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Diabetes Mellitus

Board Certified In Nutrition Support Pharmacy – BCNSP

Lecturer of Clinical Nutrition – Nutrition Diploma – Tanta University
Lecturer Of Clinical Nutrition Pharm D Program Faculty Of Pharmacy –
Mansoura University-
Member Of Egyptian Medical Association for the Study of Obesity - EMASO

Insulin is usually the preferred treatment for hyperglycemia.

Insulin is the only therapy with the combined features of :

(1)rapid onset of action,

(2)wide dosing range that may be adjusted to the changing needs
for greater or lesser glucose-lowering effect,
(3)flexible scheduling to adjust to nutrient intake,
(4)multiple routes of administration (subcutaneous, IV).
(5)lack of drug-drug interactions.

oral agents should be discontinued and insulin therapy initiated

when a patient who was taking oral agents to control glucose levels
is admitted to the hospital.

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Intravenous Insulin Therapy

• Human regular U-100 insulin is commonly used for IV insulin therapy.
• approved rapid-acting insulin (lispro U-100, aspart, and glulisine) for IV infusion, but there is
no advantage to using any of these medications in place of regular insulin.
• Insulin lispro U-200, should not be given by IV infusion.
• continuous IV insulin infusion may be initiated at 0.5 to 1 units/h, 2 or more units/h in case
of insulin resistance. BG monitored once/hr.
• a concentration of 1 unit per 1 to 10 mL IV NS or ½ NS solution and infused using
calibrated electronic volumetric pumps.
• flushing 20 mL of the IV insulin solution through the tubing before connecting the tubing to
the IV access catheter to the patient to occupy adherence sites for insulin on polyvinyl
chloride tubing.
• NPO → acting to restrain hepatic glucose production (basal insulin).
• During PN or continuous EN → increased to manage both the hepatic glucose output and
the glucose from nutrition.

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Subcutaneous Insulin Preparations

• Neutral protamine Hagedorn (NPH), glargine, detemir, degludec, and

human regular U-500 are basal insulins. a steady state insulin, the main
purpose of controlling hepatic glucose output.
• Bolus insulin is given to achieve a peak insulin level after meals to
coincide with rising postprandial glucose.
• Bolus insulins include rapid-acting insulins (lispro, aspart, and glulisine).
• The combination of basal and bolus insulin can mimic physiological
insulin production by providing insulin over 24 hours regardless of
nutrient intake (basal) and insulin peaks for mealtime coverage (bolus).

Subcutaneous Insulin Preparations

• Rapid-acting and short-acting insulins can be used for the correctional

component of therapy where an extra dose must be added to the
prescheduled bolus when the premeal glucose is elevated.
• premixed insulin combinations of basal and bolus insulin in fixed-dose
preparations, which could be used by patients who would have difficulty
measuring or administering multiple insulin products.
• In hospitalized patients, it is generally advantageous to use basal and
bolus insulins separately, as opposed to premixed formulations( not
easily adjusted)

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Insulin Time Action Curves

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Sliding-Scale Insulin Therapy

• In sliding-scale orders, a predetermined dose of regular or rapid-acting insulin is
given subcutaneously in response to glucose values measured at predetermined
time intervals.
• The sliding-scale approach is reactionary, because the insulin dose is always
determined by the current glucose measurement.
• In addition, sliding-scale regimens do not mimic normal physiology. Often, the
glucose measurements and regular insulin injections are done every 6 hours. rapid-
acting insulin (Every 4hrs)
• the use of sliding scales may put the patient at risk for wide fluctuations in glucose
levels.
• AACE and the ADA recommend against prolonged use of sliding scales as the sole
approach to insulin therapy.

Basal-Bolus Insulin Therapy

• For noncritically ill patients, the preferred approach for subcutaneous
insulin administration is basal-bolus dosing.
• The basal-bolus approach mimics normal physiological insulin
patterns.
• the ADA recommends that patients receive the total daily dose of insulin
as 3 components: basal insulin to control fasting glucose, bolus doses
of regular or rapid-acting insulin before meals, and a correctional bolus
dose added to the before-meal dose when premeal glucose levels
exceed the targeted level.
• For patients with poor oral intake or those who are NPO, the ADA
recommends basal insulin and bolus doses of regular or rapid-acting
insulin to “correct” blood glucose levels

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Estimation of the Total Daily Insulin Dose

• In the first method, the total daily insulin dose may be estimated from the
number of units the patient required to control blood glucose in the
outpatient setting.

