Chronic Disease Management and Multimorbidity
This domain tests individualized, longitudinal care for people living with two or more chronic conditions, where single-disease guidelines conflict. The exam rewards you for prioritizing safety, self-management capacity, and drug-nutrient interactions over rigid targets.
Disease-specific anchors
- Diabetes: carbohydrate consistency or counting, individualized A1c goals (often <7% when achievable safely), and hypoglycemia vigilance with insulin or sulfonylureas. Weight management and activity remain central.
- Chronic kidney disease without dialysis: protein roughly 0.55–0.8 g/kg with adequate energy; dialysis raises protein to 1.0–1.2 g/kg (hemodialysis) or 1.2–1.3 g/kg (peritoneal). Current guidance discourages reflexive restriction of fruits and vegetables; address hyperkalemia case by case.
- Heart failure: sodium generally under 2,000–3,000 mg daily and fluid restriction (often 1.5–2 L) mainly in hyponatremia; a DASH-style pattern is reasonable.
- Chronic obstructive pulmonary disease: 30–35 kcal/kg with calorie-dense, small, frequent meals; energy deficits and muscle wasting drive outcomes more than carbohydrate load.
Multimorbidity skills
- Deprescribe and reconcile: the Beers criteria and STOPP/START flag high-risk medications; watch warfarin and vitamin K consistency, ACE inhibitors and potassium, and monoamine oxidase inhibitors and tyramine.
- Screen for frailty and sarcopenia; target 1.2–1.5 g/kg protein with resistance activity where feasible.
- Use motivational interviewing and teach-back; health literacy and food access shape what plans succeed.
- Shared decision-making matters when guideline targets compete with quality of life.
Worked example
A 78-year-old woman with heart failure, stage 3b chronic kidney disease, and type 2 diabetes on insulin asks about diet. Three sets of restrictions would leave her eating little. Priority goes to glycemic safety (consistent carbohydrate, hypoglycemia education), moderate sodium restriction (about 2,000 mg), no blanket potassium restriction because her potassium is 4.4 mmol/L, and protein near 0.8 g/kg. One page, one shopping list, one follow-up call.
Traps
Stacking renal, cardiac, and diabetic restrictions until intake collapses; applying dialysis protein targets to non-dialyzed patients; over-restricting potassium in normokalemic patients; and ignoring that illness-related anorexia in multimorbidity often requires oral nutritional supplements rather than more rules.