Stacie Savage, 2019
Finger and toe nails are a part of the human body like hair and skin and eyes. Like other body systems, the nails are a tissue that can manifest complications of diabetes. Recent research has demonstrated a relationship between nail integrity and diabetes suggesting that uncontrolled diabetes can create a thicker and more porous nail.
Advanced glycation end-products (AGEs) are the result of when glucose and a fat or protein are bonded together through the Milliard Reaction (Luevano-Contreras & Chapman-Novakofski, 2010). This is also what a high A1c is - a measure of the amount of glucose and hemoglobin (protein) that is bound together due to a consistently high amount of glucose in the blood stream. In someone without diabetes or with consistently normal blood glucose levels, this bond takes place in only small, harmless amounts.
To become an AGE (advanced glycation end-product), a molecule undergoes 3 stages. First, a glucose molecule bonds with a protein over hours or days forming a Schiff base; this bond is reversible. In the spans of days to weeks, the bond becomes an Amadori and hemoglobin A1c is an example of this. Third and lastly is the formation of the AGE taking months or years, and this stage is irreversible (Luevano-Contreras & Chapman-Novakofski, 2010). AGEs then bond with other proteins and accumulate in tissues (Gkogkolou & Bohm, 2012).
An observable sign of the accumulation of AGEs in tissue is of the nail plate. Nails are keratinized epithelial tissue providing the protein for which the AGEs to bond with. Then the AGEs form further bonds as either a protein adduct (protein-AGE) or protein crosslink (AGE-protein-AGE) (Gkogkolou & Bohm, 2012). This creates a compromise to the integrity of the nail (Sihota et al., 2019). The more prolonged hyperglycemia is, as measured by hemoglobin A1c, the more porous, less dense, and rough the nail is (Sihota et al., 2019).
From a nutrition practitioner's standpoint, the five axes of evidence (dietary, anthropometrics, clinical, drug, biochemical) is an important part of the nutrition assessment for the patient effected by chronic hyperglycemia and nails compromised by AGEs.
In the dietary axis, common factors leading to uncontrolled type 2 diabetes are the Standard American Diet, high carbohydrate dietary pattern, sugary drinks, and highly processed foods. The anthropometrics axis may indicate obesity with a waist circumference >40” for males and >35” for females as chronic hyperglycemia is associated with the metabolic syndrome and uncontrolled diabetes. The biochemical axis will show signs of hyperglycemia via blood glucose, serum glucose, and hemoglobin A1c. The drug axis may include antihyperglycemic agents such as metformin, Lantus, and Novolog. Lastly, the clinical axis will likely include supportive evidence for type 2 diabetes such as diabetic foot ulcers, necrosis, polydipsia, polyuria, and thickened, translucent-opaque nails examined during the nutrition-focused physical exam.
Nutrition Assessment
An example of a relevant nutrition diagnostic statement using Kight’s method addressing an effected nail of the uncontrolled diabetic is as follows:
Nutrition diagnostic statement
Altered body composition integrity (thick, porous, opaque nails affecting all fingernails and toe nails) and altered nutritional biochemistry integrity (A1c >6.5%) related to inappropriate caloric distribution (high carbohydrate eating pattern, Standard American Diet) and altered nutrient disposition (AGEs).
Nutrition Goals
Reduce A1c 1-2% in 3 months (proximal goal)
Maintain A1c <7% (distal goal)
Maintain blood glucose <180mg/dL during hospital stay
Maintain preprandial blood glucose 80-130mg/dL and post-prandial <180mg/dL indefinitely (ADA, 2018)
Nutrition Interventions
Low carbohydrate diet (<30-45g/meal, <15g/snack)
Increase non-starchy vegetable intake
Increase protein intake (30g/meal)
Reduce sugar intake
Encourage adherence to medications (as necessary)
References
American Diabetes Association. (2018) Standards of Medical Care in Diabetes - 2018. The Journal of Clinical and Applied Research and Education. 41(1).
Gkogkolou, P. & Bohm, M. (2012). Advanced glycation end products. Key players in skin aging? Dermato-Endocrinology 4:3, 259-270.
Luevano-Contreras, C. & Chapman-Novakofski, K. (2010). Dietary advanced glycation end products and aging. Nutrients 2, 1247-1265, doi: 10.3390/nu2121247
Peppa, M., Uribarri, J., & Vlassara, H. (2003). Glucose, advanced glycation end products, and diabetes complications: What is new and what works. Clinical Diabetes. Council’s Voice. 21(4), 186-187.
Sihota, P., Yadav, R., Dhiman, V., Bhadada, S., Mehandia, V., & Kumar, N. (2019). Investigation of diabetic patient’s fingernail quality to monitor type 2 diabetes induced tissue damage. Scientific Reports. www.nature.com/scientificreports
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