In Brief Multiple staff members and departments have a responsibility for various FROM aspects of nutrition therapy for glycemic management in the hospital setting. Implementation is initiated by physicians, nurse practitioners, and physician’s assistants and planned and operationalized by registered dietitians. Meals are R delivered by food service staff, and nurses monitor and integrate glycemic ESEARCH TO PRACTICE / control components into patients’ medical treatment plan. Although nutrition therapy is recognized as an important aspect of care in the hospital setting, it can also be challenging to appropriately coordinate meals with blood glucose monitoring and insulin administration. This article addresses current meal- time practices and recommendations to improve these processes in acute care. The Mealtime Challenge: Nutrition and Glycemic Control in the Hospital I N P ATIENT GLYCEMIC GLYCEMIC ATIENT Management of diabetes and hyper- (RDs) regarding current hospital meal glycemia has become an important service practices are also included. Donna B. Ryan, MPH, RN, RD, quality care indicator in the hospital setting. Multiple health care organi- Nutrition Therapy in the Hospital CDE, and Carrie S. Swift, MS, RD, MNT is a well-recognized component BC-ADM, CDE zations offer guidelines for glycemic of diabetes management, and experts M control, including recommendations agree that it should be integrated into ANA for medical nutrition therapy (MNT) the glycemic management of hospi- and consistent-carbohydrate meal 1,2,4 talized patients. MNT is the legal G 1–4 plans. Additionally, the appropriate definition of nutrition counseling pro- EMENT timing of nutrition delivery, point-of- vided by an RD.7 The term applies care (POC) blood glucose monitoring, to the nutrition care process, which and insulin therapy in the hospital is includes assessment of nutrition status; I recognized as a crucial step in the safe provision of nutrition interventions and effective care of patients.3,5 such as diet modification, counsel- Although these goals are essential ing, or specialized nutrition therapy; 8 to reducing harm and improving out- and monitoring and evaluation. RDs knowledgeable in glycemic manage- comes, how to achieve them can be ment are the preferred health care a challenge for hospitals. A quality team members to provide diabetes improvement approach with strong MNT.7 Because of limited hospital administrative support and a multidis- staffing of clinical dietitians, MNT ciplinary steering committee is needed provided by an RD is generally only to improve the quality of patient available by consultation or to patients care.2,3,6 identified to be at high nutritional This article summarizes nutrition risk. The broader term “nutrition therapy goals and recommendations therapy” will be used in this article for glycemic control in noncritically to include other aspects of nutrition ill, hospitalized patients; reviews the care provided by various health care rationale for consistent-carbohy- professionals during hospitalizations. drate meal plans and liberalizing the Glycemic control is the primary nutrition goal for hospitalized patients “diabetic diet;” and describes suc- with diabetes. Additional nutrition cessful mealtime practices to improve therapy goals include promoting opti- coordination of meal delivery with mal caloric and nutrient intake to meet blood glucose monitoring and insu- metabolic needs; aiding in recovery lin administration. Results from an from illness, surgery, and disease; and informal survey of inpatient diabetes allowing for food preferences related educators and registered dietitians to patients’ personal, cultural, ethnic, Diabetes Spectrum Volume 27, Number 3, 2014 163 Table 1. Key Nutrition Recommendations for Diabetes and Glycemic Control in the Hospital Topic Details Nutrition therapy Implementation of nutrition therapy improves the care of patients with diabetes and hyperglycemia during hospitalization. RDs who are knowledgeable about glycemic control are the preferred team members to provide MNT.1–4 Consistent-carbohydrate meal plan The consistent-carbohydrate meal plan is the established standard for hospitalized patients with diabetes and is useful to improve the accuracy of mealtime insulin administration.1,4 • Evidence does not support the use of “no concentrated sweets” or “no sugar” diets. Sucrose-containing foods may be incorporated into a consistent-carbohydrate meal plan.7 • The “ADA diet” is not current practice and should not be used. It may unnecessarily restrict calories and patients’ preferred foods. Since 1994, ADA has not recommended a specific type of diet or macronutrient distribution.9 Liberalized diets Inadequate nutrition intake is common in hospitalized patients. To