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Nutrition Management of Diabetes in Acute Care
Can J Diabetes 38 (2014) 90e93
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Nutrition Management of Diabetes in Acute Care Dana Whitham RD, MSc, CDE * St. Michael’s Hospital, Toronto, Ontario, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 December 2013 Received in revised form 16 January 2014 Accepted 17 January 2014
Nutrition therapy in hospital includes the integration of diabetes into the care plan for the presenting condition, basic self-management education and care coordination to promote optimal glycemic control in hospital and an appropriate plan for discharge. Estimated nutrient requirements for people with diabetes are the same as those for the general population, and diets should be designed based on individual metabolic needs. Distribution of meals and snacks should employ a consistent carbohydrate meal-planning approach for both patient safety and management of glycemia. Referral to a registered dietitian for a full assessment is warranted for those at higher risk for hyperglycemia, including those on insulin or nutrition support. Consideration may be given to the use of lower carbohydrate oral nutrition supplements. A team approach should be employed to ensure there is coordination among blood glucose testing, insulin administration and meal timing. Self-management education should focus on patient safety, and an appropriate plan for discharge should be created to manage the ongoing needs of patients with this chronic disease. Ó 2014 Canadian Diabetes Association
Keywords: carbohydrate diabetes diet enteral inpatient meal planning nutrition oral nutrition supplements parenteral Mots clés : glucide diabète régime entéral en milieu hospitalier planification des repas nutrition compléments nutritionnels oraux parentéral
r é s u m é La thérapie nutritionnelle à l’hôpital comprend l’intégration du diabète au plan de soins qui tient compte de l’état de santé, de l’enseignement de base sur la prise en charge autonome et de la coordination des soins pour promouvoir une régulation glycémique optimale à l’hôpital et un plan approprié au moment du congé. Les besoins estimés en substances nutritives des personnes ayant le diabète sont les mêmes que ceux de la population générale, et les régimes devraient être élaborés selon les besoins métaboliques individuels. La distribution des repas et des collations devrait utiliser une approche cohérente de planification des repas axée sur les glucides pour la sécurité du patient et la prise en charge de la glycémie. La consultation d’un diététiste pour obtenir une évaluation complète est justifiée pour ceux qui sont exposés à un risque élevé d’hyperglycémie, dont ceux recevant de l’insuline ou un soutien nutritionnel. L’utilisation de compléments nutritionnels oraux plus faibles en glucides peut être envisagée. Une approche d’équipe devrait être utilisée pour assurer la coordination des analyses de la glycémie, de l’administration d’insuline et de l’heure des repas. L’enseignement sur la prise en charge autonome devrait mettre l’accent sur la sécurité du patient, et un plan approprié au moment du congé devrait être élaboré pour prendre en charge les besoins des patients atteints de cette maladie chronique. Ó 2014 Canadian Diabetes Association
Introduction People with diabetes are more likely to be hospitalized and have longer lengths of stay than those without diabetes (1). One survey estimated that 22% of all hospital inpatient days in the United States involved individuals with diabetes (2), and diabetes is known to account for up to 25% of intensive care admissions (3). Older adults, particularly those with complicated socioeconomic conditions, are at risk for both malnutrition (3) and readmission to
* Address for correspondence: Dana Whitham, RD, MSc, CDE, St. Michael’s Hospital, Toronto, Ontario, Canada. 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.01.007
hospital (4), highlighting the importance of developing coordinated diabetes care plans upon discharge. A recent report suggests that among medical and surgical units within Canadian hospitals, malnutrition rates are as high as 45% (5). Malnutrition may lead to decreased tolerance of treatment, poor prognosis, increased rates of hospital-acquired infections, poor wound healing and longer lengths of stay (6). Optimizing nutritional status in hospital, therefore, is an essential component of any nutrition care plan. However, the provision of extra foods, snacks or supplements commonly used to treat malnutrition can complicate the management of hyperglycemia in hospital. Additionally, poor intake in hospital may predispose patients to hypoglycemia. This article reviews issues affecting glycemic control while in hospital and
D. Whitham / Can J Diabetes 38 (2014) 90e93
notes some nutrition strategies to manage inpatients with diabetes. Nutrition Care of Patients with Diabetes While in Hospital In addition to managing nutritional status, the goal of nutrition therapy in acute care is to treat illness. Nutrition recommendations from the Canadian Diabetes Association emphasize foods low in energy density and high in volume so as to optimize satiety. Although this may be appropriate in the ambulatory setting, it may not be a priority within the nutrition management of acute illness. In hospital, therapeutic diets should be evidenced based yet maintain enough flexibility to accommodate changes in eating while in hospital and deviations from guidelines, dietary reference intakes or the principles of Canada’s Food Guide may be necessary to meet short-term nutrition requirements. Comprehensive nutrition care plans must consider that the management of diabetes is not a solitary goal, but rather an essential component of the optimization of nutritional status and the management of acute conditions. In general, energy requirements in individuals with diabetes are not different from those without the disease. A recent study concluded that the Harris-Benedict equation accurately predicts resting energy expenditure in patients with diabetes when compared to indirect calorimetry (7). The American Diabetes Association guidelines indicate that the metabolic needs of most patients with diabetes in hospital range between 25 and 35 kcal/kg per day (8). Despite an adequate provision of calories in hospital, patients often take in an insufficient amount of both