Chapter 9

Nutritional
Management
of Diabetes Mellitus

1
 Classification, 1 of 2

• Type 1 diabetes: Autoimmune beta-cell

destruction, usually leading to absolute
insulin deficiency
• Type 2 diabetes: Progressive loss of beta-cell
insulin secretion; frequently in the
background of insulin resistance
• Gestational diabetes mellitus (GDM): Diabetes
diagnosed in the second or third trimester of
pregnancy that was not clearly overt diabetes
prior to gestation
2
 Classification, 2 of 2

• Other causes:
- Monogenic diabetes syndromes (such as
neonatal diabetes and maturity-onset diabetes
of the young [MODY])
- Diseases of the exocrine pancreas (such as
cystic fibrosis)
- Drug- or chemical-induced diabetes (such as
with glucocorticoid use, in the treatment of
HIV/AIDS, or after organ transplantation)

3
 Type 1 Diabetes, 1 of 2

• Immune-mediated (5%−10%)
- Beta-cell destruction
- Antibodies to insulin attack beta cells
- Little or no insulin
• 90% with type 1 diabetes have at least one
islet cell or endogenous insulin
autoantibody present at diagnosis.
• Obvious sooner than clinical symptoms
arrive.
4
 Type 1 Diabetes, 2 of 2

• These include:
- Islet cell autoantibodies (ICA)
- Glutamic acid decarboxylase autoantibodies
(GADA)
- Insulinoma-associated 2 autoantibodies (IA-2A)
- Insulin autoantibodies (IAA),
- Zinc transporter autoantibodies (ZnT8A)

5
 Common Presenting Symptoms:
Type 1
• Polydipsia (thirst) • Polyphagia (hunger)
• Polyuria (frequent • Weight loss
urination)
- Kidneys reabsorb most • Fatigue
of glucose. - Lack of glucose
- Increased serum glucose entering cells
exceeds renal threshold stimulates appetite.
—so it must excrete.
- Inability to obtain
- More urine needed.
- Renin-angiotensin
energy from glucose
system activates thirst leads to fatigue and
and urination. weight loss.
6
Biochemical Events in DKA, 1 of 2

• Shift to fat metabolism with production of

the ketone bodies: Acetone, acetoacetic
acid and beta-hydroxybutyric acid.
• Large amounts of acid produced by
metabolism of the ketone bodies.
• Depletes the supply of bicarbonate.
• Result: Metabolic acidosis.

7
Biochemical Events in DKA, 2 of 2

• Hyponatremia secondary to fluid shifts

caused by severe hyperglycemia.
• Insulin deficiency and acidosis will cause
potassium to shift to the extracellular space.
• Diabetic ketoacidosis (DKA) can develop in
less than 24 hours.
• Many patients in DKA present with nausea
and vomiting, and a fruity odor to their
breath from the ketone buildup.
8
 Classification: Type 2 Diabetes

• Type 2
- Accounts for 90%−95% of diabetes diagnosed
- Insulin resistance and relative insulin
insufficiency
- Obesity common, particularly abdominal
obesity
• Secondary
- Pancreatitis, hormone tumors, medications,
genetic disorders, and pancreatectomy

9
 Type 2 Diabetes

• Causes: Relative insulin deficiency

• Insulin resistance at the cellular level and
• Reduction in insulin production in the beta cells and
• Reduced beta cell mass: May be due to apoptosis
without compensatory regeneration.
• Causal factors of beta cell destruction include:
- Prolonged exposure to elevated glucose levels
(glucotoxicity).
- Increased fatty acid concentrations (lipotoxicity).
- Infiltration of proinflammatory cytokines.
- Deposition of islet cell amyloid have been postulated to
explain the damage to the beta cells.
10
 Metabolic Staging of Type 2,
1 of 2
• Compensatory: Insulin resistance of the muscle and
liver cells stimulates the pancreas to produce more
insulin.
- Normal glucose levels are maintained.
- Beta cells hypersecrete insulin in compensation for
insulin resistance.
• B cell failure (early): Impaired glucose tolerance:
- Postprandial euglycemia fails.
- Lack of insulin secretory capacity due to lack of:
• Gastric inhibitory polypeptide (glucose-dependent
insulinotropic polypeptide [GIP])
• Glucagon-like peptide 1 (GLP-1)
11
 Metabolic Staging of Type 2,
2 of 2
• Beta failure (late): Inability to maintain
fasting glucose levels in target range.
- Diabetes.
- 50% of cells have failed.

