Preoperative carbohydrate loading in surgical patients with type 2 diabetes: Are concerns supported by data?

Currently, there is a lack of consensus on the provision of preoperative carbohydrate loading in patients with type 2 diabetes mellitus (T2DM) due to theoretical concerns including the possibility of delayed gastric emptying, perioperative hyperglycemia, and poor surgical outcomes. This narrative review summarizes the accumulating evidence on preoperative carbohydrate loading in this population and whether these concerns are supported by preliminary evidence. In general, the available research suggests that carbohydrate loading may be implemented in those with T2DM without increased risk for intra- and postoperative hyperglycemia or surgical complications. However, there is strong justification for future research to definitively study this highly debated and timely topic. Ultimately, the inclusion of preoperative carbohydrate loading for surgical patients with DM should be guided by the surgical team's clinical judgment and individualized based on patient needs and characteristics.

Use of a diabetes-specific nutritional shake to replace a daily breakfast and afternoon snack improves glycemic responses assessed by continuous glucose monitoring in people with type 2 diabetes: a randomized clinical pilot study.

INTRODUCTION: This pilot study evaluated the impact of a diabetes-specific nutritional shake (DSNS) used twice daily by people with type 2 diabetes (T2D) on glycemic response assessed by continuous glucose monitoring (CGM). RESEARCH DESIGN AND METHODS: Adults (n=81) with T2D managed by oral medications were studied in a randomized, open-label, three-group parallel study design. The study was conducted in two phases over 14 days: Baseline (days 1-6), during which study participants consumed their habitual self-selected diets (SSD), followed by the Intervention (days 7-14), during which participants were randomized as follows: (1) SSD group received no study product (n=32); (2) DSNS breakfast/afternoon snack (Bkfst/AS) group consumed one DSNS as a breakfast meal replacement and a second to replace their mid-afternoon snack (n=24); (3) DSNS breakfast/prebed snack (Bkfst/PBS) group consumed one DSNS as a breakfast meal replacement and added a second as a prebed snack (n=25). Glucose was assessed by CGM throughout the study. Additionally, participants were asked about snacking behaviors, cravings, and other questions related to the use of DSNS as meal replacements and snacks. RESULTS: All groups reduced their postprandial glycemic response (positive area under the curve (pAUC, mg/min*dL-1)) and adjusted peak value (mg/dL) when compared with the baseline phase. Participants consuming DSNS in place of their usual breakfast showed greater reductions in pAUC compared with the SSD group (p=0.008) for the DSNS Bkfst/AS group with a trend (p=0.069) for the DSNS Bkfst/PBS group. Adjusted peak value showed greater reductions in both DSNS groups as compared with the SSD group (p=0.002 for DSNS Bkfst/AS and p=0.010 for DSNS Bkfst/PBS). Nocturnal glucose variability was significantly decreased during the intervention phase compared with baseline phase in the DSNS Bkfst/AS group (p=0.020), with no significant differences between groups. After intervention, the DSNS Bkfst/AS group had a significantly lower percentage of participants (17%) reporting cravings for starchy meals/sides compared with before the study (33%) (p=0.046). This group also reported a significant increase in confidence in choosing foods to control their diabetes (from 58.3% to 91.7%, preintervention vs postintervention, respectively, p=0.005). CONCLUSIONS: Use of DSNS to replace breakfast and as an afternoon snack improves both glycemic control and behavioral factors related to dietary management of diabetes. TRAIL REGISTRATION NUMBER: NCT04230889.

A Pilot Study to Assess Clinical Utility and User Experience of Professional Continuous Glucose Monitoring Among People With Type 2 Diabetes.

IN BRIEF Glucose variability is a potential independent risk factor of poor clinical outcome among people with diabetes, with adequate measurement technically difficult and cumbersome. For this study, a novel 14-day continuous sensor was used to assess glucose variability among people with type 2 diabetes (T2D). The aim was to characterize glucose profiles for up to 2 weeks in T2D and to survey device utilization in a standard clinical setting and its potential to collect clinically meaningful data.

A Comprehensive Nutrition-Focused Quality Improvement Program Reduces 30-Day Readmissions and Length of Stay in Hospitalized Patients.

