources of protein should be at least 60% animal-source foods.
This is the dietary cure for CKD in Japan.
The amount of salt should be 3 g or more but less than 6 g per day. The salt intake should be carefully determined because patients may lose their appetite if the amount of salt is too low. In Thailand, it is recommended that patients consume 5 to 6 g or less, or one teaspoonful of salt. This is almost the same as the recommended intake in Japan.
The amount of energy is recommended to be 25 to 36 kcal/day per kg standard body weight. A healthy body weight should be maintained.
The amount of protein should be reduced to 0.6 to 0.8 g/day per kg standard body weight. Mild cases may start with 0.8 to 1.0 g/day. We try to keep to at least 0.8 g/kg because many elderly people tend to be at risk of malnutrition. In Thailand, the recommendation is similar at 0.6 to 0.8 g.
It is very important to get the amino acid score close to 100 in terms of protein intake.
To be specific,
1) starch-based products or protein-adjusted food should be used as staple foods instead of rice, bread, and noodles because the amino acid score of refined rice is as low as 65.
2) Protein should be sourced from animal-derived food at 60% or more.
Source: CKD Medical Care Guide 2013 (edited by the Japanese Society of Nephrology)

25. Issues in Dietary Cure If you depend on an ordinary staple food:
The amount of dishes will decrease.
If the amount of dishes is small:
Your appetite will decline, and
You will lack energy.
Sugar
You will supplement energy with sugar or oil (sweet/greasy).
Butter
The amount of main and side dishes should not be reduced. The amount of protein will be increased if ordinary staple food is used. This is a problem with the dietary cure. As a result, patients may lose their appetite and be short of energy. It will be insufficient and ineffective even if sugar and oil are used for supplementation, ultimately resulting in renal hypofunction.
You will not continue the dietary cure.
Your renal function will deteriorate.
Kidney

26. Points in Meal Planning for Patients with CKD
1. Reduce the amount of protein in a staple food. → Select low protein rice according to dietary restrictions. 2. Use meat/fish/eggs for main dishes so that good-quality protein can be ingested. Good-quality protein: make the amino acid score Use less salt for seasoning. Use broth and spices effectively. 4. Ensure sufficient energy. → Use flour-formulated candy or oil and fat (medium chain fatty acid). Or use commercially available low protein energy replenishing food.
The key points of meal planning in CKD patients are:
1. Reduce protein intake in staple food.
2. Use meat/fish/eggs for main dishes to achieve sufficient protein intake.
3. Use a small amount of salt. Use broth and spices effectively.
4. Use powdered candy and oil/fat (medium chain fatty acid).
Use special treatment food cleverly to continue the dietary cure!
It is difficult to continue a dietary cure unless special food for treatment is used!

27. Use of Special Food for Treatment
Reduced salt/potassium/phosphorus soy sauce
MCT powder Low protein
Low Protein (1/10)
Khao Hom Cooked Rice
Special food for treatment
Energy replenishing food
Low protein food
Food for salt control
Food for reducing phosphorus
Reduced salt seasonings
e.g. soy sauce, miso sauce, dip and ketchup
Food intended to reduce protein in staple food
Rice, noodles and bread
Flour-formulated candy /Carolina - dissolve starch, sugar with less sweetness
Starch
Rice, rice cakes, flour and noodles
Medium chain fatty acid food
Oil-form, powder, jelly, and confection
If you use special food for treatment as your staple food, you can reduce the units in Table 1 and in turn, increase the amount of high-quality protein in Table 4. The foods facilitate supplementation in the case of energy deficiency.
Used for hyperphosphatemia
e.g. low phosphorus milk
Special treatment food should essentially be used because standard food is not enough to secure sufficient energy due to the possible imbalance of amino acids and the inappropriate restriction of phosphorus and potassium.
In particular, it is essential to introduce low-protein rice, since crops cover a larger portion of meals as staple foods. Additionally, it is useful to use soy sauce containing plenty of dashi (clear broth) added here in Japan, where soy sauce is an indispensable condiment. Other additives include oil powder with medium-chain triglycerides that ensures good energy replenishment, while it does not irritate the stomach and it is not greasy.

