MNT is an essential component of inpatient glycemic management in patients with diabetes and hyperglycemia and contributes to an anabolic environment in patients with an acute illness requiring hospitalization. Lack of attention to MNT in the hospital contributes to unfavorable changes in blood glucose and inappropriate use of insulin therapy [2•
]. No randomized controlled studies have compared different nutritional strategies in the hospital, but the use of consistent carbohydrate diabetes meal-planning system has been shown effective in facilitating glycemic control in the hospital setting [18••
]. This system is based on the total amount of carbohydrate offered rather than on specific calorie content at each meal. An advantage to the use of consistent carbohydrate meal plans is that they facilitate matching the prandial insulin dose to the amount of carbohydrate consumed [21
]. In surgical patients or in those patients requiring clear or full liquid diets, delivery of approximately 200 g of carbohydrate per day in equally divided amounts at meal and snack times is recommended. Use of clear liquids containing sugar is recommended. After surgery, food intake should be initiated as quickly as possible and as tolerated with progression from clear liquids to full liquids to solid foods [25
]. A “clear liquid diet” is the most frequently ordered as the first postoperative meal. Although generally well tolerated, liquid diets fail to provide adequate nutrients to the postsurgical patient. After surgery, food intake should be initiated as quickly as possible, and progression from clear liquid to full liquid to solid foods should be completed as rapidly as tolerated [21
]. provides a summary of a nutrition approach to the hospitalized patient with diabetes.
General approach to nutrition in hospitalized patients with diabetes
In critically ill patients, who are in a catabolic state, EN and PN can prevent and correct the effects of starvation and malnutrition. Solid evidence indicates that EN is preferable to PN because of the higher risk of infectious and noninfectious complications with PN therapy [24
]. Specialized diabetic enteral formulas appear to reduce postprandial hyperglycemia, as well as glycemic variability and insulin requirements compared with the use of standard formula in patients with type 2 diabetes. Recent randomized trials and meta-analyses have reported that PN may result in increased risk for infectious complications and mortality in critically ill patients [6
]. The increased risk of complications and mortality during PN therapy may be related to the development of hyperglycemia [50
] or to the administration of soybean-based lipid emulsions with high content of linoleic acid and ω-6 PUFA [58
, 70]. Avoidance or correction of hyperglycemia with intensified insulin treatment or the use of new lipid emulsions with low concentration of saturated fatty acids may improve clinical outcome in critically ill patients treated with PN [62
Future studies are needed to determine the safety and beneficial effects of specialized diabetic versus standard enteral formulas in improving glycemic control in the hospital and long-term care facilities. In addition, randomized controlled trials are needed to determine the safety and efficacy in clinical outcome between intensive versus less intensive insulin therapy and between new versus traditional-based lipid emulsions in critically ill patients.