BACKGROUND: Although screening patients for malnutrition risk on hospital admission is standard of care, nutrition shortfalls are undertreated. Nutrition interventions can improve outcomes. We tested effects of a nutrition-focused quality improvement program (QIP) on hospital readmission and length of stay (LOS). MATERIALS AND METHODS: QIP included malnutrition risk screening at admission, prompt initiation of oral nutrition supplements (ONS) for at-risk patients, and nutrition support. A 2-group, pre-post design of malnourished adults with any diagnosis was conducted at 4 hospitals: QIP-basic (QIPb) and QIP-enhanced (QIPe). Comparator patients had a malnutrition diagnosis and ONS orders. For QIPb, nurses screened all patients on admission using an electronic medical record (EMR)-cued Malnutrition Screening Tool (MST); ONS was provided to patients with MST scores ≥2 within 24-48 hours. QIPe had ONS within 24 hours, postdischarge nutrition instructions, telephone calls, and ONS coupons. Primary outcome was 30-day unplanned readmission. We used baseline (January 1-December 31, 2013) and validation cohorts (October 13, 2013-April 2, 2014) for comparison. RESULTS: Patients (n = 1269) were enrolled in QIPb (n = 769) and QIPe (n = 500). Analysis included baseline (n = 4611) and validation (n = 1319) comparator patients. Compared with a 20% baseline readmission rate, post-QIP relative reductions were 19.5% for all QIP, 18% for QIPb, and 22% for QIPe, respectively. Compared with a 22.1% validation readmission rate, relative reductions were 27.1%, 25.8%, and 29.4%, respectively. Similar reductions were noted for LOS. CONCLUSIONS: Thirty-day readmissions and LOS were significantly lowered for malnourished inpatients by use of an EMR-cued MST, prompt provision of ONS, patient/caregiver education, and sustained nutrition support.

The clinical and economic impact of the use of diabetes-specific enteral formula on ICU patients with type 2 diabetes.

BACKGROUND & AIMS: Patients admitted to intensive care units (ICUs) often need enteral nutrition (EN) support. For patients with type 2 diabetes (T2D), standard EN formulas may not provide ideal nutrients. The purpose was to investigate whether use of a diabetes-specific formula (DSF) could provide clinical and health economic benefits (compared to standard formulas) in critically ill patients with T2D. METHODS: This study was a retrospective analysis of medical records and expenditure data covering a 5-year period (2009-2013) from the hospitalization database of the National Taiwan University Hospital. Records of ICU patients who had T2D and were receiving enteral feeding with either the DSF or non-diabetes-specific formula (non-DSF) for at least 5 days were included in the analysis. Mortality, ICU length of stay (LOS), diabetes-related medications, and total costs of care (including all costs covered by the National Health Insurance and private expenses) were considered as the primary outcomes. RESULTS: A total of 158 patient records were analyzed in the DSF group and 794 in the non-DSF group. The baseline demographics including age, gender, weight, body mass index (BMI), and comorbidity patterns were mostly comparable between the groups. Compared to those receiving non-DSF, patients with T2D receiving DSF were found to have significantly decreased mortality (5.1% vs. 12.3%, P = 0.0118) and reduced need for insulin prescription (29.1% vs. 38.4%, P = 0.0269). ICU LOS was shorter for DSF patients, but no statistical difference was found (13.0 days vs. 15.1 days, P = 0.1843). However, significantly lower total ICU costs were reported for DSF patients (6700 USD vs. 9200 USD, P < 0.0001). CONCLUSIONS: The use of DSF in ICU patients with T2D is correlated with significant reduction in mortality and improved health economic outcomes.

Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial.