12
 Insulin Action and Insulin
Resistance
• Healthy
- Insulin binds receptor.
- Stimulates GLUT4
(glucose transporter) to
go to cell membrane
and “open door” for
glucose.
• Type 1
- No Insulin released.
• Type 2
- Insulin does not bind
the receptor. Alila Medical Media/Shutterstock.

13
 Risk Factors Indicating the Need to
Screen For Diabetes and Prediabetes
• Family history
- First-degree relative with diabetes
• Medical history
- Cardiovascular disease, polycystic ovary syndrome,
women diagnosed with gestational diabetes
• Biochemical indices
- HgA1c ≥5.7%, impaired glucose tolerance (IGT)* or
impaired fasting glucose (IFG)**, high-density
lipoprotein cholesterol ≤35 mg/dL or triglycerides
≥250 mg/dL
*IGT is a higher than normal glucose level 2 hours after an oral glucose tolerance test (140-199 mg/dL). A result in that range is consistent with prediabetes.
**IFG is is a higher than normal fasting glucose level (100-125 mg/dL). A result in that range is consistent with prediabetes.
Data from American Diabetes Association. Classification and
diagnosis of diabetes. Sec. 2. In: Standards of Medical Care in 14
Diabetes 2017. Diabetes Care. 2017;40(suppl 1):S11−S24.
 Risk Factors Indicating the Need to
Screen For Diabetes and Prediabetes

• Clinical conditions
- Hypertension (HTN): ≥140/90 mm Hg
- Factors associated with insulin resistance
(acanthosis nigricans, severe obesity), physical
inactivity
• Ethnicity
- High-risk ethnicity: African American, Latino,
Native American, Asian American, Pacific
Islander

15
 Diabetes Screening

• DIAGNOSTIC CRITERIA FOR DIABETES

- Hemoglobin A1C ≥6.5
- Fasting plasma glucose (FPG) ≥126 mg/dL (7.0
mmol/L)
- Postprandial glucose (PPG) ≥200mg/dL
- OGTT at 2 hours ≥200 mg/dL
- A random plasma glucose ≥200 mg/dL in the
presence of the classic clinical symptoms of
diabetes

16
 Gestational Diabetes Mellitus,
1 of 2
• Definition: Any degree of abnormal glucose
tolerance with first appearance or recognition
during pregnancy
- Prevalence of GDM 2%−10% of all pregnancies 
on the rise due to obesity and sedentary
behavior in US.
- Higher rates among ethnic communities/ limited
economic resources.
- Pregnancy distorts the normal hormonal milieu
toward one of insulin resistance and decreased
insulin output.
17
 Gestational Diabetes Mellitus,
2 of 2
• First trimester, insulin secretion increases 
accumulation of adipose tissue.
• Late gestation = several fold increase in
circulating postprandial free fatty acid levels
increasing insulin resistance.
• Several pregnancy hormones facilitate:
- Human placental lactogen (hPL) (increases up to
30 fold).
- Human placental growth hormone (hPGH),
increases 6−8 fold.
18
Screening for Gestational
Diabetes Mellitus

19
MNT Recs: Effectiveness of Nutrition Therapy
2017 DM Standards of Care,
1 of 4
• Promote healthful eating patterns,
emphasizing a variety of nutrient-dense
foods.
- Achieve and maintain body weight goals.
- Attain individualized glycemic, blood pressure
and lipid goals.
- Delay or prevent the complications of DM.
• Address individual needs based on personal
and cultural preferences.

20
MNT Recs: Effectiveness of Nutrition Therapy
2017 DM Standards of Care,
2 of 4
• Maintain healthful eating by providing
nonjudgmental messages.
• Provide practical tools for healthy eating
patterns without focusing on
macronutrients, micronutrients, or single
foods.

