Typical diabetic nephropathy develops with the appearance of microalbuminuria, followed by the appearance of overt proteinuria, resulting in a decreased renal function. In clinical practice, however, since there are cases in which the renal function declines without the appearance of overt proteinuria, the present state and contributing factors at this center were examined. The eGFR slope was calculated for 1326 patients with type 2 diabetes mellitus in whom the eGFR had been measured more than 8 times in the 2 years until June 2017, and cases with less than -5 mL/min/1.73 m2/year were classified as Rapid decliners. Overall, 174 cases (13.1 %) were Rapid decliners. Even if limited to 1106 cases with stage 1 or 2 nephropathy, 119 cases (10.8 %) were Rapid decliners. A logistic regression analysis showed that low hemoglobin at baseline was a significant independent risk factor for a Rapid decline in the eGFR in all cases and in stage 1, 2, and 3 nephropathy.
The patient was a 76-year-old man with a 26-year history of type 2 diabetes mellitus who was receiving insulin treatment. He was referred to our department by his primary care physician in order to undergo diabetes educational intervention due to poor glycemic control because of cognitive impairment. On admission, his HbA1c level was 9.1 % and cognitive impairment was observed. After admission, a blood culture was positive for Streptococcus mitis, and echocardiography revealed aortic and mitral valve vegetation. CT and MRI demonstrated renal infarction and multiple cerebral infarctions. A diagnosis of infective endocarditis was made, and patient improved after receiving medical treatment with penicillin G and surgery. On discharge, the patient's cognitive function had improved and stable glycemic control had been achieved (HbA1c 7 to <8 %). In elderly diabetes patients, even when severe infection is present, the main complaints can often be atypical symptoms, such as cognitive impairment and poor glycemic control. Physicians should be alert to the possibility that severe infections, such as infective endocarditis, may underlie these symptoms and that close examination is necessary.
The cornerstone of diabetes treatment is diet therapy, which is applicable to all patients, regardless of the cause and stage of their diabetes, age, or sex. "The Food Exchange List for Dietary Guidance for Persons with Diabetes" (or "food exchange list" ) is a list that has made it easier for patients and their families, as well as doctors and medical staff, to understand and perform diet therapy for diabetes. The existence of such a list is significant, and its contribution to diabetes therapy is immeasurable. However, the recent rapid development of food logistics, processing, and preservation technology, as well as external sources of food, such as ready-made meals and take-out or eating out, along with the multinationalization of meals along in line with the globalization of food culture have changed the food environment of Japanese people, diversifying the situation. These changes in the food environment have had a huge effect on diet therapy for patients with diabetes, making it difficult to use the conventional "food exchange list." Therefore, our committee conducted a questionnaire survey targeting academic councilors and nutritionist members in order to evaluate the current status and address issues regarding what we need to do in order to provide more practical diet therapy. The survey period was from June 6th to July 8th, 2018, with the targets consisting of 701 academic councilors and 469 nutritionists. We used the "My Page" section of the website of The Japan Diabetes Society and received answers from 341 of the target subjects (response rate of 29.1 %). While 60 % of them responded that they "always use it" or "often use it" regarding the most frequently used "food exchange list - 7th edition," over 70 % responded that they "do not use it often" or "do not use it at all" when it comes to the "practical use version of the food exchange list - 2nd edition" and the "food exchange list for diabetic nephropathy - 3rd edition." Cited reasons concerning the difficulty of using the "food exchange list - 7th edition" were as follows: (1) Some patients find it difficult to understand the contents of food exchange list. (2) There is a huge gap between the ideal diet to be instructed and the actual diet of patients. and (3) People tend to use visually intuitive media as a source of dietary information such as Internet and magazines. In contrast to the "practical use version of the food exchange list - 2nd edition" and the "food exchange list for diabetic nephropathy - 3rd edition," the classifications of Tables 1 to 6 of the "food exchange list - 7th edition" are frequently used and have become widespread. We saw through our survey that these tables are indeed well-recognized. There are likely many cases in which, despite having received nutrition education, people continue to eat ready-made meals or eat out instead of cooking on their own because they lack the knowledge and understanding of diabetes as well as the motivation to perform diet therapy. In addition, from the survey, patients turned out to be influenced by media. Exposed to the flood of information, patients tend to believe misleading dietary information, and there are many cases where medical staff and doctors need to correct their misconception. Since our food environment has become diverse and we are entering a super-aging society, we need to develop educational media that are more convenient to review and easier to understand, taking into consideration the convenience of ready-made meals and eating out.