28. Use of Low Protein Staple Food 1)
If you use a staple food with less protein:
You can increase the amount of dishes.
If the amount of dishes is increased:
Your appetite will increase,
You can replenish your diet with energy, and
With good-quality protein.
Food containing quality protein
Low-protein staple food will permit a larger amount of dishes and lead to appetite stimulation. If good quality protein is consumed selectively, the dietary cure can be continued, and renal function can be maintained. Patients would readily accept low-protein non-sticky rice in Thai cooking.
Your dietary cure will continue.
Food containing poor quality protein
Your renal function will be maintained.
Kidney

29. Use of Low Protein Staple Food 2)
Low Protein (1/10) Khao Hom Rice
Low Protein (1/10) Khao Hom Cooked Rice
(1 kg/package)
(125 g/piece)
Here are some examples of low-protein staple foods.
On the left side, Khao Hom rice with low protein content. And on the right side, cooked Khao Hom rice with low protein content that is packed in a boil-in bag and requires microwaving before serving.
The chart on the left side shows a comparison of nutrient components between general rice and low-protein rice. Low-protein rice contains less protein, potassium, and phosphorus. The amount of protein is about one tenth. No potassium is detected. Phosphorus is about two fifths. The energy amount is almost the same. The chart on the right side shows a comparison of nutrient components between ordinary Khao Hom rice and low-protein Khao Hom rice in a boil-in bag. The low-protein products contain about one tenth of the amount of protein, no potassium, and about half of the amount of phosphorus. The energy amount is almost the same.

30. Use of Low Protein Staple Food 3)
◆If patients with Stages 3-5 CKD eat normal cooked rice three times a day, the amount of protein will be about 15 g or the recommended daily protein intake, and the amount of rice will be too much for the amount of the dishes.
　→If the rice is replaced with low protein rice (1/10), the amount of protein will be as little as only 4% of the recommended daily protein amount. (In the case of a body weight of 60 kg, a calorie intake of 2000 kcal and a protein intake of 40 g.)
Renal disease diet based on normal rice
Renal disease diet based on low protein rice
Amount (g)
Energy
Protein
Rice
600
1002 15
984
1.5
Potato 50
3.8
0.8 4
Fruit
100
0.5
Seasoning
As appropriate　 20 2
Vegetable
200 53
4.7
300.0 80 7
Oil and fat 60
540
450
Sugar 30
120
Egg 76
6.2
Fish 40 81
8.3
Meat 70
184
13.5
158
11.6
Fine-textured tofu 29
2.5
Milk
Total
2001 39
2011
Here are menus containing 40 g protein each, while the daily energy amount is set at 2,000 kcal. We compared two types of staple food: ordinary rice and low-protein rice.
If you eat ordinary rice, you will consume 15 g protein from three meals per day. The remaining 25 g protein will be allotted to main and side dishes. You will then only be allowed to eat 70 g meat and 50 g soft tofu. On the other hand, if you eat low-protein rice containing one tenth of the amount of protein, the protein amount will be as low as 1.5 g, even for three meals. You can then have 38.5 g protein in the other dishes.