21
MNT Recs: Effectiveness of Nutrition Therapy
2017 DM Standards of Care,
3 of 4
• Individualized MNT program, preferably by an
RD.
• For type 1 and type 2 on insulin therapy that is
flexible: Educate on carbohydrate counting
(and in some cases fat and protein grams) to
determine meal time insulin doses.
• For individuals where insulin is fixed: Have a
consistent meal pattern with respect to
amount and timing of CHO to improve
glycemic control.
22
MNT Recs: Effectiveness of Nutrition Therapy
2017 DM Standards of Care,
4 of 4
• For patients with type 2 who are not taking
insulin, who have limited literacy or
numeracy, and who are elderly or prone to
hypoglycemia, emphasis is on weight
control, portion sizes, and healthy choices/
• MNT reduces HbA1c and improves
outcome: Should be reimbursed by
insurance companies.

23
 MNT Recs: Eating Patterns and
Macronutrient Distribution
2017 DM Standards of Care, 1 of 2
• No single dietary distribution of calories
from among CHO, protein, fat.
• Lifestyle modifications that benefit
overweight and obese individuals with type
2 DM.
• Variety of eating patterns acceptable for
management of type 2 DM, including
Mediterranean, DASH, and plant-based
diets.
24
 MNT Recs: Eating Patterns and
Macronutrient Distribution
2017 DM Standards of Care, 2 of 2
• CHO intake from whole grains, vegetables,
fruits, legumes, and dairy foods, with
emphasis on foods high in fiber and lower in
glycemic index.
• Avoid sugar-sweetened beverages and foods
with added sugar to control weight and
reduce risk of CVD and fatty liver.

25
 MNT Recs: Protein
2017 DM Standards of Care
• Ingested protein increases insulin response
without increasing plasma glucose
concentrations.
• In type 2, higher protein diets (28%−40% of
total energy) reduced A1C and improved
lipid levels.
• Carbohydrate sources high in protein should
NOT be used for treating hypoglycemia.

26
 MNT Recs: Fat
2017 DM Standards of Care
• Patients with DM have 2−4 times greater risk for
CVD, striking at a younger age.
• Moderate amounts of healthy fats can prevent
rapid spikes in glucose.
• Mediterranean diet high in MUFA may improve
glucose metabolism and improve CVD risk.
• More effective than a diet low in fat and high in
carbohydrate.
• Eat foods rich in omega-3 such as fatty fish and
nuts and seeds to prevent or treat CVD.
27
 MNT Recs: Supplements
2017 DM Standards of Care
• Evidence on fish oil supplements do not
support supplementation.
• Herbal and micronutrient supplements are
not supported by research.
• Use of nonnutritive sweeteners has the
potential to reduce calorie and CHO
consumption and if substituted for caloric
sweeteners or intake of additional calories
from other sources.
28
 Glycemic Index, 1 of 2

• The type of CHO consumed is secondary to the total

quantity eaten in affecting glycemic response.
• The digestibility of a given CHO sources affects blood
glucose excursions differently.
• The glycemic index (GI) describes the quantity and
rate at which different carbohydrate foods influence
blood glucose response.
• 50 g of carbohydrate-containing foods are ranked
according to how much they raise glucose levels in
comparison to either 50 g of glucose or 50 g of white
bread.
29
 Glycemic Index, 2 of 2

• Foods are ranked in comparison to the

ranking of glucose:
• Low glycemic foods are designated as less
than 55.
• Intermediated GI foods have a designation
of between 56 and 70.
• High those over 70 are considered to be
high GI.

30
 Glycemic Load, 1 of 2

• The glycemic load (GL) attempts to reconcile

the digestibility rate of foods with the
amount of carbohydrate they contain.
• Calculated by multiplying the GI ranking of
the food by the number of grams of
carbohydrate in a serving and then dividing
by 100.

31
 Glycemic Load, 2 of 2

• For example: The GI of a bagel is 72.

• There are approximately 75 g of carbohydrate
in a 5-oz bagel vs. 30 g of carbohydrate in the-
2 oz bagel.
• The GL of a 5-oz bagel is 54:
- 72 (GI) × 75 (g of carbohydrate) = 5400/100
= 54 (GL).
• The GL of a 2-oz bagel is 22:
- 72 (GI) × 30 (g of carbohydrate) = 2160/100
= 22 (GL).
32
33
 Fiber, 1 of 2

• Dietary fiber, two types: Soluble and

insoluble
- Insoluble fiber provides bulk to the stool and
reduces gut transit time, which can alleviate
constipation.
- Soluble fiber forms gels in the intestine, which
can bind cholesterol molecules and remove them
through excretion in the feces.
- Soluble fiber also slows gastric emptying, and
dietary fiber can reduce glucose levels when
consumed in quantities approaching 50 g.
34
 Fiber, 2 of 2

• Dietary fiber, two types: Soluble and

insoluble (continued)
- Recommendations for fiber intake:
25−35 g per day or 14 g of fiber per 1000
calories.
- Actual fiber intakes for Americans are
significantly below recommendations in the
range of 13−15 g per day.