carbohydrates and calories, leading to an increased risk for hypoglycemia (9). One study, designed to examine the estimated requirements, the average daily meal consumption and the factors affecting intake in hospitalized patients with diabetes, provided some concerning data. First, the metabolic requirements of 434 patients (mean age 65.9 years; body mass index 31.4 kg/m2) were estimated to be approximately 2100 kcals, based on the Mifflin-St. Jeor equation. Second, the intake by study participants was very poor. Over 3 days, the average caloric intake was no more than 828 kcals (9), and subjects consumed less than half of the carbohydrate provided (mean intake 107 to 117 g/day). Additionally, between 18% and 34% of the subjects consumed no food at all (some of them had an nil per os [NPO] order), and breakfast was the meal most commonly cited for no intake. Only 25% consumed all of their meals at the start of the 4-day test period. Patient interviews were conducted to determine the reasons for the inadequate meal consumption. Patient-related issues, such as loss of appetite and dislike of the foods offered, accounted for 42.2% of the factors leading to inadequate intake. Treatment issues (32.6%) included NPO orders or interruptions of mealtimes. Illness-related issues (15.1%) included nausea and vomiting, fatigue and pain. Finally, system issues, including the need for assistance in eating or the inaccessibility of the meal tray, were cited as factors in 1.9% of subjects. This study highlights the increased risk for hypoglycemia in hospital. In addition to the intake issues listed above, ensuring that a sufficient amount of carbohydrate is provided and adequately distributed is of additional importance for optimal glucose control. Nutrition recommendations for the proportion of carbohydrates, protein and fat in the diet are the same for people with diabetes as for those without diabetes. A range of macronutrient content is recommended to allow for flexibility and to suit the needs and preferences of the individual. Therapeutic diets planned for use in patients with diabetes should fit within the acceptable macronutrient distribution ranges of between 45% and 60% for carbohydrates, between 15% and 35% for protein and between 30% and 45% for fat (10). No single meal plan or “diabetic diet” is defined in the management of diabetes. To prevent hyperglycemia and its
91
associated complications, energy intake should be adjusted to patients’ requirements, avoiding over-nutrition and excessive glucose intake. Protein intake should be adjusted to the degree of metabolic stress. Overly restrictive diets should not be used in a short duration of stay and may actually contribute to poor nutrition intake (8). Both the Canadian Diabetes Association and the American Diabetes Association recommend that organizations implement a consistent carbohydrate diabetes meal-planning system (8,11). Especially for patients taking insulin, consistency in both timing and carbohydrate amount is essential to limit hyper- and hypoglycemia. In most situations, diets that limit sources of concentrated sweets or sugar are no longer appropriate because they unnecessarily restrict sucrose without consideration of the overall carbohydrate content of the meals (12). Consistent carbohydrate-based diabetes diets A consistent carbohydrate diet is considered the most appropriate in hospital, both because carbohydrate has the greatest effect on blood glucose and also because a consistent provision of carbohydrate is ideal for patient safety (8,11). These plans provide the needed consistency in day-to-day meals and snacks but without the structure of having to ensure that the carbohydrate is distributed among starch, fruit and milk as would be seen in the exchangebased diets. A greater variety of food can be selected and more or less protein and fat can be allowed as per preference and appetite. For individuals who practise carbohydrate counting and those with poor appetites, nausea, vomiting or the inability to consume the whole meal, the carbohydrate amounts listed on the menus can assist patients and providers to estimate intake more accurately and, subsequently, the appropriate amount of insulin required for the meal. Carbohydrate lists can be created for the food items seen in the menu rotation at the hospital and can be made available by the food-service department. Patients and families should also be encouraged to disclose any additional foods consumed so as to assist healthcare practitioners in determining appropriate insulin doses. Patterned and exchange-based diabetes diets Traditionally used for many years, exchange-based diets provide fixed calorie levels with explicit distribution of carbohydrate, protein and fat. Exchange diets are designed with set amounts of food groups (starches and grains, meats and alternatives, fruit, vegetables, milk products and fat) at each meal in order to provide a consistent calorie level and a balanced intake each day. Carbohydrate choices are distributed throughout 3 meals and, depending on the calorie levels, the addition of morning, afternoon and bedtime snacks. As a benefit, these diets provide consistency in carbohydrate and also in the provision of food groups high in protein, which may be beneficial in situations of metabolic stress. As a limitation, these patterns limit individuals’ abilities to select more or less of certain foods or food groups that might be preferable and would ultimately improve overall intake in hospital. Based on the work processes within most hospitals, meals are generally provided within relatively short time intervals. In general, no more than 5 to 6 hours separate meal times, which creates a situation in which the overnight time frame is quite long, and a bedtime snack may be required to prevent hypoglycemia. It also creates an issue in which daytime snacks may not be required and may lead to hyperglycemia. Consideration of meal times is essential when creating an appropriate medication regimen and in managing patients on existing insulin regimens. Regardless of the method of delivery, the primary goals of nutrition therapy in hospital are to manage glycemic control so as
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to promote recovery from illness, surgery or disease; to integrate glycemic control into the treatment of the primary diagnosis or presenting illness; and to create appropriate discharge plans.