31. Use of Low Protein Staple Food 4)
The protein reduced in a staple food can be allocated to quality dishes.
In the case of protein of 40 g and a calorie intake of 2000 kcal:
- If the protein intake in a staple food is reduced to 1/10:
This is something like a conversion of the table I already showed you into a photo. If you eat low-protein rice, you will be able to allot an additional 13.5 g of good protein to the other dishes!
Put simply, you can eat an additional 40 g fish, one egg and more vegetables!
Protein: 1.5 g
Protein: 15 g
- You can increase the amont of protein in dishes by 13.5 g!
　(The protein intake can be increased, i.e. 40 g fish/one egg/vegetables.)
Source: Jinzobyo no Hito no Kondate Calendar (meal plan for patients with kidney diseases (the publication department of Kagawa Nutrition University))

32. CKD classification: G3b
Effects of Suppressing Renal Function Deterioration by Dietary Cure (external information)
Two cases experiencing reductions in the speed of the exacerbation of renal function (GFR) after the start of dietary cure
Fig. 1) Results of dietary cure (Case 1)
CKD classification: G4
Fig. 2) Results of dietary cure (Case 2)
CKD classification: G3b
Start of dietary cure
Start of dietary cure
GFR (mL/min)
GFR (mL/min)
(Year / Month)
(Year / Month)
68-year-old male weighing 72 kg with diabetes mellitus
He was on a dietary cure with a daily protein intake of 39 g and a daily salt intake of 5.5 g. The renal function exacerbation speed had been 29 mL/min a year before the dietary cure. After the start of the dietary cure, the speed improved to 2.9 mL/min.
75-year-old male weighing 75.9 mg with nephrosclerosis
The renal function exacerbation speed improved from 21 mL/min a year to 0.3 mL/min after the start of the dietary cure. Good results were obtained even with a daily protein intake of 55 g and a daily salt intake of 8.0 g because his renal function had had reserve capacity at the time of the start of the dietary cure.
This is an extract from the collection of menus for 40 g protein intake from the publishing department of the Women’s Nutrition University. It is a chart showing two cases in which the dietary cure improved the speed of deterioration of the glomerular filtration rate (GFR).
The chart on the left side shows the data in the case of a 68-year-old male with Stage 4 CKD before the dietary cure. He implemented the dietary cure with a daily protein intake of 39 g (0.54 g/kg) and a salt intake of 5.5 g. The GFR deterioration speed was improved from 29 ml/min in the year before treatment to 2.9 ml/min after the start of the cure.
The chart on the right side shows the data in the case of a 75-year-old male with Stage 3b CKD before the dietary cure. He implemented the dietary cure with a daily protein intake of 55 g (0.72 g/kg) and a salt intake of 8.0 g. The GFR deterioration speed was improved from 21 ml/min in the year before treatment to 0.3 ml/min after the start of the cure.
　　　　　　　　　Data on dietary cure
Case 1:
- Daily protein intake: 39 g (0.54 g/kg)
- Salt: 5.5 g
　　　　　　　　　 Data on dietary cure
Case 2:
- Daily protein intake: 55 g (0.72 g/kg)
- Salt: 8.0 g
Extracted from Tanpakushitsu 40g no Kondateshu (menu containing 40 g protein) the publication department of Kagawa Nutrition University

33. Use of Energy Replenishing Food
Over 48% of patients with Stages 4-5 CKD and over 75% of patients with ESRD suffer from Protein Energy Wasting (PEW)/malnutrition.
United States Renal Data System (USRDS), 2009
According to a 2009 data report by the United States Renal Data System (USRDS), more than 48% of Stage 4-5 CKD patients and more than 75% of ESRD patients suffer from Protein Energy Wasting (PEW)/malnutrition.
That is, patients tend to lack energy or suffer from malnutrition due to a decreased appetite caused by uremia if they fail to consume sufficient protein and energy.
It is therefore extremely important to instruct patients to commence the dietary cure, which permits sufficient energy replenishment equivalent to protein restriction.
Surprisingly, over half of Stage 4 CKD patients are basically malnourished.