35
 Medical Treatment of Diabetes

• Blood glucose
monitoring
- Finger sticks
- Continuous
ambulatory blood
glucose
monitoring
• Oral medications Kwangmoozaa/Shutterstock.

• Insulin
- Injection
- Insulin pump
36
 Glycemic Targets
(ADA Standard of Care 2017)
• HgbA1c
- < 7% generally for nonpregnant healthy adults
- <7.5% across all pediatric age groups
- <6.5% more stringent for select individuals such as
those not prone to hypoglycemia, long life
expectancy
- <8% for limited life expectancy, risk of
hypoglycemia, elderly
• Blood glucose (keep as normal as possible)
- Before meal glucose 80−130 mg/dl
- After meal glucose <180 mg/dl
37
Self-Monitoring of Blood Glucose,
1 of 2
• Monitoring of blood glucose (BG) can be done via
fingerstick or device.
• Patients on intensive insulin regimen (multiple
dose insulin or insulin pump) should monitor BG:
- Prior to meals and snacks.
- Postprandial.
- At bedtime.
- Prior to exercise.
- When BG is suspected to be low.
- This can be up to 6−8 times daily.

38
Self-Monitoring of Blood Glucose,
2 of 2
• Frequent SMBG results in a decrease in
HgA1C (−0.2% per additional test/day).
• Patient not on intensive insulin, SMBG has
variable effect on outcome: May be useful in
select type 2 DM patients.

39
Insulin Action Times

40
 Medications: Alpha-Glycosidase
Inhibitors
• Alpha-glycosidase inhibitors target the
gastrointestinal tract.
• Known as starch blockers, these drugs slow
the digestion and absorption of
carbohydrate in the intestines.
• Attenuate the rise in blood glucose after a
meal.

41
 Medications: Sulfonylureas

• Target the pancreas to secrete greater

amounts of insulin.
• Only effective in those who have sufficient
number of functioning beta cells.
• Can cause hypoglycemia and weight gain.
• Sulfonylureas are contraindicated in people
with advanced liver and kidney disease.
• Examples of agents in this group are glipizide
(Glucotrol) and glyburide (Micronase).
42
 Medications: Byguanides, 1 of 2

• Metformin (Glucophage): The most widely

prescribed drug for the treatment of
diabetes in the world.
• Metformin works by suppressing glucose
production in the liver, although its exact
mechanism of action is unknown.
• Improves the muscle and liver cells
sensitivity to insulin.

43
 Medications: Byguanides, 2 of 2

• It is a first-line drug, especially in those who

are overweight or obese, as it does not
contribute to weight gain or hypoglycemia.
• Although in general a fairly benign drug,
metformin can cause nausea and vomiting
in susceptible individuals.
• Long-term use of metformin may lead to
vitamin B12 deficiency.

44
 Plate Method, 1 of 2

• Visual rendering of the appropriate amounts of

the major food groups to eat at each meal.
• Benefit of incorporating all of the food groups,
not simply those with carbohydrate.
• Easy to understand.
• Reproducible in almost any dining situation and
enforces a basic method of portion control.
• Patients are instructed to divide their plate into
three sections by bifurcating the plate and then
bifurcating one of the halves again.
45
 Plate Method, 2 of 2

• The largest section, or one-half of the plate, is

filled with nonstarchy vegetables.
• The other two sections are made up of protein
and starchy foods, respectively.
• A glass of milk and a small piece of fruit
accompany the plate.
• The American Diabetes Association includes a
step-by-step method to assemble a healthy
plate.
[Link]/food-and-fitness/food/plan
ning-meals/create-your-plate/ 46
 Basic Carbohydrate Counting
Method, 1 of 2
• Carbohydrate and available insulin are the most
important factor determining glycemic response.
• Meal plans based on carbohydrate counting have
become a popular and flexible method of meal
planning.
• Basic carbohydrate counting involves adding up the
total amount of carbohydrate, regardless of its
source, to be eaten at a meal either in choices or in
grams.
• One carbohydrate choice provides 15 g of
carbohydrate.
47
 Basic Carbohydrate Counting
Method, 2 of 2
• Allows for consistency in meal carbohydrate
intake, but does not teach healthy eating
guidelines or how to choose healthier
carbohydrate selections.
• Combining the use of basic carbohydrate
counting with the GI can assist people with
diabetes in selecting those carbohydrates
that are digested slowly and will have less
impact on blood glucose levels.
48
 CHO Counting

