The Role of Medical Nutrition Therapy in Successful Glycemic Management

When it comes to glycemic management in the hospital setting, hyperglycemia is present in every unit. In order to standardize care, it requires a cross functional team with multiple clinicians, staff members, and departments all working together. With March being National Nutrition Month, we are focusing on one of the most important areas of collaboration, nutrition.

Understanding and monitoring a patients’ nutritional intake is a vital part of successfully managing glycemic control. Carbohydrates are the macronutrients that have the most impact on blood glucose. Because of the direct correlation between nutrition and glycemic management, medical nutrition therapy (MNT) is an integral component in maintaining glycemic control for hospitalized patients and must address special challenges related to illness, changes in medications, and erratic meal schedules.

While in the hospital, patients receive nutrition from a variety of sources, including meals, IV solutions, TPN and tube feed products, and for each patient, managing nutrition requires a significant amount of coordination.  Physicians, nurse practitioners, pharmacists, and registered dietitians must work together to develop and implement the medical treatment and nutrition plan.

For most hospital settings, common nutritional interventions include consistent carbohydrate meal plans, progression diets, and nutrition support.  Traditionally, providers have ordered diets for hospitalized patients with diabetes by writing “ADA diet” or 1800 calorie ADA diet.  However, today’s best practice is centered on offering meal plans based upon comparable carbohydrate content.  It’s intended to meet the individual nutritional needs of the patient and to facilitate better glycemic control.

In addition to determining the appropriate nutritional plan for each patient, the coordination of nutrition with all the elements of glycemic management is extremely important. Beyond just making sure steps occur, the timing of the nutrition delivery, blood glucose checks, and insulin therapy in the hospital is essential for effective glycemic management.  For example, regardless of the type of meal plan, trays must be delivered in line with the nursing checks of blood glucose.  And the intake of carbohydrates must be monitored and recorded after each meal, so that the appropriate dose of insulin can be administered.

In a perfect case scenario, a patient would eat all the recommended food at regular intervals to better match the insulin dose necessary, but this is commonly not the case. There are a number of barriers to controlling what patients are consuming and when they are eating. Patients in the hospital setting often have an altered appetite, nausea or other medical conditions impacting their carbohydrate intake and insulin required. They might be eating other food that visitors are bringing into the hospital that nurses are unaware of and not accounting for. And finally, a patient’s meal schedule might simply be interrupted because of scheduled procedures, other nursing priorities, or delays in the hospital mealtime processes.

For some hospitals, there is also the added difficulty of “room service.” As more organizations place an emphasis on patient satisfaction, many facilities have transitioned to on-demand meal delivery giving patients more flexibility and choice of when they receive their meals. While it can be successful, it complicates the workflow and coordination of the corresponding blood glucose checks and bolus doses.

Despite these obstacles, many hospitals have successfully implemented initiatives to standardize the clinical processes and support timeliness of meal delivery and blood glucose checks. While the initiatives vary, and countless examples can be found, key elements exist in all effective MNT programs for glycemic management, including:

• A multi-disciplinary team
• Registered dietitian referrals for high nutritional risk
• Nutritional assessment
• Comprehensive review of workflow to identify gaps in meal delivery and glucose management
• Improved communication with all stakeholders including patients and families, dietary, pharmacy, and nursing departments
• Ongoing education for staff, patients, and family members to increase understanding of the meal delivery and glucose management system

In addition to these elements, the use of an electronic glucose management system like EndoTool® can significantly help in standardizing the process. With EndoTool, nurses record the nutrition, receive a recommend insulin dose or supplemental carbs, and are reminded of the timing for blood glucose checks with alerts and notifications.

The management of nutrition in the acute care setting is just as important as checking a patient’s blood glucose and administering insulin. The two are interdependent. To improve glycemic management, the coordination of a patient’s nutrition has to be a priority, and it requires all departments and staff work together.