34. Structure of MCT as Energy Replenishing Food
Medium Chain Trigliceride
LCT
Long chain fatty acid 12 or more carbon molecules
General oil and fat
MCT
C: carbon
HO: hydroxyl group
O: oxygen
Medium chain fatty acid 8 to 10 carbon molecules
I would now like to talk about MCT. It is attracting attention as an energy replenishing food.
MCT stands for Medium-chain Triglyceride. It contains fatty acids whose length is about half of that of general cooking oil (which has Long-chain Triacylglycerol: LCT), having different characteristics from usual oil and fat.
- The length of fatty acids of MCT is about half of LCT (= low molecular weight).
Different characteristics from ordinary oil and fat

35. Decomposition of MCT Medium chain fatty acid Long chain fatty acid
2014/3/6
Decomposition of MCT
The decomposition of medium chain fatty acids was maximized in three hours. Most of them were decomposed within ten hours.
Rate of fatty acids decomposed (%)
Medium chain fatty acid
Long chain fatty acid
This chart shows the measurements of the amounts of fatty acids that are broken down after the administration of medium-chain fatty acids and long-chain fatty acids. The degradation of medium-chain fatty acids is maximized three hours after administration. Most of them are decomposed within ten hours after administration. Medium-chain fatty acids are degraded four times faster than long-chain fatty acids.
(hours)
●The amount of fatty acids decomposed was measured after medium or long chain fatty acids were administered to human subjects.
Source: Furman, R. H., Medium Chain Triglycerides, University Pa Press (1968) 35

36. General Food Including MCT
No concerns
◆Fat content of breast milk:
◆ Fat content of milk and other dairy food:
◆Coconut oil and palm kernel oil:
About 3%
3%-5%
7%-14% 牛乳
Medium-chain fatty acids are natural ingredients in breast milk, cow’s milk, and the core of seeds of palm family plants such as coconuts and palm fruit.
We usually consume medium-chain fatty acids in standard food.

37. Outline of MCT Consumption Study in Elderly Patients with Malnutrition
2014/3/6
Purpose
Comparison of the nutrition-improving effect between long chain triglyceride (LCT) and medium chain triglyceride (MCT) in the elderly
Subjects
　　Elderly people residing in long-term care hospitals (mean Alb: 3.4g/dL, BMI: 17.5kg/m2)
Methods
　　Nutrition replenishment with emulsified beverage (with supplementary food)
　　The intake of LCT/MCT is 6 g/day.
　　Usual diet + approx. 180 kcal energy + approx. 6 g protein
Evaluation
　　Body weight, serum albumin, prealbumin, total cholesterol and others
Daily nutritional intake:
Energy: 1300 kcal
Protein: 56 g
Lipid: 28 g
Carbohydrate: 195 g
Completion of enrollment
From 4 weeks in advance
Study period
12 weeks
This shows the results of a study presenting MCT’s impact in terms of improving the nutritional state of elderly malnutrition patients.
Patients with malnutrition staying at long-term care hospitals were divided into two groups. The first group took long-chain fatty acids (LCT) and the second group took medium-chain fatty acids (MCT) as an additive to emulsified beverages in addition to their usual diet for twelve weeks.
Measurement
Week -4
Week 0
Week 3
Week 6
Week 9
Week 12
Nosaka et al., Journal of Japanese Society of Clinical Nutrition: 32(1) (2010)

38. Results of MCT Consumption Study in Elderly Patients with Malnutrition - 1
The MCT group showed a significant elevation compared with before use. There was a significant difference from the LCT group.
The MCT group showed a significant elevation compared with before use. There was a significant difference from the LCT group.
(mg/dL)
(mg/dL)
LCT group
MCT group
LCT group
MCT group † † † † † †
Serum prealbumin * *
Serum prealbumin * * † * † †
Here are the results.
The chart on the left side is the data on changes in serum pre-albumin levels. The MCT group exhibited significantly higher values from Week 6 onward than the LCT group.
The chart on the right side is the data on changes in serum albumin levels. The MCT group exhibited significantly higher values from Week 9 onward than the LCT group and the start of the study.
(Week)
(Week)
Data: mean + SD, LCT: n=11 (M=2, F=9), MCT: n=11 (M=3, F=8)
*A significant difference between the two groups. A significant difference from before the start of use (p<0.05) 　 †