• Total CHO for meals/snacks is considered

the first priority for food planning.
• High competency.
• Does not distinguish types of CHO.
• Becoming very common (vs. exchange lists).
• Food portions containing 15 g of CHO are
considered to be 1 CHO serving.

49
 CHO Counting Step-Wise
Approach
• First calculate how much CHO needed for an
individual:
1. Calculate total daily calorie needs.
2. Calculate % calories from CHO.
3. Convert calories to grams of CHO.
4. Distribute throughout the day.
• Meals and (if necessary) snacks

50
 ICR and CF, 1 of 2

• Insulin Carbohydrate Ratio (ICR) defines the

amount of carbohydrate processed by one
unit of insulin.
• The correction factor (CF), also known as
the sensitivity factor, defines the number of
points the blood glucose will be lowered by
one unit of insulin.
• A variety of equations exist for determining
ICR and CFs.
51
 ICR and CF, 2 of 2

• In general they include variations of adding

together all the insulin given on an average day
- Includes both basal and bolus insulin (total daily
dose, TDD), dividing by a constant or a multiple of
body weight in pounds to arrive at the ICR and CF.
• In practice often 450 or 500 divided by the TDD
is used to determine the ICR.
• CR is determined by dividing 1500−2000
divided by the TDD.

52
 Example, 1 of 2

• Patient has ICR of 10.

• Her CF is 40.
• Her baseline glucose is 280 mg/dL.
• Goal: 90 gm CHO meal with target blood
glucose of 120.
- Insulin needed to cover CHO meal = g CHO/ICR
= 90/10 = 9 units of insulin to cover CHO

53
 Example, 2 of 2

• Insulin needed to decrease BG to target =

(baseline BG − target BG)/CF
• = (280 − 120)/40 = 160/40 = 4 units
• Total units to cover meal and obtain optimal
target glucose = 9 + 4 = 13
• Note if exercising, subtract 1−2 units regular
or short-acting insulin for meal closest to
activity.

54
 Complications: Hypoglycemia
with Exercise—Type 1, 1 of 2
• Normal response to moderate exercise:
 insulin output and  in glucagon secretion
 glycogenolysis and gluconeogenesis
• In insulin therapy, presence of elevated circulating
insulin, glycogenolysis is blunted and insulin-
enhanced muscle glucose uptake augmented,
leaving the individual at risk for hypoglycemia.
• Counterregulatory mechanisms (catecholamines,
growth hormone, and cortisol) present in healthy
individuals that help prevent hypoglycemia during
exercise.
55
 Complications: Hypoglycemia
with Exercise—Type 1, 2 of 2
• Curtailed by repeated episodes of low blood
glucose in type 1 DM.
• Prolonged insulin sensitivity following
moderate to vigorous exercise can induce
hypoglycemia up to 36 hours after exercise
in children with type 1 DM.

56
 Complications: Hypoglycemia
with Exercise—Type 2, 1 of 2
• Improvements in glycemic control stimulated
by physical activity are generally due to
reductions in insulin resistance in skeletal
muscle.
• Exercise increases GLUT4 abundance and
blood glucose transport, improving glycemic
control.
• Hypoglycemia in those persons not taking
insulin or insulin secretagogues is usually rare,
but can happen.
57
 Complications: Hypoglycemia
with Exercise—Type 2, 2 of 2
• The compensatory decline in insulin
remains: Decline in endogenous plasma
insulin levels exceeds transport of glucose
into the muscle cells.
• Insulin secretagogues do advise caution.
• Reduction of glucose levels may continue up
to 72 hours post exercise.
• Alterations in CHO intake not recommended
for type 2.
58
 Insulin Guidelines for Exercise

