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ESPEN Congress Leipzig 2013 LLL Session - Nutrition support in diabetes and dyslipidemia Parenteral and enteral nutrition in diabetic patients L. Sobotka (CZ)
ESPEN Congress Leipzig 2013
LLL Session - Nutrition support in diabetes and dyslipidemia
Parenteral and enteral nutrition in diabetic patients
L. Sobotka (CZ)
LLL- Live - Module 21
Nutritional support in diabetes Type I and II
Lubos Sobotka Charles University - Medical Faculty
Hradec Kralove Czech Republic
Diabetes and dyslipidaemia Leipzig – Germany, September 2, 2013
Learning Objectives
To know the different approach in nutrition support to the patients with type I and type II diabetes
To know how to give insulin to patient with T1DM during nutrition support.
To know how to plan nutrition support in patient with insulin resistance – type II DM
To be familiar with concept of hypocaloric nutrition support in obese type II diabetic patient
The goal of nutrition support is priority
Short-term goals
Long-term goals
The type od diabetes is important
obese
adult
normal or increased insulin secretion
lean
young or middle age
absolute lack of insulin
INSULIN RESINSTANCE
INSULIN SENSITIVITY
LABILE rel. STABLE
The knowledge of pathophysiology is essential
Chiasson J-L et al, CMAJ 2003
Replacement of electrolyte deficits is vital
Chiasson J-L et al, CMAJ 2003
DKA - diabetic ketoacidosis HHS - hyperglycemic hyperosmolar state
Electrolyte deficits and nutrition support in diabetic patients
If not supplemented these deficits can
lead to a fall of plasma levels of:
K, P, Mg
Refeeding syndrome
Composition of nutrition support in patient with diabetes
Energy
Proteins
Electrolytes
Microelements
Carbohydrates
Principally
dependent on:
- nutritional goals
- clinical situation
CHO (glucose) intake & oxidation
Sobotka L et al, Czech Med. 1988
CHO (glucose) intake & oxidation
Insulin infusion
Obese T1DM Lean T1DM
Glucose disposal
(mg min−1 kg−1)
1 mU
min−1 kg−1 5.18±1.43 6.76±1.43
100 mU
min−1 kg−1 9.69±1.48 12.02±2.16
Glucose oxidation
(mg min−1 kg−1)
1 mU
min−1 kg−1
1.55±0.64
2.77±1.20
100 mU
min−1 kg−1 2.81±0.52 3.54±1.17
Musil et al. 2013
Glucose disposal and oxidation in obese and lean type I. diabetic patients
Insulin infusion
Obese T1DM Lean T1DM
Glucose disposal
(mg min−1 kg−1)
1 mU
min−1 kg−1 5.18±1.43 6.76±1.43
100 mU
min−1 kg−1 9.69±1.48 12.02±2.16
Glucose oxidation
(mg min−1 kg−1)
1 mU
min−1 kg−1
1.55±0.64
2.77±1.20
100 mU
min−1 kg−1 2.81±0.52 3.54±1.17
Musil et al. 2013
Glucose disposal and oxidation in obese and lean type I. diabetic patients
Postprandial situation
CHO
glucose
Glycogen,
Glycerol
Glucose oxidation
Postprandial situation
CHO
glucose
Glycogen, NADPH DNA, RNA, AA
Glycerol
Glucose oxidation
PPP
Postprandial situation
Mixed nutrition
Chylo, VLDL (lipid emulsion)
CHO
LPL
Lipids
FA
HSL
FA
TG
Remnants
FA
TG
FA
TG
VLDL
Glucose oxidation
Maximal CHO (glucose) intake - resting adult subject -
Maximal glucose oxidation 4 mg•kg-1•min-1
6 g•kg-1•day-1
400 g•day-1
Maximal CHO (glucose) intake - resting adult subject -
Maximal glucose oxidation 4 mg•kg-1•min-1
6 g•kg-1•day-1
400 g•day-1
1600 Kcal – REE in resting conditions
ICU patient
The effects of neuroendocrine stress response
Hammarqvist F et al. 2011- Basics in Clinical Nutrition
The effects of neuroendocrine stress response
Hammarqvist F et al. 2011- Basics in Clinical Nutrition
Takala et al 1990
Endogenous (hepatic) glucose production (mg.kg-1.day-1)
Healthy subjects
Critically ill patients
Overnight fast ~ 2.5 – 3 3.5 – 10
Long fast ~ 1.5 3.5 – 10
Postprandial ~ 0.5 – 1 1.5 – 10
Tappy L. 2004 - Basics in Clinical Nutrition
Glucose oxidation in Sepsis
Glucose Infusion, mg / kg/ min
Burke et. al., Ann. Surg 1979
Role of ‘nonglucose carbohydrates’
Fructose – is metabolized to fructose
Polyols:
– Sorbitol – is metabolized to fructose
– Xylitol – pentose cycle
Residual I4C activity in the gastrointestinal contents at 1,3, 6, and 24 hours after administration of 20.4 Ci of 14C
sorbitol, expressed as percent of administered dose.
