Nutrition Support of the Diabetic Patient

Abstract

Diabetes, as the component of the past medical history of individuals requiring nutrition support, poses specific problems to the clinician managing the patient. Besides an exaggerated glucose response to nutritional intervention, diabetics may have conditions or treatments that increase the morbidity and mortality associated with nutrition support therapy. As such, nutritional intervention should only be considered in patients for whom therapy is appropriately indicated. Then, the caloric dose, rate, and route of enteral and parenteral nutrition needs to be determined precisely. Glucose homeostasis along with etiologies and clinical manifestations of hyper- and hypoglycemia are to be clearly understood before initiating any nutritional support therapy in the diabetic. Without such, confusion may arise in determining the etiology of glucose problems occurring in patients from all the possible variables that influence the final serum glucose concentration in the patient. A cautious approach to initiating nutrition support is recommended, starting with low flow rates (10 to 20 mL/h for enteral nutrition and 40 mL/h for parenteral nutrition) and gradual incremental increases (in the 10- to 20-mL/h/d range) based on careful observation of blood glucose concentrations. A goal for tolerance should be established for each patient at the beginning of therapy, specifically, acceptable peak and trough glucose concentrations. This provides an extremely good template for adjusting the route (subcutaneous or intravenous) or type (intermittent vs continuous infusion) of insulin therapy. When the nutrient dose is stabilized at the optimal rate and insulin requires no further adjustment, transition of the patient to more appropriate, chronic therapy such as long-acting insulin or oral hypoglycemics is desired. The management of the diabetic patient on nutrition support is a challenge for even the most experienced individual. The potential for complications is abundant. A cautious, conservative approach is recommended with particular attention to minimizing the sources of both glucose and insulin administration.