with supplement use and should be considered for those whose metabolic needs can be met with a specialty product. Enteral nutrition
Determining insulin doses In a stable patient who is consuming regular meals in hospital, providing a fixed dose of mealtime or bolus insulin is the most common approach. Because the carbohydrate amount of the meal in either the exchange-based diets or the carbohydrate-consistent diets remains the same, the insulin dose can be standardized. Adjustments of the base dose can then be made to accommodate pre-meal hyperglycemia. Any food-related adjustment is based on the carbohydrate component of the meal only; for example, if the individual eats only half of the carbohydrate foods provided, the bolus dose is reduced by half. Alternatively, in some patients, an insulin-to-carbohydrate ratio could be determined and the dose adjusted at each meal based on the amount of carbohydrate to be consumed. Mealtime insulin can also be injected after the meal in the situation of nausea, vomiting or poor appetite. Although it is not complex to adjust the dose of bolus insulin with the meal, the coordination of blood glucose testing, meal timing and insulin delivery within the inpatient setting remains a challenge. Rapid insulin should be administered within 30 minutes of a capillary test and no more than 15 minutes before the meal (1). One review found that rapid insulin was given more than 20 minutes in advance of the meal in the majority of cases (1). Proper administration of insulin in coordination with the meal will likely require a review and restructuring of the current work flow and process in hospital. Involving patients in their diabetes care can be of benefit because some patients can take on full ownership of their insulin dosing and blood glucose testing. Alternatively, patients could remind the staff to check blood glucose levels and give insulin at appropriate times.
Unless contraindicated, patients requiring nutrition support should be fed enterally. In the context of diabetes, enteral nutrition is associated with less hyperglycemia and lower insulin requirements compared to parenteral nutrition (PN). Enteral nutrition should be administered early, ideally within the first 24 hours of admission to the intensive care unit and after hemodynamic stabilization. Early initiation of enteral nutrition has been indicated to be well tolerated and to have benefits for nutrition status, wound healing and postoperative complications (14). Enteral nutrition prescriptions should be determined on the basis of patients’ metabolic needs. Standard enteral formulas contain between 1 and 2 kcal/mL and are generally high in carbohydrate and low in fat and fibre. These formulas promote rapid gastric-emptying rates and nutrient absorption. The carbohydrate content of formulas range from as much as 54% of calories down to as low as 34% in some newer diabetes products (17). Specialty diabetic products replace carbohydrate with monounsaturated fat while also providing 10 to 15 g/L of dietary fibre (17). No specific guidelines exist for patients with diabetes requiring nutrition support, and the evidence for promoting specialty diabetic enteral products has not yet been endorsed by the American Society for Parenteral and Enteral Nutrition (18). Research regarding the use of lower carbohydrate enteral formulas has been limited in duration, has focused on oral use only or was conducted in long-term care, rehabilitation or outpatient settings. For individuals on continuous feeds, staff must be prepared to prevent and treat hypoglycemia if interruptions in feeding occur and insulin or insulin secretagogue doses have already been delivered. For those on bolus feeding schedules, insulin doses should be administered after the bolus has been delivered. Parenteral nutrition
Postoperative, NPO or clear-fluid diets Energy from carbohydrate is necessary during illness or recovery from surgery so as to preserve brain function and lean body mass. Clear- and full-fluid diets should provide no fewer than 130 grams per day and ideally closer to 200 grams of carbohydrate daily, distributed throughout the meals. Non-caloric fluids and sugar-free liquid diets are not appropriate (13). Despite research to suggest otherwise, many patients are put on postoperative diet progressions that move from NPO status through a clear-fluid diet to a regular therapeutic diet in an as-tolerated manner. This process, however, can negatively impact intake in a crucial time frame during which appropriate calories and nutrients are required for healing (14). Advancement to a regular diet directly from NPO status has been shown to be well tolerated and to provide adequate nutrients without delay (14), and it is considered a component that enhances recovery after surgery. Nutrition interventions aimed at increasing calories and protein through food or supplements have demonstrated positive outcomes, including improvements in weight (15) and nutritional status (16). One systematic review determined that the addition of standard oral nutrition supplements resulted in fewer hospital readmissions, especially for older patients (16). Standard oral nutrition supplements range from 50% to 67% of calories as carbohydrate, whereas specialty diabetic products range from 33% to 47% of calories as carbohydrate but commonly contain fewer calories. Studies have demonstrated improvements in glucose control (both fasting and postprandial) with use of the lower carbohydrate supplements designed for people with diabetes (3). As such, the use of lower carbohydrate products may alleviate some of the hyperglycemia commonly seen
Hyperglycemia is the most common complication associated with PN; it occurs in 10% to 88% of hospitalized patients receiving PN (19). Although the benefit of parenteral nutrition in improving the nutrition status of malnourished patients is clear, parenteral nutrition is also associated with an increased risk for infections and mortality, with a component of that risk being related to the development of hyperglycemia (19). In one study, patients with elevated blood glucose readings (>8 mmol/L) prior to and within 24 hours of initiating parenteral nutrition had poorer outcomes and increased mortality rates (19). According to the recommendations of the American Society for Parenteral and Enteral Nutrition, parenteral nutrition should be initiated at half of the estimated energy needs or approximately 150 to 200 grams for the first 24 hours (20). Individualization down to as low as 100 to 150 grams of dextrose (21) or 1.5 to 2 mg/kg/min (18) may be considered in a hyperglycemic patient on insulin therapy. Upon control of blood glucose, the dextrose dose can be increased. If the parenteral nutrition contains insulin, it is necessary to maintain the ratio of insulin to dextrose if adjustments are made in dextrose calories (22). Care should also be taken with low-dextrose, high-fat concentrations; recent studies demonstrate worsening insulin resistance with high levels of free fatty acids (23, 24). Upon stabilization, carbohydrates should be maintained with at least 2 mg/kg/min and not exceed a rate of 4 to 5 mg/kg/min or 20 to 25 kcal/kg/d (20,21). Discharge Planning Self-management discharge education should focus on survival skills and centre on the prevention and treatment of hypoglycemia,
D. Whitham / Can J Diabetes 38 (2014) 90e93
consumption of appropriate amounts and types of carbohydrate and the distribution of meals and snacks suited to the individual. Diabetes is a chronic disease requiring long-term follow up, so inpatient care providers should ensure that appointments are made (ideally within 1 month [2]) with community-based diabetes care teams, tertiary diabetes care centres or primary care physicians.
