Sick Day Adjustments to Meal Plans

Hospital admission

• Diabetes self-management knowledge and behaviors should be assessed on admission and individualized diabetes self-management education provided. Diabetes self-management education should include right skills needed after discharge, such as medication dosing and administration, glucose monitoring, and recognition and treatment of hypoglycemia (Moghissi, 2009).
• Clearly identify a diagnosis of diabetes mellitus in the medical record make sure to include the type of diabetes.
• Known diabetics should have blood glucose results available to all members of the health care team.

Hospitalized patients frequently develop hyperglycemia and metabolic changes arising from the stress response that accompanies medical procedures and acute illnesses. Plummer, Finnis, et al. (2016) identified stress induced hyperglycemia in 17% of ICU patients without diabetes. 

Myocardial infarction, stroke , influenza, infection, surgery, medications, injuries, or any significant stress can increase blood glucose in diabetics and non-diabetics. The body responds to stress and illness by increasing the secretion of glucocorticoids, norepinephrine, epinephrine, growth hormone and inflammatory mediators: cytokines, tumor necrosis factor, Interleukin-2. The action of these substances cause elevated plasma glucose by increasing hepatic glucose output (glycogenolysis & gluconeogenesis) and decreasing insulin mediated uptake by peripheral tissue.

Diabetics have a decreased ability to cope with illness or stress related hyperglycemia. The absence of insulin or its effects inhibit the body's ability to store excess glucose and suppress the catabolic effects of glucagon. Diabetics may lack the ability to regain euglycemia even when stress is short-term, as may occur during strenous physical exercise. This fact necessitates constant vigilance and frequent blood glucose monitoring.

ADA 2023 Recommendations For Diabetes Care in the Hospital  (excerpts

• Blood glucose (BG) monitoring should be initiated for any non-diabetic patient at high risk for hyperglycemia
  • high-dose glucocorticoid therapy
  • enteral or parenteral nutrition therapy
  • octreotide or immunosuppressive medication 
• A specialized glucose management team should be consulted for all hospitalized patients with diabetes
• All people admitted to hospital with diabetes or hyperglycemia require A1C testing if there is no record within 3 months.
• Hospitalized patients with diabetes who are eating should have point of care glucose monitoring before meals.  Hospitalized patients who are not eating should have glucose monitoring every 4-6 hours. 
• Point of care glucose testing should be done every 30 minutes to every 2 hours for those receiving IV insulin.

2023 ADA GLYCEMIC TARGETS IN HOSPITALIZED Adults

• Insulin therapy should be initiated for treatment of verified persistent hyperglycemia starting at a threshold of ≥180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140–180 mg/dL (7.8–10 mmol/L) is recommended for the majority of critically ill and non-critically ill patients."
• Non-critically ill patient BG goals: "There is no clear evidence for specific blood glucose goals. If treated with insulin, the premeal blood glucose targets generally <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, provided these targets can be safely achieved."
• More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), or 100-180 mg/dL (5.6-10.0 mmol/L) may be appropriate for selected patients if they can be achieved without significant hypoglycemia.
• Hypoglycemia treatment should prevent a blood glucose value of <70 mg/dL or (3.9 mmol/L)