• In the second method, for patients managed with IV insulin therapy, the
total daily dose for subcutaneous insulin can be estimated as
approximately 50% to 70% of the dose used intravenously to control
blood glucose for 24 hours.

• In the third method, the clinician may use formulas based on body weight
to estimate the total daily insulin dose (type 1 diabetes: 0.3 to 0.5
units/kg/d; type 2 diabetes: 0.5 to 0.8 units/kg/d; very insulin- resistant
type 2 diabetes and high-dose glucocorticoids: 0.9 to 1.5 units/kg/d).

Estimation of the Total Daily Insulin Dose

• In the fourth method, “The 1500 Rule and 1800 Rule”.

• After estimating the total daily insulin dose, begin by administering
half of the estimated total daily dose as basal insulin.
• Administer the other half of the total daily dose as the sum of all
bolus doses (nutrition) to be given at meal times.
• The basal dose → acc. fasting morning glucose.
• the 3 premeal bolus doses → titrated to the glucose measured
prior to the next meal.

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The 1500 Rule and the 1800 Rule

To calculate the sensitivity factor

The 1500 Rule and the 1800 Rule

◂ total daily insulin requirement is 60 ◂ for rapid-acting insulin
units. ◂ total daily insulin requirement is 60
◂ the sensitivity factor is 25 (1500/60 = units.
25), ◂ the sensitivity factor is 30 (1800/60 = 30)
◂ the premeal glucose is 195 mg/dL and ◂ the premeal glucose is 195 mg/dL and
the target is 120 mg/dL the target is 120 mg/dL
◂ (195 – 120 = 75) ◂ 2.5 units of rapid-acting insulin (75/30 =
◂ 3 units of regular insulin (75/25 = 3) 2.5)

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Nutrition Assessment
• assessment of diabetic patients:
• a review of medical, nutrition, and medication histories
• a nutrition-focused physical examination.
• evaluation of anthropometric and laboratory data.
• The dietary history →helps identify nutrient deficiencies or risk for
deficiencies.
• the patient’s diabetes-related medical history:
• glucose control.
• self-monitoring practices.
• adherence to diet and lifestyle modifications.
• medications → affect glucose levels or gastrointestinal (GI) function.
• diabetes complications.
• the patient’s educational needs as pertains to diabetes.
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Nutrition Assessment
• inspect skin integrity because patients with long-standing diabetes are
particularly at risk for skin breakdown and poor wound healing.

• albumin, protein and transferrin have poor utility as nutrition markers,

may be beneficial when evaluating the inflammatory response.

• Hyperglycemia and renal dysfunction due to diabetic nephropathy may

also affect laboratory values.

• Prealbumin levels decrease with hyperglycemia and levels may be

increased in patients with kidney disease (degrade by kidneys).
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Energy Requirements
• Indirect calorimetry → the gold standard for measuring energy expenditure.
• The appropriate equation → (eg, age, weight, height, minute ventilation, and maximum
body temperature).
• No equation is 100% accurate, but they can provide a starting point → response may be
monitored and nutrition therapy adjusted accordingly.
• Many patients with type 2 diabetes are obese.
• hypocaloric is defined as 65% to 70% of target energy requirements,
• 11 to 14 kcal per kg actual body weight if BMI is between 30 and 50,
• or 22 to 25 kcal per kg ideal body weight (IBW) if BMI is greater than 50.
• Overfeeding should be avoided →hyperglycemia.
• Hyperglycemia:
• increased mortality,
• PN complications,
• risk for pneumonia and acute kidney injury,
• impaired wound healing
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Protein Requirements

◂ healthy patients with diabetes is 0.8 to 1.0 g/kg/d.

.
◂ during stress or illness is 2 g/kg/d.
◂ critically ill obese patients is 2 g per kg IBW (BMI =30-40), is
2.5 g per kg IBW (BMI >40).
◂ with diabetic nephropathy is 0.8 g/kg/d

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Electrolytes
◂ insulin → facilitates glucose entry into cells → hypophosphatemia and hypokalemia
(intercellular shifts of P and K).
◂ Hyperglycemia → a hyperosmolar state → movement of fluid from the intracellular to the
extracellular compartment and a dilutional decrease in the serum sodium level.