Conclusions Effective management of diabetes in hospital involves a delicate balance of optimizing nutritional status and treating illness while minimizing hyperglycemia and avoiding hypoglycemia. A consistent carbohydrate diet has been endorsed as the ideal approach by both the American and Canadian Diabetes associations. The consistency provided by the diet makes the medical management easier, yet the flexibility of the diet is enough to promote an increase in patient satisfaction and intake. The barriers to adequate nutrition in hospital include poor appetite; conditions causing difficulty in eating or the inability to eat; NPO status; delayed or interrupted meals because of surgery, tests or procedures; increased needs resulting from catabolic stress; and provision of meals and food at times that are different from patients’ usual times (12,24). Because of the many factors affecting individuals’ intake in hospital, the risk for hypoglycemia is high. Hypoglycemia is a limiting factor for optimal glycemic control in hospital, especially in individuals requiring insulin. In addition to the meal-related issues known to predispose an individual to hypoglycemia, reduction in intravenous dextrose and frequent and unexpected interruptions in enteral feeding or parenteral nutrition (2) should also be considered. Malnutrition rates in hospital are also high, and the provision of extra foods, snacks and supplements are often required in the attempt to optimize nutritional status. The use of lower carbohydrate oral supplements should be considered so as to limit the hyperglycemia frequently seen with the provision of nutrition support. Postoperatively, progression to a regular therapeutic diet should be instituted as soon as it can be tolerated so as to promote proper healing and maintenance of lean body mass. In terms of enteral nutrition, there is insufficient evidence at this time to recommend the use of lower carbohydrate or specialty enteral products designed for patients with diabetes. Nutrition-support prescriptions should be based on the overall metabolic needs of patients, with a preference for enteral nutrition over parenteral nutrition whenever possible. In terms of coordination of care of patients while in hospital, collaboration on all levels is required, including those who design the therapeutic diets and those who deliver the meals. Diabetes adds another level of complexity to the system, and the ideal situation includes coordination of blood glucose testing, insulin administration and meal timing to promote glycemic control. The final step in care coordination in hospital involves discharge education and the creation of an appropriate plan for follow up.
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References 1. Freeland B, Penprase BB, Anthony M. Nursing practice patterns: timing of insulin administration and glucose monitoring in the hospital. Diabetes Educ 2011;37:357e62. 2. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care 2011;34(Suppl 1):S11e61. 3. Elia M, Ceriello A, Laube H, et al. Enteral nutrition support and use of diabetesspecific formulas for patients with diabetes: a systematic review and metaanalysis. Diabetes Care 2005;28:2267e79. 4. Healy S, Black D, Harris C, et al. Inpatient diabetes education is associated with less frequent hospital re-admission among patients with poor glycemic control. Diabetes Care 2013;36:2960e7. 5. Allard JP, Jeejeebhoy KN, Laporte M, et al. Malnutrition in Canadian hospitals: preliminary results from the Canadian Malnutrition Task Force. Clin Nutr 2011; 6:218. 6. Kelly IE, Tessier S, Cahill A, et al. Still hungry in hospital: identifying malnutrition in acute admissions. Q J Med 2000;93:93e8. 7. Kamimura MA, Avesani CM, Bazanelli AP, et al. Are prediction equations reliable for estimating resting energy expenditure in chronic kidney disease patients? Nephrol Dial Transplant 2011;26:544e50. 8. American Diabetes Association. Nutrition recommendations and interventions for diabetes. Diabetes Care 2008;31(Suppl 1):S61e78. 9. Modic M, Kozak A, Siedlecki S, et al. Do we know what our patients with diabetes are eating in hospital? Diabetes Spectr 2011;24:100e6. 10. Otten J, Hellwig L. Acceptable macronutrient distribution ranges. Meyer Dietary Reference Intakes. Washington, DC: National Academies Press, 2006, pg. 70. 11. Houlden R, Capes S, Clement M, Miller D. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: in-hospital management of diabetes. Can J Diabetes 2013;37(Suppl 1): S77e81. 12. Swift CS, Boucher JL. Nutrition Care for Hospitalized Patients with Diabetes. Diabetes Spectrum 2005;18:34e8. 13. Boucher JL, Swift CS, Franz MJ, et al. inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional. J Am Diet Assoc 2007:105e11. 14. Warren J, Bhalla V, Cresci G. Postoperative diet advancement: surgical dogma vs. evidence-based medicine. Nutr Clin Prac 2011;26:115e25. 15. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults. Cochrane Database Syst Rev 2011. 16. Stratton RJ, Hébuterne X, Elia M. A systematic review and meta-analysis of the impact of oral nutritional supplements on hospital readmissions. Ageing Res Rev 2013;12:884e97. 17. Via M, Mechanick JI. Inpatient enteral and parenteral nutrition for patients with diabetes. Curr Diab Rep 2011;11:99e105. 18. McMachon M, Nystom E, Braunschweig C, et al. Nutrition support of adult patients with hyperglycemia. J Parent Ent Nutr 2013;37:23e36. 19. Pasquel FJ, Spiegelman R, McCauley M, et al. Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients. Diabetes Care 2010;33:739e41. 20. Kumph J, Gervasio J. Complications of parenteral nutrition. In: The A.S.P.E.N. Nutrition Support Core Curriculum, 2nd edn. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, pg. 325. 21. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parent Ent Nutr 2009;33: 277e316. 22. Austhof SI, Habib M. Parenteral feeding in diabetes patients: RDs can play a pivotal role in glycemic control. Today Dietit 2011;13:44. 23. Umpierrez GE, Smiley D, Robalino G, et al. Intravenous intralipid-induced blood pressure elevation and endothelial dysfunction in obese African-Americans with type 2 diabetes. J Clin Endocrinol Metab 2009;94:609e14. 24. Liu Z, Liu J, Jahn LA, et al. Infusing lipid raises plasma-free fatty acids and induces insulin resistance in muscle microvasculature. J Clin Endocrinol Metab 2009;94:3543e54.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Nutrition Management of Diabetes in Acute Care Dana Whitham RD, MSc, CDE * St. Michael’s Hospital, Toronto, Ontario, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 December 2013 Received in revised form 16 January 2014 Accepted 17 January 2014