BACKGROUND: Hospitalized, malnourished older adults have a high risk of readmission and mortality. OBJECTIVE: Evaluation of a high-protein oral nutritional supplement (HP-HMB) containing beta-hydroxy-beta-methylbutyrate on postdischarge outcomes of nonelective readmission and mortality in malnourished, hospitalized older adults. DESIGN: Multicenter, randomized, placebo-controlled, double-blind trial. SETTING: Inpatient and posthospital discharge. PATIENTS: Older (≥65 years), malnourished (Subjective Global Assessment [SGA] class B or C) adults hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. INTERVENTIONS: Standard-of-care plus HP-HMB (n = 328) or a placebo supplement (n = 324), 2 servings/day. MEASUREMENTS: Primary composite endpoint was 90-day postdischarge incidence of death or nonelective readmission. Other endpoints included 30- and 60-day postdischarge incidence of death or readmission, length of stay (LOS), SGA class, body weight, and activities of daily living (ADL). RESULTS: The primary composite endpoint was similar between HP-HMB (26.8%) and placebo (31.1%). No between-group differences were observed for 90-day readmission rate, but 90-day mortality was significantly lower with HP-HMB relative to placebo (4.8% vs. 9.7%; relative risk 0.49, 95% confidence interval [CI], 0.27 to 0.90; p = 0.018). The number-needed-to-treat to prevent 1 death was 20.3 (95% CI: 10.9, 121.4). Compared with placebo, HP-HMB resulted in improved odds of better nutritional status (SGA class, OR, 2.04, 95% CI: 1.28, 3.25, p = 0.009) at day 90, and an increase in body weight at day 30 (p = 0.035). LOS and ADL were similar between treatments. LIMITATIONS: Limited generalizability; patients represent a selected hospitalized population. CONCLUSIONS: Although no effects were observed for the primary composite endpoint, compared with placebo HP-HMB decreased mortality and improved indices of nutritional status during the 90-day observation period. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.govNCT01626742.

Addressing Disease-Related Malnutrition in Healthcare: A Latin American Perspective.

Alarmingly high rates of disease-related malnutrition have persisted in hospitals of both emerging and industrialized nations over the past 2 decades, despite marked advances in medical care over this same interval. In Latin American hospitals, the numbers are particularly striking; disease-related malnutrition has been reported in nearly 50% of adult patients in Argentina, Brazil, Chile, Costa Rica, Cuba, Dominican Republic, Ecuador, Mexico, Panama, Paraguay, Peru, Puerto Rico, Venezuela, and Uruguay. The tolls of disease-related malnutrition are high in both human and financial terms-increased infectious complications, higher incidence of pressure ulcers, longer hospital stays, more frequent readmissions, greater costs of care, and increased risk of death. In an effort to draw attention to malnutrition in Latin American healthcare, a feedM.E. Latin American Study Group was formed to extend the reach and support the educational efforts of the feedM.E. Global Study Group. In this article, the feedM.E. Latin American Study Group shows that malnutrition incurs excessive costs to the healthcare systems, and the study group also presents evidence of how appropriate nutrition care can improve patients' clinical outcomes and lower healthcare costs. To achieve the benefits of nutrition for health throughout Latin America, the article presents feedM.E.'s simple and effective Nutrition Care Pathway in English and Spanish as a way to facilitate its use.

Transcultural Diabetes Nutrition Algorithm: Brazilian Application.

The prevalence of obesity, pre-diabetes, and type 2 diabetes (T2D) is increasing worldwide, especially in the developing nations of South America. Brazil has experienced an exponential increase in the prevalence of these chronic non-communicable diseases. The rising prevalence is probably due to changing eating patterns, sedentary living, and a progressive aging of the population. These trends and their underlying causes carry untoward consequences for all Brazilians and the future of Brazilian public health and the healthcare system. Lifestyle changes that include healthy eating (nutrition therapy) and regular physical activity (structured exercise) represent efficient inexpensive measures to prevent and/or treat the aforementioned disorders and are recommended for all afflicted patients. Regrettably, the implementation of lifestyle changes is fraught with clinical and personal challenges in real life. The transcultural Diabetes Nutrition Algorithm (tDNA) is a therapeutic tool intended to foster implementation of lifestyle recommendations and to improve disease-related outcomes in common clinical settings. It is evidence-based and amenable to cultural adaptation. The Brazilian Diabetes Association, Society of Cardiology and Ministry of Health guidelines for nutrition therapy and physical exercise were considered for the Brazilian adaptation. The resultant tDNA-Brazil and its underlying recommendations are presented and explained.

Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among Medicare patients with COPD.

BACKGROUND: COPD is a leading cause of death and disability in the United States. Patients with COPD are at a high risk of nutritional deficiency, which is associated with declines in respiratory function, lean body mass and strength, and immune function. Although oral nutritional supplementation (ONS) has been associated with improvements in some of these domains, the impact of hospital ONS on readmission risk, length of stay (LOS), and cost among hospitalized patients is unknown. METHODS: Using the Premier Research Database, we first identified Medicare patients aged ≥ 65 years hospitalized with a primary diagnosis of COPD. We then identified hospitalizations in which ONS was provided, and used propensity-score matching to compare LOS, hospitalization cost, and 30-day readmission rates in a one-to-one matched sample of ONS and non-ONS hospitalizations. To further address selection bias among patients prescribed ONS, we also used instrumental variables analysis to study the association of ONS with study outcomes. Model covariates included patient and provider characteristics and a time trend. RESULTS: Out of 10,322 ONS hospitalizations and 368,097 non-ONS hospitalizations, a one-to-one matched sample was created (N = 14,326). In unadjusted comparisons in the matched sample, ONS use was associated with longer LOS (8.7 days vs 6.9 days, P < .0001), higher hospitalization cost ($14,223 vs $9,340, P < .0001), and lower readmission rates (24.8% vs 26.6%, P = .0116). However, in instrumental variables analysis, ONS use was associated with a 1.9-day (21.5%) decrease in LOS, from 8.8 to 6.9 days (P < .01); a hospitalization cost reduction of $1,570 (12.5%), from $12,523 to $10,953 (P < .01); and a 13.1% decrease in probability of 30-day readmission, from 0.34 to 0.29 (P < .01). CONCLUSIONS: ONS may be associated with reduced LOS, hospitalization cost, and readmission risk in hospitalized Medicare patients with COPD.

Enteral nutrition and immune modulation of acute pancreatitis.

Enteral nutrition has been strongly recommended by major scientific societies for the nutritional management of patients with acute pancreatitis. Providing severe acute pancreatitis patients with enteral nutrition within the first 24-48 h of hospital admission can help improve outcomes compared to parenteral nutrition and no feeding. New research is focusing in on when and what to feed to best improve outcomes for acute pancreatitis patients. Early enteral nutrition have the potential to modulate the immune responses. Despite this consistent evidence of early enteral nutrition in patients with acute pancreatitis, clinical practice continues to vary due to individual clinician preference. Achieving the immune modulating effects of enteral nutrition heavily depend on proper placement of the feeding tube and managing any tube feeding associated complications. The current article reviews the immune modulating effects of enteral nutrition and pro- and prebiotics and suggests some practical tools that help improve the patient adherence and tolerance to the tube feeding. Proper selection of the type of the tube, close monitoring of the tube for its placement, patency and securing its proper placement and routine checking the gastric residual volume could all help improve the outcome. Using peptide-based and high medium chain triglycerides feeding formulas help improving feeding tolerance.

Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group.

The prevalence of malnutrition ranges up to 50% among patients in hospitals worldwide, and disease-related malnutrition is all too common in long-term and other health care settings as well. Regrettably, the numbers have not improved over the past decade. The consequences of malnutrition are serious, including increased complications (pressure ulcers, infections, falls), longer hospital stays, more frequent readmissions, increased costs of care, and higher risk of mortality. Yet disease-related malnutrition still goes unrecognized and undertreated. To help improve nutrition care around the world, the feedM.E. (Medical Education) Global Study Group, including members from Asia, Europe, the Middle East, and North and South America, defines a Nutrition Care Pathway that is simple and can be tailored for use in varied health care settings. The Pathway recommends screen, intervene, and supervene: screen patients' nutrition status on admission or initiation of care, intervene promptly when needed, and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. This article is a call-to-action for health caregivers worldwide to increase attention to nutrition care.

Transcultural diabetes nutrition algorithm (tDNA): Venezuelan application.

