Management of diabetic patients requiring nutritional support.

A retrospective analysis was performed on 70 patients with diabetes mellitus who required nutritional support over the 10-yr period 1979-1989. Information was available for 65 patients, of whom 55 had non-insulin-dependent diabetes mellitus (NIDDM). Enteral nutrition (EN, 750-2200 kcal/day) was given to 40 NIDDM patients (group A) and 6 insulin-dependent diabetic (IDDM) patients (group B), and parenteral nutrition (PN, 1600-2400 kcal/day) was given to 18 NIDDM patients (group C) and 4 IDDM patients (group D). Three NIDDM patients required both types of feeding. Preadmission diabetes treatment remained the same during feeding for 31% of the total group (38% of group A, 33% of group B, 23% of group C, and 0% of group D). The NIDDM patients in group C who received insulin during PN required a high daily dose of approximately 100 U. The IDDM patients on PN required an increase of 225% from their preadmission daily dose. The likelihood of a patient requiring a major change from preadmission diabetes therapy depended mainly on the severity of the underlying illness and on the type of feeding (greater with PN) but not on preadmission therapy, age of patient, or type of EN (cyclic vs. continuous). Hypoglycemic episodes were uncommon in all groups. There were no significant differences between the prefeeding and feeding blood glucose levels and HbA1c results.     

Practical nutritional care of elderly demented patients

PURPOSE OF REVIEW: Much of the research into nutrition and dementia focuses on end-of-life decisions about the ethics and efficacy of non-oral feeding. However, there are very many issues that arise long before that stage is reached. This review examines very recent papers that address the practical, day-to-day issues arising from the time that an individual with dementia needs help with eating and drinking. RECENT FINDINGS: Evaluations of interventions aimed at increasing body weight demonstrate that weight gain is possible in dementia. Helping people with dementia to overcome problems with eating and drinking poses ethical and emotional problems for carers, particularly in the interpretation and management of apparent food refusal. Evidence-based practice can be incorporated into routine services for people with dementia and lead to improved nutritional care. Research needs to move away from the problems of providing adequate food in hospitals and care homes, to incorporating the views of people with dementia and their carers in the design of services in non-institutional settings. SUMMARY: Few practical solutions to the nutritional problems of people with dementia have been presented in recent papers. Increased energy intake from food or supplements promotes weight gain, but effective interventions to overcome aversive behaviours have still not been described.     

Guidelines for nutritional support in intensive care unit patients: a critical analysis

PURPOSE OF REVIEW: Guidelines are supposed to be helpful in clinical practice. Guidelines are also supposed to rest upon the evidence that there is. In the field of clinical nutrition the problem is that many clinical trials are not conclusive because they are underpowered and sometimes have an inferior design. RECENT FINDINGS: The publication of the Canadian guidelines one year ago initiated a lively debate. The Canadian guidelines used meta-analysis as a tool to review the literature. This resulted in both a sound evaluation of studies as well as some controversial recommendations. The Canadian guidelines are here put in a perspective in which the older type of guidelines are compared, and some of the points of recommendation are scrutinized. SUMMARY: What all guidelines agree upon is the shortage of solid knowledge, the conviction that complications related to nutritional therapy in the intensive care unit are not acceptable, and that enteral nutrition is preferable if it can be given without risk. Beyond that, many controversies remain and the need for high quality prospective studies must be emphasized. In addition, such studies must address the clinically important questions that the guidelines try to answer.     

Evaluation of a continuing educational intervention for primary health care professionals about nutritional care of patients at home

Objective

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals’ familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

Design

Observational cohort study.

Setting

10 primary health care centers in Stockholm County, Sweden.

Participants

140 district nurses/registered nurses and general practitioners/physicians working with home care.

Intervention

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

Measurements

The intervention’s effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

Results

In the intra-group analyses, statistically significant changes occurred in the IG’s responses to 28 of 32 items and the CG’s responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

Conclusion

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals’ level of knowledge about important aspects of nutritional care.

     

糖尿病病人营养支持治疗的研究进展

糖尿病病人的代谢与营养需求之间相互关联,通过限制营养摄入来控制血糖易导致病人发生营养不良,感染加重,创面难愈合,入住监护室时间延长,病死率增高等一系列问题.研究表明,对糖尿病病人进行合理的营养支持治疗是必要而可行的,如何在营养支持治疗的同时做好血糖控制是实施的关键.糖尿病病人专用营养制剂的研究有着很好的应用前景.     