Nutrition therapy in hospital includes the integration of diabetes into the care plan for the presenting condition, basic self-management education and care coordination to promote optimal glycemic control in hospital and an appropriate plan for discharge. Estimated nutrient requirements for people with diabetes are the same as those for the general population, and diets should be designed based on individual metabolic needs. Distribution of meals and snacks should employ a consistent carbohydrate meal-planning approach for both patient safety and management of glycemia. Referral to a registered dietitian for a full assessment is warranted for those at higher risk for hyperglycemia, including those on insulin or nutrition support. Consideration may be given to the use of lower carbohydrate oral nutrition supplements. A team approach should be employed to ensure there is coordination among blood glucose testing, insulin administration and meal timing. Self-management education should focus on patient safety, and an appropriate plan for discharge should be created to manage the ongoing needs of patients with this chronic disease. Ó 2014 Canadian Diabetes Association
Keywords: carbohydrate diabetes diet enteral inpatient meal planning nutrition oral nutrition supplements parenteral Mots clés : glucide diabète régime entéral en milieu hospitalier planification des repas nutrition compléments nutritionnels oraux parentéral
r é s u m é La thérapie nutritionnelle à l’hôpital comprend l’intégration du diabète au plan de soins qui tient compte de l’état de santé, de l’enseignement de base sur la prise en charge autonome et de la coordination des soins pour promouvoir une régulation glycémique optimale à l’hôpital et un plan approprié au moment du congé. Les besoins estimés en substances nutritives des personnes ayant le diabète sont les mêmes que ceux de la population générale, et les régimes devraient être élaborés selon les besoins métaboliques individuels. La distribution des repas et des collations devrait utiliser une approche cohérente de planification des repas axée sur les glucides pour la sécurité du patient et la prise en charge de la glycémie. La consultation d’un diététiste pour obtenir une évaluation complète est justifiée pour ceux qui sont exposés à un risque élevé d’hyperglycémie, dont ceux recevant de l’insuline ou un soutien nutritionnel. L’utilisation de compléments nutritionnels oraux plus faibles en glucides peut être envisagée. Une approche d’équipe devrait être utilisée pour assurer la coordination des analyses de la glycémie, de l’administration d’insuline et de l’heure des repas. L’enseignement sur la prise en charge autonome devrait mettre l’accent sur la sécurité du patient, et un plan approprié au moment du congé devrait être élaboré pour prendre en charge les besoins des patients atteints de cette maladie chronique. Ó 2014 Canadian Diabetes Association
Introduction People with diabetes are more likely to be hospitalized and have longer lengths of stay than those without diabetes (1). One survey estimated that 22% of all hospital inpatient days in the United States involved individuals with diabetes (2), and diabetes is known to account for up to 25% of intensive care admissions (3). Older adults, particularly those with complicated socioeconomic conditions, are at risk for both malnutrition (3) and readmission to
* Address for correspondence: Dana Whitham, RD, MSc, CDE, St. Michael’s Hospital, Toronto, Ontario, Canada. 1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.01.007
hospital (4), highlighting the importance of developing coordinated diabetes care plans upon discharge. A recent report suggests that among medical and surgical units within Canadian hospitals, malnutrition rates are as high as 45% (5). Malnutrition may lead to decreased tolerance of treatment, poor prognosis, increased rates of hospital-acquired infections, poor wound healing and longer lengths of stay (6). Optimizing nutritional status in hospital, therefore, is an essential component of any nutrition care plan. However, the provision of extra foods, snacks or supplements commonly used to treat malnutrition can complicate the management of hyperglycemia in hospital. Additionally, poor intake in hospital may predispose patients to hypoglycemia. This article reviews issues affecting glycemic control while in hospital and
D. Whitham / Can J Diabetes 38 (2014) 90e93
