Managing Inpatient Nutrition for Optimal Glycemic Control

I will never forget rounding in a busy ICU just before lunchtime, standing within earshot of a patient with type 2 diabetes ordering her lunch: a cheeseburger, fully loaded, with a side of french fries and chocolate ice cream for dessert. I cracked a smile as my stomach growled and my mouth watered; it sounded delicious.

The patient’s tray arrived within 30 minutes and on it was a lone bowl mounded with steamed broccoli. She let out an audible wail of protest. With a primal empathy, I commented to those bustling around the nurses’ station, “Couldn’t we have at least started with a whole wheat bun?”

There is no doubt  that humans have a complicated relationship with food. When we are sick, we all seek out foods to comfort us, like hot tea and Popsicles. It’s difficult to think of food and nutrition as medicine when we are sick. But that is exactly how we, patients and medical professionals, need to shift our thinking.

Medical Nutrition Therapy Prevents Poor Clinical Outcomes

Ask most inpatient clinicians what medical nutrition therapy entails and the first thing that spills forth is meeting the increased metabolic demands of illness using enteral or parenteral feed formulas.

Far more than supplementing with feeding formulations, medical nutrition therapy, too, includes what patients eat during their inpatient stay. All jokes about the uninviting food that arrives on a hospital tray aside, institutions often provide appropriate nutrition following low-protein guidelines for patients with renal insufficiencies, low-sodium guidelines for patients with cardiac issues and consistent carbohydrate guidelines for patients with diabetes.

Many institutions with whom we work have adopted patient-controlled meal plans which allows patients to choose from a menu of options or bring food from home. This approach poses a challenge for the medical nutrition therapy plan that should involve the patient and the clinical team. While the patients are more satisfied with choosing meals, the entire plan of care can be impacted by not partnering with them to create and follow an inpatient medical nutrition therapy plan. This is especially true with our patients who are either dependent on or require insulin to control their blood glucose (BG) around meal time. Patients with diabetes are at risk while hospitalized to experience extreme blood glucose highs (BG >180 mg/dL) and lows (BG <70 mg/dL), both of which contribute to delayed and/or poor healing.¹

The American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) as early as 2004 have recommended basal-bolus insulin therapy over use of correction scales in the inpatient plan of care. To prevent poor clinical outcomes, administering premeal bolus insulin dosing needs to coincide with a solid medical nutrition therapy plan:²

• Perform a thorough nutrition assessment including food preferences and nutrition management practices when not hospitalized.
• Collaborate with the patient and family members in the development of an inpatient medical nutrition therapy centered on the patient’s criteria for getting better.
• Observe nutrition choices, provide feedback, guide and intervene.

A small study³ performed at University of Pittsburgh Medical Center powerfully emphasizes this need. The study divided patients with diabetes into two groups. One group received institutional meals that followed consistent carbohydrate guidelines, but no nutrition consult. The other received patient-controlled meals with a nutrition consult.

The researchers observed that patients in either group who brought food from outside the hospital experienced greater hyperglycemia. Although neither group experienced severe hypoglycemia (BG <40 mg/dL), the patient-controlled meal group experienced greater hypoglycemia (BG <70 mg/dL). The data suggests choosing too little a carbohydrate portion and not actual meal consumed contributed to these hypoglycemic events. Further, the study identified a high percentage of patients never received nutrition education from a registered dietitian as part of their diabetes management, providing an opportunity for hospitals to deliver education or direct them to more extensive medical nutrition therapy in the outpatient setting.

Committing ourselves as inpatient medical professionals to incorporate a patient-centered medical nutrition therapy plan into our respective practices will fortify our patients’ plans of care.  Through collaboration we can guide our patients to connect the importance of a meal’s role in preventing poor clinical outcomes and more importantly building a better quality of life.

So, looking back at the arrival of the steamed broccoli, starting with a whole wheat bun is not the solution. What we need to do is first start with a conversation.

References:

1. Whitham, D. Nutrition Management of Diabetes in Acute Care. Canadian Journal of Diabetes. 2014;38(2):90-93.
2. Pastors J, Warshaw H, Daly A, Franz M, Kulkarni K. The Evidence for the Effectiveness of Medical Nutrition Therapy in Diabetes Management. Diabetes Care 2002;25(3):608-613.
3. Curll M, Dinardo M, Noschese M, Korytkowski MT. Menu selection, glycaemic control and satisfaction with standard and patient-controlled consistent carbohydrate meal plans in hospitalised patients with diabetes. Qual Saf Health Care 2010;19(4):355-9.