Health care for diabetic patients in developing countries: a case from Egypt

The aim of this was to evaluate the pattern of care for diabetic patients in Alexandria as a model from a developing country. It is a cross-sectional multi-centric. One thousand diabetic patients who had diabetes for no less than one year were randomly selected from 14 out-patient clinics and diabetic centres. Results showed that monitoring of the glycaemic state was based, almost entirely upon fasting blood glucose levels, with only a small minority (4%) having HbA measurements. During the previous 12 months, an electrocardiogram had not been performed in 26% of the subjects studies and the fundus was not examined in 38%. Twenty nine percent did not receive neurological examination, and feet were not inspected in 24%. Testing for albuminuria, serum creatinine, blood cholesterol, and triglycerides was performed only in 34%, 37%, 36% and 32% respectively. Patient's habits in seeking care revealed that 78% regularly attended the medical centre for follow up, 64% followed dietetic instructions, and 89% were compliant with prescribed therapy. Only 8% did self examination of blood glucose and 26% checked glucose in urine by themselves. Generally, the pattern of care provided for health insured diabetic patients is better than that received by non-health-insured cases. It is concluded that in Egypt the quality of diabetes care differs in many aspects from the recommended standards and that structural as well as organisational improvements are urgently needed, particularly to guarantee adequate care to non-health insured patients.     

社区综合护理对糖尿病患者的干预效果研究

目的通过对糖尿病患者实施社区综合护理干预,评价社区综合护理干预对糖尿病患者的治疗效果。方法130名糖尿病患者随机分为干预组(n=70)和对照组(n=60),对干预组进行1年的综合护理干预,对照组为传统糖尿病治疗,对干预前后糖尿病患者的糖尿病相关知识知晓、自我行为管理及血糖、血脂等各项临床指标进行监测。结果社区综合护理干预一年后干预组的糖尿病相关知识知晓率及自我行为管理率较干预前显著提高,并显著高于对照组的提高率(均P<0.05),空腹血糖、餐后2小时血糖、糖化血红蛋白较干预前显著降低(P<0.05)。结论社区综合护理干预,可有效提高糖尿病患者对糖尿病知识的了解程度和自我行为管理,并降低糖尿病患者血糖、糖化血红蛋白和血脂水平。     

Indigent health care plan for Tennessee

The author describes the development of an Indigent Health Care Program for the State of Tennessee from the campaign pledge of the Governor, through the development of an Indigent Care Cabinet Council, to the development and enactment of appropriate legislation required to implement this program. The program deals with availability of health care services, accessibility to health care services and funding mechanisms. The backbone of the program is the involvement of the local community and the coordinating and networking of the existing private, community and state health care providers.     

Effect of a nutritional supplement used for diabetic foot ulcers on microalbuminuria

We evaluated if a nutritional supplement containing arginine, glutamine, β-hydroxy-β-methyl butyrate commonly used to improve the healing of diabetic foot ulcers had any effect on the kidney function in the diabetic patients. We hypothesized that the action on the skin may be nonspecific and that the supplement might also act on other structural elements of the kidney. We compared the evolution of the blood creatinine and of the overnight albumin excretion in 16 diabetic subjects with mild to moderate nephropathy 6 months prior to and during the 6 months of treatment. The creatinine level remained stable during the treatment, while microalbuminuria decreased to nearly 50% of the initial value (p < 0.000).     

Differences in nutritional care in pressure ulcer patients whether or not using nutritional guidelines

OBJECTIVE: Malnutrition, characterized by a loss of lean body mass, enhances the risk of pressure ulcers (PUs). Because the intrinsic risk factor nutritional status in PU development can be influenced by practitioners' interventions, the use of clinical guidelines might be a satisfactory management approach. This study investigated the influence of using nutritional guidelines in daily practice on the actual nutritional care that PU (prone) patients receive, and barriers with regard to providing nutritional support were also explored. METHODS: A cross-sectional study was carried out in 1087 hospitals, nursing homes, and home care organizations in the Netherlands, Germany, and the United Kingdom. Because this study focused on comparing nutritional care in daily practice in PU (prone) patients using and not using nutritional guidelines, for the analyses two groups (health care organizations with and without guidelines) were identified. Differences between groups were tested using chi-square test and by analysis of variance. RESULTS: Respondents from 363 organizations participated in the study, of which 66.1% used nutritional guidelines for PU care in practice. Significant differences between organizations with nutritional guidelines versus organizations without guidelines were mostly on nutritional screening (P = 0.001) and the extent of nutritional assessments that included significantly more weight history recalls, weight measurements, and body mass index measurements (all P < 0.05). The most important barrier to providing nutritional support for PU (prone) patients in both groups was knowledge and skills. CONCLUSION: Using a nutritional guideline in PU care contributes to the amount of nutritional screening conducted in daily practice and to the content and extent of the assessment.