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Inpatient Management of Diabetes and Hyperglycemia: Implications for Nutrition Practice and the Food and Nutrition Professional

https://doi.org/10.1016/j.jada.2006.10.006Get rights and content

Abstract

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the inpatient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.

Section snippets

The Evidence for Improved Inpatient Glycemic Control

Hyperglycemia itself has been linked to poor outcomes in hospitalized patients (1, 3). Hyperglycemia has been associated with immunosuppression, negative effects on the cardiovascular system, blood pressure changes, catecholamine elevations, platelet abnormalities, electrophysiologic changes, brain ischemia, and changes in the vascular endothelial cells (1, 3). In addition, thrombosis associated with hyperglycemia may explain the increased thrombotic events commonly seen in hospitalized

Implications of Glycemic Targets on Medical Care

Achieving blood glucose targets requires that all members of the health care team work together to develop, review, and/or maintain standards and protocols on the following topics (1):

  • Screening for hyperglycemia on admission and/or identification of hyperglycemia during hospitalization.

  • Guidelines for discontinuation of oral diabetes medications for individuals with diagnosed diabetes, and use of insulin therapy, as appropriate, for all patients with hyperglycemia.

  • Integration of blood glucose

The Goals of MNT for Hospitalized Diabetes Patients

MNT is an essential component of diabetes management for persons with diabetes (18) and thus should be integrated with the medical treatment plan. MNT includes an assessment of nutritional status and the provision of diet modification, counseling, or specialized nutrition therapy (19). Implementing MNT, however, can be challenging when the person with diabetes is hospitalized. Individualization of MNT during hospitalization, along with intensive medical management, is required if individuals

Use of a Consistent Carbohydrate Diet in Inpatient Settings

The consistent carbohydrate meal planning system for hospitals was developed to provide a practical way of serving food to diabetes patients in a hospital setting while improving metabolic control (22). This system is not based on specific calorie levels, but on the amount of carbohydrate at each meal or snack. The carbohydrate amount is consistent from meal to meal and day to day with the focus on the total amount of carbohydrate in a meal (22). The primary sources of carbohydrate are fruits,

Special Nutrition Issues and Considerations for Inpatient Settings

In the hospital setting, it is often difficult for patients to follow their usual food plan and in many cases their oral intake is less than usual. Barriers that may impact an individual’s nutrition status include: increased nutrient and calorie needs due to catabolic stress, variation in medications, illness-induced appetite suppression, and the possible need for enteral or parenteral nutrition support. Use of nutrition supplements or nutrition support may be required to meet the person’s

Liquid and Progression Diets

Noncaloric (sugar-free) liquid diets are not appropriate for individuals with diabetes or illness-induced hyperglycemia. Calories and carbohydrates are needed to meet increased glucose requirements during illness and surgery (22). Individuals on clear or full liquid diets should receive approximately 200 g of carbohydrate throughout the day divided in equal amounts at meals and snack times to prevent starvation ketosis (25, 26, 27, 28, 29) (Table 2). Advancing from clear liquid to full liquid

Implications of Glycemic Targets for Food and Nutrition Professionals

Achieving blood glucose targets requires that food and nutrition professionals work with other members of the health care team, utilizing a quality improvement approach, to address nutritional issues that may impact a patient’s ability to achieve glycemic control. Food and nutrition professionals need to not only make recommendations for change, but assess the outcomes of these changes and make additional recommendations. Key areas of focus to improve inpatient glycemic control are:

  • Screening

J. L. Boucher is director, Health Programs and Performance Measurement, HealthPartners, Health Behavior Group, Minneapolis, MN.

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    J. L. Boucher is director, Health Programs and Performance Measurement, HealthPartners, Health Behavior Group, Minneapolis, MN.

    C. S. Swift is dietetics coordinator, Walla Walla Veterans Affairs Medical Center, Walla Walla, WA.

    M. J. Franz is a nutrition/health consultant with Nutrition Concepts by Franz, Inc, Minneapolis, MN.

    K. Kulkarni is coordinator, Diabetes Center, St Mark’s Hospital, Salt Lake City, UT.

    R. G. Schafer is a clinical dietitian, Diabetes Clinic, Bay Pines Veterans Affairs Medical Center, Bay Pines, FL.

    E. Pritchett is a clinical dietitian, Mariners Hospital, Tavernier, FL; at the time the paper was written, she was with Quality Management, American Dietetic Association, Chicago, IL.

    N. G. Clark is Vice President, Clinical Affairs, American Diabetes Association, Alexandria, VA.

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