Diabetes

• Assessing glycemic control in a patient with T2DM in the in-patient setting


  1. Investigations - HbA1c, capillary blood glucose

  2. Observations - anthropometry, clinical, dietary intake
• What is a long-term measure of glycaemic control?

  HbA1c
• In the UK, HbA1c target is <48mmol/mol, 53mmol/mol if on hypoglycaemia-associated drugs
• Individualised target ranges are usually set, with support of diabetes-specialist nurse
• Patients may self-monitor using continuous glucose monitoring sensors
• There are no specific guidelines for capillary blood glucose targets, these will vary between patients
• Anthropometry


  • Recent weight changes may support understanding of glycaemic control
• Biochemistry


  • Lipid profile helps to assess cardiovascular risk, the higher this is may be linked to poor glycaemic control
• Clinical observations


  • Blood pressure, eye function, foot condition, injection sites, physiological stress, steroid treatments, medication/insulin management
• Dietary


  • Meal patterns, usual dietary intake, carbohydrate intake, types of carbohydrates, overall healthfulness of diet, any dietary interventions previously done
• Continuous feeding


  May lead to persistently higher blood glucose levels depending on the rate and concentration of feed being given
• Bolus feeding


  May cause sharp spikes in glucose but would mimic normal eating patterns more closely
• Enteral feeding is usually simple carbohydrate-based, so will have an impact on glycaemia (usually increase glucose levels)
• It is recommended that diabetes medication is modulated to prevent hyperglycaemia rather than dietary restriction
• Options for enteral feeds


  1. Traditionally standard feeds have been used

  2. More recently diabetes-specific feeds have been developed
• Diabetes-specific feeds


  Use mono-unsaturated fat and fructose/alternative carbohydrates to avoid glucose spikes
• Ojo et al 2019 systematic review found that all studies showed diabetes-specific feeds lowered glucose parameters, improved glycaemic control, and lowered insulin requirements
• The Ojo et al review also found that diabetes-specific feeds improved postprandial blood glucose compared to standard feeds, and provided better clinical outcomes such as reduced risk of acquired infections and pressure ulcers
• The Ojo et al review found that different studies observed different effects on lipid profile, with some finding no difference in cholesterol between groups and some finding higher cholesterol in diabetes-specific feed groups
• The studies in the Ojo et al review were old, ranging from 1998 to 2009, so newer formulations of diabetes-specific feeds may not have been investigated
• Each trial in the Ojo et al review had a different diabetes-specific feed formulation, so it's difficult to determine which is the most appropriate
• The different studies in the Ojo et al review also used different feeding modes (continuous, intermittent, bolus) and some were orally fed, making it hard to determine which is the best approach
• Pros of diabetes-specific feeds in enteral nutrition patients


  • Improve poor glycaemic control
  • Improved conditions = improved outcomes both short and long term
  • Evidence shows efficacy: improved postprandial glucose, lower insulin requirements
  • Improved clinical outcomes: risk of acquiring infections, pressure ulcers
  • Consistent decision-making among dietitians
• Cons of diabetes-specific feeds in enteral nutrition patients

  • Higher levels of fat may impact patients already at greater risk of poor cardiometabolic outcomes
  • High fructose content may lead to lactic acidosis
  • Need more evidence on mortality, morbidity, length of stay
  • Heterogeneity of diabetes-specific feeds used, limited evidence for any one particular recipe/product
  • Some studies used individualised recipes, difficult to do in hospitals
  • Costs are much higher than standard feeds, not routinely available in the NHS