notes some nutrition strategies to manage inpatients with diabetes. Nutrition Care of Patients with Diabetes While in Hospital In addition to managing nutritional status, the goal of nutrition therapy in acute care is to treat illness. Nutrition recommendations from the Canadian Diabetes Association emphasize foods low in energy density and high in volume so as to optimize satiety. Although this may be appropriate in the ambulatory setting, it may not be a priority within the nutrition management of acute illness. In hospital, therapeutic diets should be evidenced based yet maintain enough flexibility to accommodate changes in eating while in hospital and deviations from guidelines, dietary reference intakes or the principles of Canada’s Food Guide may be necessary to meet short-term nutrition requirements. Comprehensive nutrition care plans must consider that the management of diabetes is not a solitary goal, but rather an essential component of the optimization of nutritional status and the management of acute conditions. In general, energy requirements in individuals with diabetes are not different from those without the disease. A recent study concluded that the Harris-Benedict equation accurately predicts resting energy expenditure in patients with diabetes when compared to indirect calorimetry (7). The American Diabetes Association guidelines indicate that the metabolic needs of most patients with diabetes in hospital range between 25 and 35 kcal/kg per day (8). Despite an adequate provision of calories in hospital, patients often take in an insufficient amount of both carbohydrates and calories, leading to an increased risk for hypoglycemia (9). One study, designed to examine the estimated requirements, the average daily meal consumption and the factors affecting intake in hospitalized patients with diabetes, provided some concerning data. First, the metabolic requirements of 434 patients (mean age 65.9 years; body mass index 31.4 kg/m2) were estimated to be approximately 2100 kcals, based on the Mifflin-St. Jeor equation. Second, the intake by study participants was very poor. Over 3 days, the average caloric intake was no more than 828 kcals (9), and subjects consumed less than half of the carbohydrate provided (mean intake 107 to 117 g/day). Additionally, between 18% and 34% of the subjects consumed no food at all (some of them had an nil per os [NPO] order), and breakfast was the meal most commonly cited for no intake. Only 25% consumed all of their meals at the start of the 4-day test period. Patient interviews were conducted to determine the reasons for the inadequate meal consumption. Patient-related issues, such as loss of appetite and dislike of the foods offered, accounted for 42.2% of the factors leading to inadequate intake. Treatment issues (32.6%) included NPO orders or interruptions of mealtimes. Illness-related issues (15.1%) included nausea and vomiting, fatigue and pain. Finally, system issues, including the need for assistance in eating or the inaccessibility of the meal tray, were cited as factors in 1.9% of subjects. This study highlights the increased risk for hypoglycemia in hospital. In addition to the intake issues listed above, ensuring that a sufficient amount of carbohydrate is provided and adequately distributed is of additional importance for optimal glucose control. Nutrition recommendations for the proportion of carbohydrates, protein and fat in the diet are the same for people with diabetes as for those without diabetes. A range of macronutrient content is recommended to allow for flexibility and to suit the needs and preferences of the individual. Therapeutic diets planned for use in patients with diabetes should fit within the acceptable macronutrient distribution ranges of between 45% and 60% for carbohydrates, between 15% and 35% for protein and between 30% and 45% for fat (10). No single meal plan or “diabetic diet” is defined in the management of diabetes. To prevent hyperglycemia and its
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associated complications, energy intake should be adjusted to patients’ requirements, avoiding over-nutrition and excessive glucose intake. Protein intake should be adjusted to the degree of metabolic stress. Overly restrictive diets should not be used in a short duration of stay and may actually contribute to poor nutrition intake (8). Both the Canadian Diabetes Association and the American Diabetes Association recommend that organizations implement a consistent carbohydrate diabetes meal-planning system (8,11). Especially for patients taking insulin, consistency in both timing and carbohydrate amount is essential to limit hyper- and hypoglycemia. In most situations, diets that limit sources of concentrated sweets or sugar are no longer appropriate because they unnecessarily restrict sucrose without consideration of the overall carbohydrate content of the meals (12). Consistent carbohydrate-based diabetes diets A consistent carbohydrate diet is considered the most appropriate in hospital, both because carbohydrate has the greatest effect on blood glucose and also because a consistent provision of carbohydrate is ideal for patient safety (8,11). These plans provide the needed consistency in day-to-day meals and snacks but without the structure of having to ensure that the carbohydrate is distributed among starch, fruit and milk as would be seen in the exchangebased diets. A greater variety of food can be selected and more or less protein and fat can be allowed as per preference and appetite. For individuals who practise carbohydrate counting and those with poor appetites, nausea, vomiting or the inability to consume the whole meal, the carbohydrate amounts listed on the menus can assist patients and providers to estimate intake more accurately and, subsequently, the appropriate amount of insulin required for the meal. Carbohydrate lists can be created for the food items seen in the menu rotation at the hospital and can be made available by the food-service department. Patients and families should also be encouraged to disclose any additional foods consumed so as to assist healthcare practitioners in determining appropriate insulin doses. Patterned and exchange-based diabetes diets Traditionally used for many years, exchange-based diets provide fixed calorie levels with explicit distribution of carbohydrate, protein and fat. Exchange diets are designed with set amounts of food groups (starches and grains, meats and alternatives, fruit, vegetables, milk products and fat) at each meal in order to provide a consistent calorie level and a balanced intake each day. Carbohydrate choices are distributed throughout 3 meals and, depending on the calorie levels, the