[UKPedsRN]

Hi all,

I have not been in clinical nursing for a while and would love to know what diet advice is now given to type II diabetics who have to be switched onto Insulin.

How long would you say you needed to hospitalise a diabetic who is swithcing to insulin, and if you are the nurse in charge of the hospitalised patient would you allow them to eat chocolate and cookies at will, whilst you are trying to determine their insulin doseage?

[dansingrn]

The current dietary advice for those with type 2 diabetes is to maintain a healthy, balanced diet, limiting simple carbohydrates. We no longer tell patients that they can't have any "sugar." Eliminating carb containing beverages such as soda and fruit juices is important. All forms of carbohydrate, simple or complex, raise blood glucose levels. Carbs are important for growth, development, and proper metabolism, so they are not eliminated altogether. We do encourage healthy, complex carbs such as whole grains, beans/legumes,low-fat dairy, and whole fruits while limiting simple carbs. Portion control is a very important aspect of dietary advice for those with type 2 diabetes, especially when indulging in a treat.
As far as the insulin goes...you most often see a basal/bolus regimen. This means a long acting insulin given once daily (Lantus or Levemir) and a rapid acting insulin given with meals/snacks (Humalog, Novolog, Apidra). The rapid insulins are dosed using an insulin to carb ratio, so the dose varies with the carb content of the meal. For example, if the meal contains 60 grams of carb, if the ratio is 1 unit for 15 grams, the dose is 4 units. If the ratio is 1 unit for 10 grams, the dose is 6 units. The ratio is determined by comparing a pre-meal blood glucose level with a 2 hour post meal blood glucose level. The goal is to get the post meal level to be (usually) within 30-50 points of the premeal level. If a patient is eating "at will" between meals, it is difficult to accurately assess the action of the premeal insulin.
The fasting glucose level in the morning determines how well the long acting insulin has been dosed.
It is important to remember that it is carbohydrate in general, not just "chocolate and cookies" that are raising blood glucose. So the patient shouldn't be eating any carbs between meals while determining the dose, be it candy, bread, mashed potatoes, cereal, etc.
The length of the hospitalization will vary according to the patient, and often hospitalization isn't required. The reason is that in the hospital their food, activity levels, etc., are different than they are at home, and the dose may change again as soon as they assume their usual routines at home. Weight loss and activity greatly affect insulin sensitivity in those with type 2 diabetes, so the ratios and long acting insulin doses may very well change as children grow, change weight, change activities, etc.
Hope that helps!

[classicdame]

As a diabetic and nurse I can tell you the real secret to contolling BS is to have a routine diet/medication. The scenario you described might teach the patient to just "take more insulin if you want to eat more". That is not appropriate and can cause many problems. Preferably, the diet, exercise and medication regimen should be mutually effective.

[UKPedsRN]

The reason I posed the question is that my mum was hospitalised two weeks ago and ended up in ICU, after a virus led to dehydration and acute renal failure due to long term use of metformin. Now that she is on a medical ward I was highly surpised to find her eating cookies and chocolate whilst she is being transitioned onto insulin. When her blood sugar was 315, no one was concerned except me. When I spoke to the nurse I was told that she could have anything in moderation. I pointed out that her recent blood sugar was 315, and was told "thats because we are trying to fiqure out her insulin levels! When I made my feelings clear, she did not want to hear - hence I thought my own knowledge of diabetic teaching was wrong - hence my question.
Thank you both for your responses

[nightmare]

I'm not on insulin,but the only sure way of keeping down blood sugars is to watch the carbs!I manage to keep mine down to about 5.7(102) just by carb counting and that definitely does not include cookies and chocolate(OK ,sometimes)I know a lot of type two's who follow the same regime.This ,of course,is not hospital based.I don't know what the hospital protocols are at the moment for introducing insulin.

[classicdame]

315 is not appropriate for a hospitalized patient. She will never be in control at home if she does not learn how to eat while in the hospital. You are right. Push this question up the totem pole - or whatever you call the chain of command.