39. Results of MCT Consumption Study in Elderly Patients with Malnutrition - 2
The MCT group showed a significant difference compared with before use. The LCT group didn’t show any significant difference.
The MCT group showed a significant elevation compared with before use, showing a significant difference from the LCT group.
(kg)
(mg／dL)
LCT group
MCT group
LCT group
MCT group † † † † † † † †
Body weight *
Serum cholesterol * * * † †
The chart on the left side shows data on changes in body weight. The MCT group exhibited significantly higher values from Week 3 onward than at the start of the study.
The chart on the right side shows data on changes in serum cholesterol. The MCT group exhibited significantly higher values at Week 3 than the LCT group.
(Week)
(Week)
Data: mean + SD, LCT: n=11 (M=2, F=9), MCT: n=11 (M=3, F=8)
* A significant difference between the two groups. A significant difference from before the start of use (p<0.05) 　 †

40. Mechanism Involved in Improvement of Albumin by MCT
Sufficient energy by rapid digestion, absorption, and metabolism
Reduce the state of starving
Suppress catabolism of protein
Promote synthesis of protein
Based on the aforementioned results, I believe that the mechanism of MCT in the improvement of albumin would help suppress the starved state through rapid digestion, absorption and metabolism, and improve nutritional status by promoting the synthesis of protein.
(An increase in P-mTOR can be found if you look at changes in the level of insulin signal transmission of the liver by medium-chain fatty acids in animal models on a low-protein diet. Accordingly, it is inferred that the synthesis of protein would have been promoted. In addition, the ubiquitin/proteasome system was also found to decline. It is therefore inferred that the catabolism of protein would have been suppressed.)
Improve the nutritional state (albumin)

41. Individual package (13 g)
Uses of MCT Powder
MCT powder becomes cloudy when it is dissolved. It is therefore recommended for making potage soup and white stew that contain milk. Mix MCT powder with egg dishes or minced meat. Dishes will be richly flavored, although they will look the same as usual. MCT powder replenishes dishes with energy, while general cooking oil usually ends up making food too greasy.
Mix with milk.
Suggested quantity
One teaspoonful Nisshin MCT oil or one tablespoonful Nisshin MCT powder for 100 cc milk
Mix with egg.
Suggested quantity
One teaspoonful Nisshin MCT oil or one tablespoonful Nisshin MCT powder for one egg
Cook together with rice.
Suggested quantity
Two teaspoonful of Nisshin MCT oil or two tablespoonful Nisshin MCT powder for 1 go (approx. 180 cc)
Add to porridge.
Suggested quantity
One teaspoonful Nisshin MCT oil or one tablespoonful Nisshin MCT powder for 250 g porridge
Let me explain how to use MCT powder. MCT powder becomes cloudy when it is dissolved in liquid. I would therefore like to recommend that you use milk when cooking. Mix the powder with egg dishes or minced meat. The dishes will have a richer flavor, but they will look the same as usual. You can boost the amount of energy in dishes that tend to be greasy due to ordinary cooking oil.
Nisshin MCT powder
Tablespoonful (15 mL)
Individual package (13 g)
1 tablespoonful
(4.5 g)
1.5 tablespoonful
(6.8 g)
1 sachet
(13 g)
Increase by 35 kcal
Increase by 50 kcal
Increase by 100 kcal
Omelet
Stir-fried rice