Ertel NH et al. 1983
Concentration of [14C]glucose,[14C] fructose, and [14C]sorbitol in the liver of rats
Ertel NH et al. 1983
Concentration of [14C]glucose,[14C] fructose, and [14C]sorbitol in the serum of rats
Ertel NH et al. 1983
Natah SS et al. 1997
■ - 25 g glucose ● - 25 g xylitol ◊ - 25 g lactitol
Metabolic effect of glucose, xylitol and lacticol
Natah SS et al. 1997
■ - 25 g glucose ● - 25 g xylitol ◊ - 25 g lactitol
Metabolic effect of glucose, xylitol and lacticol
Nongulcose CHO in Diabetic patients
Valero MA, Europ J Clin Nutr 2001
Plasma glucose
Nongulcose CHO in Diabetic patients
Valero MA, Europ J Clin Nutr 2001
Insulin infusion
Nonglucose carbohydrates
There is no advantage of Sorbitol or
Fructose in diabetic patients.
Plasma glucose is more easy to be
controlled
Insulin must always be infused in patients
with insulin deficit (T1DM)
How to control glucose level during artificial nutrition
Separate IV infusion
Insulin in the AIO bag
Subcutaneous insulin
Subcutaneous insulin pumps
ICU patient
Separate IV insulin infusion
Insulin in the AIO bag
Subcutaneous insulin
Subcutaneous insulin pumps
Intravenous insulin infusion in ICU
Plasma glucose level [mmol/l]
Insulin infusion rate [units/hr]
>22.2 8
19.5 – 22.2 6
16.7 – 19.5 4
13.9 – 16.7 3
11.1 – 13.9 2.5
8.3 – 11.1 2
6.6 – 8.3 1.5
5.6 – 6.6 1
< 5.5 0
McMahon MM. Nutr Clin Pract 2004
Intravenous insulin infusion algorithm for ward settings
Instructions: Glucose Infusion Rate A g/hour (e.g. 25 g/hour)
Start at B U/ml ( e.g. 2 U/ml) at C ml/hour i.e. B x C U/hour
* B - Insulin concentration (U/ml)
* C - Insulin infusion rate (ml/min)
* Measure glucose hourly initially – less frequently once stability achieved
Blood glucose (mmol/l )
Action
< 4.0 Reduce rate by 1.0 ml/hour
4.0 – 6.9 Reduce rate by 0.5 ml/hour
7.0 – 10.9* Same rate
11.0 – 15.0 If lower than last test same rate
If higher than last test rate by 0.5 ml/hour
> 15.0 If lower than last test same rate
If higher than last test rate by 1.0 ml/hour
If rate becomes 0.5 or 0 ml/hour
halve concentration (B) and restart at 0.5 ml/hour
If rate becomes 4.5 or 5 ml/hour
double concentration (B) and restart at 2.5 ml/hour
Woolfson AMJ, JPEN 1981
0,00
0,50
1,00
1,50
2,00
2,50
APACHE II 0-12 APACHE II over 12
[IU
/ho
d]
Insulin dosage n=17
Bajnarek J. et al 2008
Insulin resistance in critically ill patients
How tightly should be glucose controlled in critically ill diabetic patients?
Van den Berghe G. et al , Diabetes 2006
How tightly should be glucose controlled in critically ill diabetic patients?
Van den Berghe G. et al , Diabetes 2006
How tightly should be glucose controlled in critically ill diabetic patients?
No survival
benefit in
DM
Stable patient wit DM
Separate IV infusion
Subcutaneous insulin
Subcutaneous insulin pumps
Insulin in the AIO bag
Subcutaneous regular insulin supplementation in diabetic patients
Plasma glucose level [mmol/l]
Subcutaneous insulin dose [units]
8.3 – 11.1 1 – 2
11.2 – 13.9 2 - 4
14.0 – 16.7 3 - 6
16.8 – 19.4 4 - 8
> 19.4 5 - 10
McMahon MM. Nutr Clin Pract 2004
Insulin should be administered every 4 to 6 hours.