addition of morning, afternoon and bedtime snacks. As a benefit, these diets provide consistency in carbohydrate and also in the provision of food groups high in protein, which may be beneficial in situations of metabolic stress. As a limitation, these patterns limit individuals’ abilities to select more or less of certain foods or food groups that might be preferable and would ultimately improve overall intake in hospital. Based on the work processes within most hospitals, meals are generally provided within relatively short time intervals. In general, no more than 5 to 6 hours separate meal times, which creates a situation in which the overnight time frame is quite long, and a bedtime snack may be required to prevent hypoglycemia. It also creates an issue in which daytime snacks may not be required and may lead to hyperglycemia. Consideration of meal times is essential when creating an appropriate medication regimen and in managing patients on existing insulin regimens. Regardless of the method of delivery, the primary goals of nutrition therapy in hospital are to manage glycemic control so as
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to promote recovery from illness, surgery or disease; to integrate glycemic control into the treatment of the primary diagnosis or presenting illness; and to create appropriate discharge plans.
with supplement use and should be considered for those whose metabolic needs can be met with a specialty product. Enteral nutrition
Determining insulin doses In a stable patient who is consuming regular meals in hospital, providing a fixed dose of mealtime or bolus insulin is the most common approach. Because the carbohydrate amount of the meal in either the exchange-based diets or the carbohydrate-consistent diets remains the same, the insulin dose can be standardized. Adjustments of the base dose can then be made to accommodate pre-meal hyperglycemia. Any food-related adjustment is based on the carbohydrate component of the meal only; for example, if the individual eats only half of the carbohydrate foods provided, the bolus dose is reduced by half. Alternatively, in some patients, an insulin-to-carbohydrate ratio could be determined and the dose adjusted at each meal based on the amount of carbohydrate to be consumed. Mealtime insulin can also be injected after the meal in the situation of nausea, vomiting or poor appetite. Although it is not complex to adjust the dose of bolus insulin with the meal, the coordination of blood glucose testing, meal timing and insulin delivery within the inpatient setting remains a challenge. Rapid insulin should be administered within 30 minutes of a capillary test and no more than 15 minutes before the meal (1). One review found that rapid insulin was given more than 20 minutes in advance of the meal in the majority of cases (1). Proper administration of insulin in coordination with the meal will likely require a review and restructuring of the current work flow and process in hospital. Involving patients in their diabetes care can be of benefit because some patients can take on full ownership of their insulin dosing and blood glucose testing. Alternatively, patients could remind the staff to check blood glucose levels and give insulin at appropriate times.
Unless contraindicated, patients requiring nutrition support should be fed enterally. In the context of diabetes, enteral nutrition is associated with less hyperglycemia and lower insulin requirements compared to parenteral nutrition (PN). Enteral nutrition should be administered early, ideally within the first 24 hours of admission to the intensive care unit and after hemodynamic stabilization. Early initiation of enteral nutrition has been indicated to be well tolerated and to have benefits for nutrition status, wound healing and postoperative complications (14). Enteral nutrition prescriptions should be determined on the basis of patients’ metabolic needs. Standard enteral formulas contain between 1 and 2 kcal/mL and are generally high in carbohydrate and low in fat and fibre. These formulas promote rapid gastric-emptying rates and nutrient absorption. The carbohydrate content of formulas range from as much as 54% of calories down to as low as 34% in some newer diabetes products (17). Specialty diabetic products replace carbohydrate with monounsaturated fat while also providing 10 to 15 g/L of dietary fibre (17). No specific guidelines exist for patients with diabetes requiring nutrition support, and the evidence for promoting specialty diabetic enteral products has not yet been endorsed by the American Society for Parenteral and Enteral Nutrition (18). Research regarding the use of lower carbohydrate enteral formulas has been limited in duration, has focused on oral use only or was conducted in long-term care, rehabilitation or outpatient settings. For individuals on continuous feeds, staff must be prepared to prevent and treat hypoglycemia if interruptions in feeding occur and insulin or insulin secretagogue doses have already been delivered. For those on bolus feeding schedules, insulin doses should be administered after the bolus has been delivered. Parenteral nutrition