42. Dress noodles with MCT oil after turning off the heat!
Uses of MCT Oil
●MCT oil is light-flavored oil with less taste and odor. You can easily boost your energy intake by sprinkling it over food or beverages without causing greasiness.
●MTC oil goes well with cooked rice, porridge, egg dishes, seasonings (e.g. mayonnaise and dressing), soup, miso soup and yoghurt.
Mix with mayonnaise.
Suggested quantity
One teaspoonful Nisshin MCT oil for one tablespoonful mayonnaise
Mix with dressing.
Suggested quantity
One teaspoonful Nisshin MCT oil for one tablespoonful dressing
MCT oil is very light and non-greasy, with barely any taste or odor. It is therefore possible to boost the amount of energy by simply sprinkling it over or mixing it with food and beverages.
Mix the oil with cooked rice, porridge, egg dishes, condiments (for example, mayonnaise and dressing), soup, miso soup, and yogurt.
Dress noodles with MCT oil after turning off the heat!
Add to tom yam kung.
Suggested quantity
One teaspoonful Nisshin MCT oil for one bowl of tom yam kung (160 cc)
トムヤンクンに入れる！
トムヤンクン１杯(160cc)に
Stir-fried noodles

43. MCT Products MCT Oil MCT Powder MCT Rice Porridge
MCT Side Dish 　MCT TOFU MCT Pudding MCT Jelly
Products containing MCT include oil, powder, porridge, (jelly-form food), tofu, pudding, and Memorion (jelly).

44. Elderly Woman with Lacunar Dementia Living on Her Own:
Height: 145 cm; body weight: 43 kg at the age of 80, 38 kg at the age of 90 in May (BMI: 18.1, healthy body weight)
・May: 38 kg (BMI: 18.1) ・June: 32 kg (BMI: 15.2, pain from stress fracture) Progress of dementia ・December: 36 kg (BMI: 17.1, cognitive function improved to the level as of May) ・92Y January: 38 kg (BMI: 18.1)
MCT intake target: 15 g
Let me share a story about my mother with you.
She is 92 years old and lives on her own. She suffers from lacunar dementia. After experiencing a stress fracture at the age of 90, she remained in bed due to the pain and did not eat properly. She lost 6 kg. She lost her appetite and muscles and developed a cough. She became incapable of bathing herself. The decline in her cognitive function was exacerbated. She lost her temporal sense and called me at midnight, failing to distinguish morning from night. That came as a great surprise to me.
Fortunately, I am a national registered dietitian. First, I gave her 15 g of MCT products for calorie replenishment so that she could return to her original body weight. I added MCT products to rice and miso soup. It was helpful that she was very fond of Memorion, which is jelly-form MCT.
Six months later, she had gained 4 kg. Her body weight returned to its original level. The progress of the decline in her cognitive function appears to have been halted. She remains able to live on her own, and she never calls me at midnight anymore.

45. Summary
☞The number of patients with diabetes/hypertension is increasing in Thailand. An increase in CKD patients is expected.
☞It is important to commence a dietary cure in the early stages as a countermeasure against CKD.
☞ Over 48% of patients with CKD of Stages 4-5 and over 75% of patients with ESDR suffer from PEW/malnutrition.
☞In a dietary cure, protein intake should be restricted and sufficient energy should be ensured at the same time. Otherwise, it will result in malnutrition and/or renal function deterioration.
1) Use low protein crops. Add good quality protein to dishes instead.
2) MCT is easier to turn into energy than LCT, preventing malnutrition. MCT improves malnutrition in the elderly.
☞タイの糖尿病・高血圧患者は増加しており、CKD患者の増加が予想されま す
☞CKD対策には、初期段階からの食事療法が重要ですが、CKD4-5の48%以 上、ESDRの75%以上がPEW/malnutritionです
☞そのため食事療法で注意すべきは、たんぱく質制限と同時に十分なエネル ギー摂取ができないと、低栄養や腎機能を低下させるのです。
　具体的な対策としては、まず①低たんぱく穀物を使い、その分良質なたん ぱく質に回すこと
　②つ目は、MCTはLCTと比べエネルギーになり易く、低栄養を防ぐので利 用が望ましいと言えます。特にMCTは、高齢者の低栄養患者を改善します

46. Thank you very much for your attention