◂ Corrected Serum Sodium = Measured Serum Sodium + [0.016 × (Serum Glucose – 100)]
◂ TTT…treat hyperglycemia.

◂ Fluid and electrolyte status should be monitored closely, with supplementation given as
needed to maintain adequate urine output and normal serum electrolyte levels.

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Planning the Oral Diet

Carbohydrate and Fiber Intake

◂ The minimum carbohydrate recommendation is 130 g/d.

◂ People with diabetes (and others) should consume refined
carbohydrates, added sugars, and sugar-sweetened beverages in
moderation, while whole grains, legumes, fruits and vegetables are
recommended.
◂ For individuals on scheduled insulin doses, their diets should focus on
regularly scheduled meals.
◂ healthy food choices and portion control is recommended for elderly.

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Dietary Fat and Cholesterol Intake

◂ Saturated fat intake should not exceed 10% of total energy intake
and should be replaced with monounsaturated fats.
◂ trans fats should be avoided.
◂ Foods rich in ω-3 fatty acids (ie, fatty fish, nuts, and seeds) are
encouraged to promote cardiovascular health.

Gastroparesis
• Gastroparesis (delayed gastric emptying) → vagus nerve, which controls GI
motility, is damaged.
• signs and symptoms of gastroparesis:
• nausea, vomiting, early satiety, bloating, weight loss, and erratic glucose levels.
• Gastroparesis → common in patients with type 1 diabetes
• in patients with type 2 diabetes → by medications, specifically opioid therapy.
• Treatment:
• Low-fat, low-fiber diet,
• small frequent meals,
• remain upright 1 to 2 hours after meals,
• soft, pureed, or liquid foods.
• If a patient is vomiting, close monitoring of hydration, electrolyte, and acid-base
status,
• metoclopramide and erythromycin may be used to stimulate gastric motility.
• (gastric pacemakers) and jejunostomy EN.
• PN →is rarely indicated for diabetic gastroparesis.

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Enteral Nutrition

Formula Selection
• carbohydrate sources → slowly digestible carbohydrates (isomaltulose and sucromalt).
• low glycemic index →reduce postprandial glycemic response.

• Fat sources → Diabetes-specific formulas contain monounsaturated fatty acids and ω-3
fatty acids as the primary fat sources to counter the immunosuppressive effect of ω-6 fatty
acids.

• a fiber-containing formula →glucose control by:

• improving the patient’s insulin sensitivity
• lowering the glycemic index of the formula,
• delay gastric emptying
• decrease intestinal transit time (not used with gastroparesis).

• chromium → improved glucose control.

• compared to high-fat diabetes-specific enteral formulas, the diabetes-specific enteral
formula with slowly digestible carbohydrate did not elevate postprandial triglyceride levels.
• no clear benefit has been demonstrated for routine use in ICU patients

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Insulin Therapy During Enteral Nutrition

◂ insulin therapy with EN → if BG >180 mg/dL.
◂ The ADA and AACE advocate for the use of subcutaneous insulin regimens that
provide basal, nutrition, and correction insulin coverage in hospitalized patients and
continuous insulin infusions for select critically ill patients.
◂ start with 10 units of NPH or glargine insulin daily.
◂ Start with 1 unit of rapid-acting insulin for every 10 g carbohydrate, adjustments
made based on 2-hour postprandial BG.
◂ Close monitoring of renal function status.

Continuous Enteral Feeding

• For critically ill patients in the ICU → continuous IV insulin infusions

→ the ideal method to obtain glucose control.
• the ADA and AACE recommend:
• When scheduled EN interruptions occur or when enteral feedings
are discontinued without transition to oral intake or PN → insulin
needs should be determined as if:
• the patient is NPO.
• Or D5W with EN infusion,
• Or D 10% without EN. After abrupt stop.

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Parenteral Nutrition
parameters determine why PN:
• the degree of nutrition risk.
• the severity of malnutrition.
Supplemental PN is indicated:
• in patients who are unable to meet more than 60% of their energy
and protein needs after 7 to 10 days of EN.

Hyperglycemia is the most common metabolic complication of PN,

even for those without diabetes.