Medical nutrition therapy (MNT) is a necessary component of comprehensive type 2 diabetes (T2D) management, but optimal outcomes require culturally-sensitive implementation. Accordingly, international experts created an evidence-based transcultural diabetes nutrition algorithm (tDNA) to improve understanding of MNT and to foster portability of current guidelines to various dysglycemic populations worldwide. This report details the development of tDNA-Venezuelan via analysis of region-specific cardiovascular disease (CVD) risk factors, lifestyles, anthropometrics, and resultant tDNA algorithmic modifications. Specific recommendations include: screening for prediabetes (for biochemical monitoring and lifestyle counseling); detecting obesity using Latin American cutoffs for waist circumference and Venezuelan cutoffs for BMI; prescribing MNT to people with prediabetes, T2D, or high CVD risk; specifying control goals in prediabetes and T2D; and describing regional differences in prevalence of CVD risk and lifestyle. Venezuelan deliberations involved evaluating typical food-based eating patterns, correcting improper dietary habits through adaptation of the Mediterranean diet with local foods, developing local recommendations for physical activity, avoiding stigmatizing obesity as a cosmetic problem, avoiding misuse of insulin and metformin, circumscribing bariatric surgery to appropriate indications, and using integrated health service networks to implement tDNA. Finally, further research, national surveys, and validation protocols focusing on CVD risk reduction in Venezuelan populations are necessary.

The transcultural diabetes nutrition algorithm: a canadian perspective.

The Transcultural Diabetes Nutrition Algorithm (tDNA) is a clinical tool designed to facilitate implementation of therapeutic lifestyle recommendations for people with or at risk for type 2 diabetes. Cultural adaptation of evidence-based clinical practice guidelines (CPG) recommendations is essential to address varied patient populations within and among diverse regions worldwide. The Canadian version of tDNA supports and targets behavioural changes to improve nutritional quality and to promote regular daily physical activity consistent with Canadian Diabetes Association CPG, as well as channelling the concomitant management of obesity, hypertension, dyslipidemia, and dysglycaemia in primary care. Assessing glycaemic index (GI) (the ranking of foods by effects on postprandial blood glucose levels) and glycaemic load (GL) (the product of mean GI and the total carbohydrate content of a meal) will be a central part of the Canadian tDNA and complement nutrition therapy by facilitating glycaemic control using specific food selections. This component can also enhance other metabolic interventions, such as reducing the need for antihyperglycaemic medication and improving the effectiveness of weight loss programs. This tDNA strategy will be adapted to the cultural specificities of the Canadian population and incorporated into the tDNA validation methodology.

The transcultural diabetes nutrition algorithm toolkit: survey and content validation in the United States, Mexico, and Taiwan.

BACKGROUND: Evidence demonstrates that medical nutrition therapy (MNT) in prediabetes and type 2 diabetes (T2D) improves glycemic control and reduces diabetes risks and complications. Consequently, MNT is included in current clinical practice guidelines. Guideline recommendations, however, are frequently limited by their complexity, contradictions, personal and cultural rigidity, and compromised portability. The transcultural Diabetes Nutrition Algorithm (tDNA) was developed to overcome these limitations. To facilitate tDNA uptake and usage, an instructional Patient Algorithm Therapy (PATh) toolkit was created. Content validation of tDNA-PATh is needed before widespread implementation. SUBJECTS AND METHODS: Healthcare providers (n=837) in Mexico (n=261), Taiwan (n=250), and the United States (n=326) were questioned about challenges implementing MNT in clinical practice and the projected utilization and impact of tDNA-PATh. To assess the international portability and applicability of tDNA-PATh, the survey was conducted in countries with distinct ethnic and cultural attributes. Potential respondents were screened for professional and practice demographics related to diabetes. The questionnaire was administered electronically after respondents were exposed to core tDNA-PATh components. RESULTS: Overall, 61% of respondents thought that tDNA-PATh could help overcome MNT implementation challenges, 91% indicated positive impressions, 83% believed they would adopt tDNA-PATh, and 80% thought tDNA-PATh would be fairly easy to implement. CONCLUSIONS: tDNA-PATh appears to be an effective culturally sensitive tool to foster MNT in clinical practice. By providing simple culturally specific instructions, tDNA-PATh may help to overcome current impediments to implementing recommended lifestyle modifications. Specific guidance provided by tDNA-PATh, together with included patient education materials, may increase healthcare provider efficiency.