Stable patient wit DM
Separate IV infusion
Subcutaneous insulin
Subcutaneous insulin pumps
Insulin in the AIO bag
Subcutaneous insulin pumps
Stable patient wit DM
Separate IV infusion
Subcutaneous insulin
Subcutaneous insulin pumps
Insulin in the AIO bag
Insulin in PN solution
Safe
Insulin application together with PN
Stable patient
Christianson MA et al. JPEN 2006
Insulin availability in PN solutions is positively influenced by the presence of multivitamins and trace elements
Insulin stability in AIO systems
Major groups oral antidiabetic drugs
Drug Mechanism of action
Possible negative effect
Sulfonylurea Increase insulin secretion
Hypoglycaemia
Biguanides Decrease liver glucose production
Lactic acidosis due to decreased glucose production from lactate
Acarbose Decrease of glucose absorption
Diarrhoea
Glitazones PPAR agonists Fluid retention, weight increase, heart failure
Substrate gday-1 kcalday-1
Protein (amino acid) 100-180 400-720
Carbohydrates 120-180 480-720
Fat (lipid emulsion) 20 200
Total 1080-1640
Macronutrient content of a hypocaloric diet for obese diabetes Type II patient
Hypocaloric nutrition in critically ill obese patients
Dickerson RN et al. Nutrition 2002
Wound healing and body weight reduction
Obese diabetic woman with deep and large defect after aortocoronary by-pass. Sternum was removed. Wound was infected. Patient in stabilized state- treaded only localy using by hyaluronan-iodine complex and diabetes and obesity treated with hypocaloric diet. Complete wound healing – within 5 months During healing period – hypocaloric diet and weight loss of 18 kg
In the stabilized patient with body reserves healing can occur even during hypocaloric
nutrition
Wound healing and body weight reduction
Day 11 Day 99
Day 120 Day 165
Special enteral feeds
Fructose, xylitol, sorbitol
Slowly digestive CHO
MUFA – olive oil
Fiber
Garcıa-Rodrıguez CE et al. 2012
Short-term effect of diabetic formula in healthy subjects - CHO constituent -
Garcıa-Rodrıguez CE et al. 2012
Short-term effect of diabetic formula in healthy subjects - whole diet -
St. DS Energy [kcal] 100 100 Protein [g] 4.9/19 3.8/15 CHO [g] 11.6/47 13.6/55 Fat [g] 3.8/34 3.4/30 Fibre [g] 2.0 1.4
Cerio A et al. 2009
Bolus enteral feeding in type II diabetic patients
Cerio A et al. 2009
Bolus enteral feeding in type II diabetic patients
Hofman Z et al. 2008
A - ○
B - ●
C - □
D - ■
- low sugar/high maltodextrin
- high sucrose/moderate maltodextrin
- high fructose/moderate starch
- high fructose/moderate starch;
Energy % CHO–Fat–Prot A 49 : 35 : 16 B 49 : 35 : 16 C 45 : 38 : 17 D 35 : 49 : 16
Short-term effect of different diabetic formulas
Hofman Z et al. 2008
A - ○
B - ●
C - □
D - ■
- low sugar/high maltodextrin
- high sucrose/moderate maltodextrin
- high fructose/moderate starch
- high fructose/moderate starch;
Short-term effect of different diabetic formulas
MUFA content (g/100 ml) A 2.4 B 2.3 C 2.8 D 3.4
Hofman Z et al. 2008
A - ○
B - ●
C - □
D - ■
- low sugar/high maltodextrin
- high sucrose/moderate maltodextrin
- high fructose/moderate starch
- high fructose/moderate starch;
Short-term effect of different diabetic formulas
Fibre content (g/100 ml) A 0 B 0 C 1.5 D 2.5
Week 0
Week 6
Week 12
Diabetes-specific ONS CHO 17.6 g Fat 10.8 g Protein 8.0 g Fibre 5 g Standard ONS CHO 27.6g Fat 6.8 g Protein 7.6 g Fibre -
Magnoni D et al. 2008
Long term effect of EN diabetic formula
Magnoni D et al. 2008
Blood sugar after ingestion of DM or control EN formula
Area under curve 0-4h
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Fasting glucose 8.00 (6.10–11.40) 7.00 (5.20–11.20) (mmol/l) HbA1c 7.50 ± 0.21 7.34 ± 0.20 (%) Triglycerides 2.13 ± 0.23 1.65 ± 0.22 (mmol/l) Total cholesterol 4.95 ± 0.29 4.86 ± 0.27 (mmol/l) Fasting insulin 12.75 ± 1.44 13.53 ± 1.39 (mmol/l)
DM- ONS Standard - ONS
Long term effect of EN diabetic formula - week 12 -
Magnoni D et al. 2008
Glucose control is a crucial part of nutrition support in diabetic patients
There is an absolute deficit of insulin in type I diabetes mellitus
Type II diabetes mellitus is associated with insulin resistance and, in some cases a degree of insulin deficiency.
Glucose tolerance is impaired in stress states and inflammatory processes.
Oral antidiabetic drugs should be suspended in diabetic patients during acute illness
Continuous infusion is the preferred method of enteral or parenteral nutrition application in diabetic patients
The formulation of artificial feeds should depend on the underlying clinical state and not just on the presence of diabetes
In obese type II diabetic patients weight reduction can be useful
Key Messages
The goals of PN are not constant but reflex the state of patient.
Thank you
Lacemaker – J Vermeer
