Background. Although hyperglycemia in hospitalized patients occurs frequently and is associated with morbidity and mortality, its treatment with insulin has been shown to improve clinical outcomes. Safe and effective inpatient glycemic control requires trans-disciplinary expertise that includes dietitians, nurses, pharmacists, and physicians as well as the coordination of care among diverse health care services. Processes related specifically to diet are important because of the key role that food intake plays in the regulation of blood glucose. However, very little is known about the influence of dietary factors on outcomes in hospitalized patients with diabetes.
Objective. This investigation seeks to identify the role of dietary factors in the management of hospitalized patients with diabetes. The overall hypothesis is that glycemic control in hospitalized patients is influenced by the coordination of timing between the consumption of meals, blood glucose measurement, and insulin administration; as well as the amount and composition of meals.
Participants. Eighty-two patients were selected from a general medical ward where meal slips, 24 hour food recalls, the patient medication administration record, and other medical records were used for data collection.
Methods. Insulin administration records for the entire cohort and the cohort receiving scheduled insulin were utilized to examine the timing of insulin administration in relation to the meal and the adjustment of insulin dose based on carbohydrate intake. Twenty four-hour dietary recall was used to assess patient intake and compare calorie and carbohydrate consumption with the amounts ordered, served, and needed.
Results. Data analysis demonstrated that appropriate timing between point of care (POC) glucose measurement and meals was infrequent (28.0%). The smallest deviation in blood glucose level between post-prandial and fasting measurements was observed for the time interval where POC glucose measurement was closest to the corresponding meal, although the difference was not significant when compared with the other time intervals. Analysis of subjects' diet revealed significant differences in mean carbohydrate distribution between breakfast, lunch and dinner (84 ±16 grams, 94 ±19 grams, and 76 ±21 grams respectively [P<.01]). The mean value of calories ordered by the physician (2017 ±165) and served by food service (2415 ±447) was higher than the calculated requirement (1792 ±340) (both p<.01) and what was eaten by the patient (1685 ±576) (both p<.01). However, the amount of calories consumed was similar to what was required (p=.43).
Conclusions. Our findings suggest that POC glucose measurement, insulin administration and meal intake are inadequately coordinated in hospitalized patients with diabetes and that this may adversely affect glycemic control. Furthermore, carbohydrate consumption among meals is variable and dietary orders reflect an excessive amount of calories compared to both estimated requirements and what the patient eats. Interventions are warranted that educate health professionals about the nutritional needs for hospitalized patients with diabetes and the associated influence of diet on prandial insulin requirements. Specifically, safe and effective glycemic control with insulin requires systematic and collaborative processes that coordinate all services influencing the care of the hospitalized patient with diabetes.