Nutrition therapy for the hospitalized patient with diabetes

To summarize recommendations for medical nutrition therapy (MNT), including how to implement it to achieve glycemic control targets for hospitalized patients with diabetes.

The MNT goals for hospitalized patients with diabetics are reviewed, and suggestions are made for attaining these goals. Emphasis is placed on the importance of proper screening and referral of inpatients to MNT service and on the process of providing MNT in the hospital setting.

Implementing MNT in the hospital can be challenging because of the differences in nutrient and medication requirements compared with the home setting. Individualization of MNT during hospitalization, along with intensive medical management, generally is required if patients with diabetes are to achieve blood glucose targets. Barriers that may impact an individual's nutrition status and subsequently affect glycemic control include poor appetite, inability to eat, increased nutrient and calorie needs due to catabolic stress, variation in diabetes medications, and the possible need for enteral or parenteral nutrition support. There is limited evidence on what constitutes the optimal diet for hospitalized patients with diabetes. The consistent carbohydrate meal-planning system has been recommended because carbohydrate intake is the primary nutritional influence on blood glucose; this system focuses on the total grams of carbohydrate as the key strategy to achieve blood glucose control. Introduction of the consistent carbohydrate system requires that all healthcare disciplines understand the rationale of the system; and for the system to be effective, coordination must exist between nursing and nutrition services. Established guidelines for integration of diabetes medications with meals, snacks, or nutrition support, developed by a multidisciplinary healthcare team, will help ensure that the nutrition care plan works together with the medical treatment plan. The key areas of focus to improve inpatient glycemic control are: establishing screening criteria for appropriate referral to a registered dietitian; identifying nutrition-related issues in clinical pathways and patient care plans; implementing and maintaining standardized diet orders such as consistent carbohydrate menus; integrating blood glucose monitoring results with nutrition care plans; using standing orders for diabetes education and diabetes MNT as appropriate; and standardizing discharge follow-up orders for MNT and diabetes education post-discharge when necessary.