Parenteral Nutrition Composition, Initiation, and

Advancement

◂ carbohydrate →to spare the use of protein for energy while avoiding
hyperglycemia.
◂ 1 mg dextrose per kg/min, max. 4 to 7 mg/kg/min.
◂ at risk for refeeding syndrome, dextrose should be limited to 100 g per 24
hours in the first bag of PN.
◂ The recommended maximum dose of ILE is 2.5 g/kg/d.
◂ 100 gm with equal to or less than 1 g/kg/d commonly employed for
critically ill patients and those PN-associated liver disease.

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Monitoring
• Bedside point-of-care finger-stick glucose monitoring should be initiated.

• glucose monitoring is recommended every 4 to 6 hours, with more frequent

monitoring (every 30 minutes to 2 hours) indicated when IV insulin is used.

• Monitor magnesium, phosphorus, and potassium levels, as patients convert from a

catabolic to anabolic state by carbohydrate infusion and insulin therapy.

• “rebound hypoglycemia”
• Hypoglycemia occur with abrupt cessation of PN, regardless of whether the patient
is receiving insulin.
• Treatment:
• 10% dextrose in water infusion should be initiated.
• Or taper the infusion during the last 1 to 2 hours prior to discontinuation.

Insulin Therapy During Parenteral Nutrition

• In patients not previously treated with insulin, during PN, get average insulin doses
of 100 ± 8 units/d.
• Patients receiving PN often need insulin therapy because infusion of carbohydrate
into the systemic circulation bypasses regulators of glucose metabolism in the
intestine.
• continuous IV insulin infusions, addition of insulin to PN, and subcutaneous insulin
administration may be used with PN.
• IV insulin infusion is highly effective in reducing hyperglycemia to goal levels within
24 hours.
• after ICU discharge, the addition of insulin to the PN bag is frequently employed.
• Regular insulin is the only insulin product appropriate to add to PN.
• Only (60% to 80%) of daily insulin added in PN bag.
• 0.1 unit of regular insulin for every gram of dextrose in the PN infusion.
• For obese, insulin resistance 0.1 unit of regular insulin per 0.5 g dextrose

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Diagnosis, Classification, and Pathophysiology – Sliding-Scale Insulin Therapy

Diagnosis - Classification and Pathophysiology Basal-Bolus Insulin Therapy
Type 1 Diabetes - Type 2 Diabetes Nutrition Assessment- Energy Requirements- Protein
Prediabetic Conditions Requirements
Gestational Diabetes Electrolytes - Planning the Oral Diet
Stress-Related Hyperglycemia Carbohydrate and Fiber Intake
Measures of Glycemic Control Dietary Fat and Cholesterol Intake
Fasting Glucose - Postprandial Glucose Sodium and Alcohol Guidelines
Glycated Hemoglobin - Glycemic Variability Meal Planning and Weight Loss
Diabetes Complications, Diabetes Outcomes, and Meal Planning in Hospitals and Long-Term Care
Glycemic Control Facilities - Gastroparesis
Vascular Complications Enteral Nutrition - Formula Selection
Other Complications Associated with Hyperglycemia Delivery of Enteral Nutrition
Hyperglycemia and Inpatient Outcomes Insulin Therapy During Enteral Nutrition
Glycemic Targets for Hospitalized Patients Intermittent/Bolus Enteral Feeding
Hypoglycemia Continuous Enteral Feeding
Medications to Control Diabetes Parenteral Nutrition - Parenteral Nutrition
Oral Agents and Insulin Composition, Initiation, and Advancement –
Intravenous Insulin Therapy Monitoring - Insulin Therapy During Parenteral
Subcutaneous Insulin Injections Nutrition -
Subcutaneous Insulin Preparations

Q1

A patient is admitted to the medical intensive care unit (ICU)

for sepsis and now requires the use of continuous
intravenous (IV) insulin infusion for hyperglycemia
management. What is the appropriate target glucose range
for this patient?