Postoperative, NPO or clear-fluid diets Energy from carbohydrate is necessary during illness or recovery from surgery so as to preserve brain function and lean body mass. Clear- and full-fluid diets should provide no fewer than 130 grams per day and ideally closer to 200 grams of carbohydrate daily, distributed throughout the meals. Non-caloric fluids and sugar-free liquid diets are not appropriate (13). Despite research to suggest otherwise, many patients are put on postoperative diet progressions that move from NPO status through a clear-fluid diet to a regular therapeutic diet in an as-tolerated manner. This process, however, can negatively impact intake in a crucial time frame during which appropriate calories and nutrients are required for healing (14). Advancement to a regular diet directly from NPO status has been shown to be well tolerated and to provide adequate nutrients without delay (14), and it is considered a component that enhances recovery after surgery. Nutrition interventions aimed at increasing calories and protein through food or supplements have demonstrated positive outcomes, including improvements in weight (15) and nutritional status (16). One systematic review determined that the addition of standard oral nutrition supplements resulted in fewer hospital readmissions, especially for older patients (16). Standard oral nutrition supplements range from 50% to 67% of calories as carbohydrate, whereas specialty diabetic products range from 33% to 47% of calories as carbohydrate but commonly contain fewer calories. Studies have demonstrated improvements in glucose control (both fasting and postprandial) with use of the lower carbohydrate supplements designed for people with diabetes (3). As such, the use of lower carbohydrate products may alleviate some of the hyperglycemia commonly seen
Hyperglycemia is the most common complication associated with PN; it occurs in 10% to 88% of hospitalized patients receiving PN (19). Although the benefit of parenteral nutrition in improving the nutrition status of malnourished patients is clear, parenteral nutrition is also associated with an increased risk for infections and mortality, with a component of that risk being related to the development of hyperglycemia (19). In one study, patients with elevated blood glucose readings (>8 mmol/L) prior to and within 24 hours of initiating parenteral nutrition had poorer outcomes and increased mortality rates (19). According to the recommendations of the American Society for Parenteral and Enteral Nutrition, parenteral nutrition should be initiated at half of the estimated energy needs or approximately 150 to 200 grams for the first 24 hours (20). Individualization down to as low as 100 to 150 grams of dextrose (21) or 1.5 to 2 mg/kg/min (18) may be considered in a hyperglycemic patient on insulin therapy. Upon control of blood glucose, the dextrose dose can be increased. If the parenteral nutrition contains insulin, it is necessary to maintain the ratio of insulin to dextrose if adjustments are made in dextrose calories (22). Care should also be taken with low-dextrose, high-fat concentrations; recent studies demonstrate worsening insulin resistance with high levels of free fatty acids (23, 24). Upon stabilization, carbohydrates should be maintained with at least 2 mg/kg/min and not exceed a rate of 4 to 5 mg/kg/min or 20 to 25 kcal/kg/d (20,21). Discharge Planning Self-management discharge education should focus on survival skills and centre on the prevention and treatment of hypoglycemia,
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consumption of appropriate amounts and types of carbohydrate and the distribution of meals and snacks suited to the individual. Diabetes is a chronic disease requiring long-term follow up, so inpatient care providers should ensure that appointments are made (ideally within 1 month [2]) with community-based diabetes care teams, tertiary diabetes care centres or primary care physicians.
Conclusions Effective management of diabetes in hospital involves a delicate balance of optimizing nutritional status and treating illness while minimizing hyperglycemia and avoiding hypoglycemia. A consistent carbohydrate diet has been endorsed as the ideal approach by both the American and Canadian Diabetes associations. The consistency provided by the diet makes the medical management easier, yet the flexibility of the diet is enough to promote an increase in patient satisfaction and intake. The barriers to adequate nutrition in hospital include poor appetite; conditions causing difficulty in eating or the inability to eat; NPO status; delayed or interrupted meals because of surgery, tests or procedures; increased needs resulting from catabolic stress; and provision of meals and food at times that are different from patients’ usual times (12,24). Because of the many factors affecting individuals’ intake in hospital, the risk for hypoglycemia is high. Hypoglycemia is a limiting factor for optimal glycemic control in hospital, especially in individuals requiring insulin. In addition to the meal-related issues known to predispose an individual to hypoglycemia, reduction in intravenous dextrose and frequent and unexpected interruptions in enteral feeding or parenteral nutrition (2) should also be considered. Malnutrition rates in hospital are also high, and the provision of extra foods, snacks and supplements are often required in the attempt to optimize nutritional status. The use of lower carbohydrate oral supplements should be considered so as to limit the hyperglycemia frequently seen with the provision of nutrition support. Postoperatively, progression to a regular therapeutic diet should be instituted as soon as it can be tolerated so as to promote proper healing and maintenance of lean body mass. In terms of enteral nutrition, there is insufficient evidence at this time to recommend the use of lower carbohydrate or specialty enteral products designed for patients with diabetes. Nutrition-support prescriptions should be based on the overall metabolic needs of patients, with a preference for enteral nutrition over parenteral nutrition whenever possible. In terms of coordination of care of patients while in hospital, collaboration on all levels is required, including those who design the therapeutic diets and those who deliver the meals. Diabetes adds another level of complexity to the system, and the ideal situation includes coordination of blood glucose testing, insulin administration and meal timing to promote glycemic control. The final step in care coordination in hospital involves discharge education and the creation of an appropriate plan for follow up.
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