Transcultural diabetes nutrition algorithm: a malaysian application.

Glycemic control among patients with prediabetes and type 2 diabetes mellitus (T2D) in Malaysia is suboptimal, especially after the continuous worsening over the past decade. Improved glycemic control may be achieved through a comprehensive management strategy that includes medical nutrition therapy (MNT). Evidence-based recommendations for diabetes-specific therapeutic diets are available internationally. However, Asian patients with T2D, including Malaysians, have unique disease characteristics and risk factors, as well as cultural and lifestyle dissimilarities, which may render international guidelines and recommendations less applicable and/or difficult to implement. With these thoughts in mind, a transcultural Diabetes Nutrition Algorithm (tDNA) was developed by an international task force of diabetes and nutrition experts through the restructuring of international guidelines for the nutritional management of prediabetes and T2D to account for cultural differences in lifestyle, diet, and genetic factors. The initial evidence-based global tDNA template was designed for simplicity, flexibility, and cultural modification. This paper reports the Malaysian adaptation of the tDNA, which takes into account the epidemiologic, physiologic, cultural, and lifestyle factors unique to Malaysia, as well as the local guidelines recommendations.

Malnutrition-sarcopenia syndrome: is this the future of nutrition screening and assessment for older adults?

Malnutrition is common across varying patient populations, particularly older adults, and sarcopenia prevalence increases with advancing age. Both malnutrition and sarcopenia are associated with substantial adverse outcomes affecting both the patient and the healthcare system, including increased morbidity, mortality, rehospitalization rates, and healthcare costs. Healthcare practitioners may assess patients for either malnutrition or sarcopenia; however, many patients clinically present with both conditions, resulting in the syndrome, Malnutrition-Sarcopenia Syndrome, which is the clinical presentation of both malnutrition and accelerated age-associated loss of lean body mass, strength, and/or functionality. Clinicians are urged to screen, assess, and treat these conditions currently so as to adequately address the full spectrum of patients' nutritional issues. By examining aspects of both conditions, clinicians can more fully assess their patients' clinical and nutritional status and can tailor targeted therapies to meet their needs and improve outcomes. This proposed syndrome embodies the inherent association of malnutrition and sarcopenia, highlighting their combined impact on clinical outcomes. The objective of this review paper is to characterize Malnutrition-Sarcopenia Syndrome to advance clinical practice, by providing clinicians with the necessary background information to integrate nutritional assessment along with loss of muscle mass and functionality in their everyday clinical practice.

Diabetes-specific nutrition algorithm: a transcultural program to optimize diabetes and prediabetes care.

Type 2 diabetes (T2D) and prediabetes have a major global impact through high disease prevalence, significant downstream pathophysiologic effects, and enormous financial liabilities. To mitigate this disease burden, interventions of proven effectiveness must be used. Evidence shows that nutrition therapy improves glycemic control and reduces the risks of diabetes and its complications. Accordingly, diabetes-specific nutrition therapy should be incorporated into comprehensive patient management programs. Evidence-based recommendations for healthy lifestyles that include healthy eating can be found in clinical practice guidelines (CPGs) from professional medical organizations. To enable broad implementation of these guidelines, recommendations must be reconstructed to account for cultural differences in lifestyle, food availability, and genetic factors. To begin, published CPGs and relevant medical literature were reviewed and evidence ratings applied according to established protocols for guidelines. From this information, an algorithm for the nutritional management of people with T2D and prediabetes was created. Subsequently, algorithm nodes were populated with transcultural attributes to guide decisions. The resultant transcultural diabetes-specific nutrition algorithm (tDNA) was simplified and optimized for global implementation and validation according to current standards for CPG development and cultural adaptation. Thus, the tDNA is a tool to facilitate the delivery of nutrition therapy to patients with T2D and prediabetes in a variety of cultures and geographic locations. It is anticipated that this novel approach can reduce the burden of diabetes, improve quality of life, and save lives. The specific Southeast Asian and Asian Indian tDNA versions can be found in companion articles in this issue of Current Diabetes Reports.