improve oral intake and enhance patients’ satisfaction, liberalized diets without caloric restriction (e.g., a general diet with consistent amounts of carbohydrate), room service on demand, and increased availability of foods that meet personal, cultural, or religious food preferences have been implemented in some acute-care facilities.9 Coordination of meal delivery Diabetes educators and RDs are key interdisciplinary team members to improve coordination of meal delivery, insulin administration, and POC blood glucose monitoring to optimize glycemic control.10 and religious beliefs. Additionally, an of carbohydrate offered should be lead to increased glycemic variability. individualized discharge plan should from whole grains, fruit, legumes, With appropriate training, nursing be developed for self-management vegetables, and low-fat dairy foods, assistants and meal service represen- training and follow-up.1,3,4 Key rec- when possible. tatives can play a role in increasing ommendations for meal planning to Sucrose-containing foods can the accuracy of carbohydrate estima- meet patients’ nutrient requirements be offered on this meal plan, and tion. Bedside tray delivery provides and improve glycemic control in the including them may help an indi- opportunities for communication with hospital setting have been identified vidual meet caloric intake goals and patients and family members about the (Table 1).1– 4,7,9,10 provide for individual food prefer- carbohydrate content of menu items or ences.11 Misunderstanding of the snacks.9 With appropriate insulin dos- Consistent-Carbohydrate Meal inclusion of sucrose-containing foods ing and administration, snacks do not Planning remains common. Some patients, pro- have to be automatically included in Because of the limited available evi- viders, and hospital staff may think the nutrition plan for patients on basal dence identifying ideal meal plans that patients are not on a “diabetic insulin therapy. Inclusion of snacks for hospitalized patients, expert con- diet” unless sucrose is restricted. should be based on patients’ prefer- sensus has been the basis for current Additionally, patients and families ences and nutrition goals.12 recommendations. Because carbo- may lack understanding of the meal Guidelines should be in place to hydrate intake provides the primary plan, potentially leading to excesses address the involvement of patients nutritional effect on blood glucose, in calorie and carbohydrate intake and their family members in self-care consistent-carbohydrate meal plan- from foods brought in from outside tasks such as blood glucose monitor- ning has evolved as the accepted the facility or further restriction when ing, reporting carbohydrate intake standard for glycemic control. These well-meaning family members remove to staff members, and appropriately meal plans offer a practical method of food from the meal tray. notifying staff members about food serving food to patients, while poten- brought in from outside the hospi- tially improving glycemia. Specific Strategies for success with consistent- tal. Nurses and nursing assistants calorie levels are not recommended; carbohydrate meal planning can help to educate patients and rather, a consistent amount of carbo- A key teaching point for hospital staff their families by taking advantage hydrate is offered at meals and snacks is that the amount of carbohydrate of teachable moments during patient from day to day. For convenience of eaten, rather than the sugar content care. Resources for carbohydrate esti- implementation, many facilities pro- or the percentage of the meal eaten, mation should be readily available to vide consistent-carbohydrate meal has the greatest impact on blood glu- staff and patients. Having the carbo- plans with specific calorie levels that cose. If the only parameter monitored hydrate content of foods noted on the may not address the actual caloric at the facility is the percentage of the menu assists patients with selecting the needs of a given patient. To meet meal eaten, over- or underestimation appropriate foods and can be used by nutrient requirements, the majority of total carbohydrate consumed might nursing staff as a teaching tool to help 164 Diabetes Spectrum Volume 27, Number 3, 2014 patients better understand the con- metabolic control, and promote posi- to patients with diabetes, which has cept of carbohydrate counting. When tive health status. To meet therapeutic created additional challenges in coor- FROM patients gain a better understanding requirements, these diets may be more dination of meals with insulin therapy of which foods contain carbohydrate, restrictive than necessary, especially and blood glucose monitoring.23,24 appropriate substitutions can be made for older, malnourished,