• American Diabetes Association

recommendations:
- At least 150 min/wk of moderate-intensity
aerobic physical exercise over 3 days/week with
no more than two consecutive days without
exercise.
- Moderate to strenuous activity >45 to 60
minutes: Decrease rapid- or short-acting insulin
(1–2 U).
- Prolonged vigorous exercise: May need a 15%–
20% decrease in total daily insulin dose.
59
Carbohydrate Adjustment

60
Common Causes of Hypoglycemia

• Inadvertent or deliberate errors in insulin doses

• Excessive insulin or oral secretagogue medications
• Improper timing of insulin in relation to food intake
• Intensive insulin therapy
• Inadequate food intake
• Omitted or inadequate meals or snacks
• Delayed meals or snacks
• Unplanned or increased physical activities or exercise
• Prolonged duration or increased intensity of exercise
• Alcohol intake without food

61
Treatment of Hypoglycemia

62
Hypoglycemia vs Hyperglycemia
Symptoms

63
 Hospitalization Management,
1 of 4
• Focus on changes in:
- Nutritional intake
- Clinical status
- Monitoring of blood glucose levels
- Awareness of risk factors that can
alter glycemia

64
 Hospitalization Management,
2 of 4
• Previously tight control of glucose levels below a
target of 110 mg/dL was recommended for
patients in the hospital setting.
• The American Society for Parenteral and Enteral
Nutrition, in its clinical guidelines for nutrition
support of adult patients with hyperglycemia; the
American Association of Clinical Endocrinologists;
and the American Diabetes Association
Consensus Statement recommend a goal range of
blood glucose between 140–180 mg/dL.

65
 Hospitalization Management,
3 of 4
• For planned admissions:
- Baseline A1C should be measured (if none in
the past 3 months).
- The patient’s home regimen, ability to self-
manage, and overall knowledge and behavior
should be assessed (ideally prior to admission).
• For patients requiring insulin who are non-
critically ill:
- Basal insulin dose should be given along with
bolus correction if necessary.
66
 Hospitalization Management,
4 of 4
• Studies indicate:
- Basal bolus method is associated with fewer
complications than a sliding scale.
- Typical insulin dosing may change from the
patient’s usual regimen if their nutritional
intake declines or while they are ill

67
 Diabetes-Specific Formulations,
1 of 3
• Lower in total carbohydrate and higher in
total fat.
• Micronutrient composition is similar to
standard enteral feedings.
• The carbohydrate sources in these formulas
(e.g., isomaltulose and sucromalt): Low
glycemic index.
- Fiber

68
 Diabetes-Specific Formulations,
2 of 3
• Fat in the form of monounsaturated and
omega-3 fatty acids.
- Both the fiber and fat content of these formulas
slow gastric emptying, thereby blunting
excessive glucose rise.
- Benefit in glycemic control as well as a
diminution in the amount of insulin required to
maintain euglycemic when these feedings are
used.

69
 Diabetes-Specific Formulations,
3 of 3
• American Society for Enteral and Parenteral
Nutrition Clinical Guidelines:
- Nutrition support of adult patients with
hyperglycemia does not endorse diabetes-
specific formulations over standard formulas
for use in hospitalized patients with
hyperglycemia.

70
 PN in DM Patients, 1 of 3

• PN solutions should provide:

- Adequate carbohydrate to spare protein for tissue
synthesis while avoiding hyperglycemia.
- Carbohydrate is usually initially limited to 1.5
mg/kg to 2 mg/kg of body weight per minute to
avoid hyperglycemia.
- This translates into 100–150 g of carbohydrate
given over 24 hours.
- Once glycemic control has been established and
electrolytes stabilized, the dextrose in the PN can
be advanced to a maximum of 4 mg/kg/min.
71
 PN in DM Patients, 2 of 3

• PN can be maintained on 80% of calculated

energy requirements to avoid insulin
resistance.
- For obese patients, calorie intake should be
kept at 60%–70% of estimated needs.
- Increase in the protein content to 2 g/kg body
weight may be indicated to aid in protein
sparing.

72
 PN in DM Patients, 3 of 3

• Higher fat levels in PN displace carbohydrate

calories and may decrease the risk of
hyperglycemia.
- Normalization in blood glucose levels may also
be derived by decreasing the fat content of the
PN.
• High circulating levels of fatty acids and muscle
fat content increase insulin resistance and may
induce immunosuppression.
- For this reason, lipid emulsions above 1.3
g/kg/day are not recommended.
73