A. 80 to 110 mg/dL
B. 100 to 150 mg/dL
C. 140 to 180 mg/dL
D. 150 to 200 mg/dL

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Q2

A hospitalized patient with a history of type 2 diabetes is on a sliding-scale insulin

regimen and no other sources of insulin or antihyperglycemic agents. Glucose
monitoring occurs four times per day (before each meal and at bedtime). Yesterday,
the four measurements were 195 mg/dL (breakfast), 155 mg/dL (lunch), 79 mg/dL
(supper), and 143 mg/dL (bedtime). Regular insulin is given in response to the
elevated glucose levels according to the hospital's sliding-scale regimen, and it was
held at dinner for glucose < 90 mg/dL. The proper course of action is to:

A. Continue current sliding-scale insulin regimen

B. Institute basal-bolus insulin therapy
C. Add an oral antihyperglycemic agent
D. Initiate an insulin drip

Q3

If a patient with severe diabetic gastroparesis requires enteral

feeding, which of the following methods should be used to
initiate enteral feeding?

A. Continuous enteral feeding through a gastric tube

B. Intermittent or bolus feeding through a gastric tube
C. Continuous feeding through a jejunal tube
D. Intermittent or bolus feeding through a jejunal tube

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Q4

Which of the following statements regarding diabetic

gastroparesis is true?

A. Symptoms are related to dysmotility of the stomach and

small bowel.
B. Diabetic gastroparesis is typically observed in patients with
type 2 diabetes.
C. Symptoms include fever, diarrhea, and diaphoresis.
D. Malnourished patients with gastroparesis should be fed
parenterally.

Q5

If a patient receiving enteral nutrition develops

unexplained hyperglycemia, which of the
following is a likely factor?

A. Underfeeding
B. Resolution of severe stress
C. Overfeeding
D. Renal dysfunction

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Q6

Which of the following is characteristic of type 1

diabetes?

a. Abdominal obesity increases risk.

b. The pancreas makes little or no insulin.
c. It is the predominant form of diabetes.
d. It often arises during pregnancy.

Q7

Which of the following is true about type 2

diabetes?

a. It is usually an autoimmune disease.

b. The pancreas makes little or no insulin.
c. Diabetic ketoacidosis is a common
complication.
d. Chronic complications may develop before it
is diagnosed.

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Q8

Most chronic complications associated with

diabetes result from:

a. altered kidney function.

b. infections that deplete nutrient reserves.
c. weight gain and hypertension.
d. damage to blood vessels and nerves.

Q9

Long-term glycemic control is usually evaluated

by:

a. self-monitoring of blood glucose.

b. testing urinary ketone levels.
c. measuring glycated hemoglobin.
d. testing urinary protein levels (albuminuria).

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Q10

Regarding dietary carbohydrate, a patient with diabetes

should be most concerned about:
a. consuming an appropriate quantity of carbohydrate at each
meal or snack.
b. consuming the correct proportion of sugars, starches, and
fiber in meals.
c. avoiding added sugars and kcaloric sweeteners.
d. choosing meals with ideal proportions of protein, carbohydrate,
and fat.

Q11

Which of the following is true regarding the general use of

alcohol in diabetes?
a. A serving of alcohol is considered part of the carbohydrate
allowance.
b. Alcohol contributes to hyperglycemia and should be
avoided completely.
c. Alcohol can cause hypoglycemia and should therefore be
consumed with food if patients use insulin or medications
that stimulate insulin secretion.
d. Patients can use alcohol in unlimited quantities unless they
are pregnant.

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Q12

The most effective meal-planning strategy for managing

diabetes is:
a. carbohydrate counting.
b. an eating plan based on food lists created for persons with
diabetes.
c. following menus and recipes provided by a registered
dietitian.
d. the approach that best helps the patient control blood glucose
levels.

Q13

A patient using intensive insulin therapy is likely to follow a

regimen that involves:
a. twice-daily injections that combine short-, intermediate-,
and long-acting insulin in each injection.
b. a mixture of intermediate- and long-acting insulin injected
between meals.
c. multiple daily injections that supply basal insulin and precise
insulin doses at each meal and snack.
d. the use of both insulin and oral antidiabetic agents.

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Q14

In a person who has previously maintained good glycemic

control, hyperglycemia can be precipitated by:
a. infections or illnesses.
b. chronic alcohol ingestion.
c. undertreatment of hypoglycemia.
d. prolonged exercise.

Q15

Which dietary adjustment may be helpful for women with

gestational diabetes?
a. Consuming most of the day’s carbohydrate allotment in the
morning
b. Restricting carbohydrate to about 30 grams at breakfast
c. Avoiding food intake after dinner
d. Reducing energy intake to about 50 percent of the calculated
requirement

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