Addressing Malnutrition in Patients With Diabetes

What Is Malnutrition?

Malnutrition can be understood as a condition in which the body gets deprived or has a deficit of nutrients or energy that affects the body's functions and form. It can also result from specific nutrient deficiencies, decreased nutrient absorption, higher dietary requirements, or increased loss of nutrients in certain diseases. Sometimes, malnutrition worsens due to metabolic changes caused by treatment interventions for other conditions. This disease-causing malnutrition complicates treatment plans, increases the risk of certain diseases, hampers healing time, and negatively influences body functions, overall health, and prognosis of the diseases. Malnutrition increases the mortality risk in people with type-2 diabetes by 70 %. The burden on the health care providers and services also rises.

What Causes Food and Nutrition Insecurity?

Food insecurity is the non-accessibility and unaffordability of sufficient food or nutritious food. It does not mean people go without food, but they may not have enough food or have less food. They may be consuming less healthy foods, like packaged foods that cost less. Nutritious foods are expensive and difficult to find in some communities.

Causes of Food Insecurity:

The causes of food insecurity are based on social determinants of health. These include the place where the person was born, lives, learns, works, plays, worships, and the age of the person. Some of the causes include

• Not having employment or low income.

• Reduced access to nutritious foods.

• Not having affordable housing.

Food insecurity is difficult to solve. There are too many causes. Many programs are conducted at the state, national, and local levels to provide food assistance.

How Does Malnutrition Occur in Patients With Diabetes?

Due to its complications, people who have diabetes undergo delayed and compromised cures to diseases and bad health outcomes. However, because of the more critical sequelae of the condition, malnutrition in people with diabetes usually goes unnoticed and hence, not treated. Malnutrition usually occurs as the patients and the caregivers focus on the diet to avoid, without remaining aware of the appropriate diet to be taken, and therefore adopting or restricting wrong food choices.

Besides diabetes, certain contributing factors to malnutrition are:

• Physical factors like loss of dentition, improper dentition, poorly fitting dentures, and swallowing difficulties;

• Social factors include low income, less awareness about diet and cooking skills, and alcohol or drug abuse.

• Medical conditions, for example., eating ailments, abnormal bowel conditions, cancer, psychological issues like dementia, depression, etc.

Some of the issues mentioned above are more prevalent among diabetic patients, like depression and delayed stomach emptying. In addition, type-1 diabetic individuals have more chances of developing eating disorders, allergies, or intolerances such as celiac disease.

How to Detect Malnutrition in Patients With Diabetes?

To detect malnutrition among diabetics, the evaluation comprises an assessment of the body mass index (BMI) and the amount of unintentional weight loss that has occurred. During the examination, the period over which nutrient intake was unintentionally decreased, and the possibilities of upcoming abnormal nutrient intake should also be considered. Specifically, the Malnutrition Universal Screening Tool (MUST) may help confirm the diagnosis.

How Does Food and Nutrition Insecurity Affect Diabetes Management?

Individuals with diabetes, along with food insecurity, affect the management of diabetes. Food insecurity may increase A1C levels, complications of diabetes, hospitalizations, and poorer mental health.

Like the foods that increase the risk of type 2 diabetes, these foods, too, make it difficult to manage diabetes. Foods that are low in cost are high in carbohydrates and calories and may cause an increase in blood sugar levels. High blood sugar may result in complications of diabetes, like heart and kidney diseases, vision loss, or lower-limb amputations.

Some individuals with diabetes may not be able to afford sufficient meals in a day. Skipping meals may lead to decreased blood sugar levels. This is a dangerous complication of diabetes.

Some people with diabetes may not be able to afford healthcare costs. They may have to choose between diabetes healthcare or food. Hence, they do not take the prescription mentioned properly, or they may not check the levels of blood sugar timely. This results in serious health complications.

How to Manage Malnutrition in Patients With Diabetes?

Generally, changes in diet and dietary patterns are required for managing malnutrition, which depends on the causative factors and the patient's individual needs. The detected and the suspected individuals should get a suitable care plan comprising treatment goals from their physician and the dietician. The plan should be monitored regularly. The specific measures to be taken immediately are controlling blood sugar levels and reviewing diabetes medication in patients with type 2 diabetes.

Blood glucose targets should be set in agreement with the doctor, diabetes nurse, patient, or caregiver. Hyperglycemia is commonly treated with short-acting or long-acting insulin (often a combination of both) and through insulin pumps. However, it can also be stress-induced and should be dealt with accordingly. Hypoglycemia usually occurs due to oral hypoglycemic agents or treatment with insulin. However, it can also be caused by less carbohydrate intake because of poor diet, decreased appetite, vomiting, hyperactivity like shopping, etc., and weight loss. Therefore, encouraging appropriate nutrition is also necessary.

Oral nutrition support to combat malnutrition along with controlling diabetes includes the following:

• Having fortified food with protein,

• Taking optimum carbohydrate and fat, plus minerals and vitamins;

• Consuming mid-meal snacks;

• Taking oral nutritional supplements;

• Altered meal patterns;

• Seeking dietary advice.

The following dietary changes can help in treating malnutrition:

• To eat well, even with diabetes, one must consume three meals a day.

• Including starchy carbohydrate foods in the diet.

• Cutting down the fat intake, particularly saturated fats.

• Having more fiber-rich foods like fruits and vegetables.

• Including more protein-rich foods such as beans and lentils.

• Including at least two servings of oily fish every week.

• Limiting sugar and sugary foods.

• Reducing salt intake to six grams or less a day.

• Alcohol consumption should be strictly limited or stopped.

• Avoid diabetic foods or drinks.

What Are the Important Considerations in Patients With Malnutrition and Diabetes?

The following are the important considerations in patients with malnutrition and diabetes:

• First-line dietary advice means recommending more energy and protein-rich foods and keeping low-fat foods at bay. Small and frequent meals, including snacks and nourishing drinks, are preferred. This helps in decreasing the chances of hypoglycemia. Plenty of fluid intake between meals should be encouraged. However, drinks before meals should be avoided as they may cause early satiety and, hence, lower food intake. Sugary drinks should also be kept away, except in the case of hypoglycemia.

• Milk-based supplements have a low carbohydrate content, so they cause a smaller rise in blood glucose levels than juice-based supplements. It is better to have milk-based supplements, excluding cases of allergies or intolerances.

• Enteral tube feeding or parenteral nutrition should be considered in patients with difficulty in oral intake and improper gastrointestinal tract functioning. However, oral nutrition support should be discontinued when the patient becomes comfortable ingesting food orally. Yet, the dietary recommendations need to be followed.

• A registered dietician should be consulted to seek proper dietary education, especially regarding the timings of meals and portion sizes.

Conclusion:

It is imperative to recognize and treat malnutrition in patients with diabetes, as it deteriorates the patient's general health, and immune response causes more complications related to the condition and compounds the expense of diabetes care to an increase of over 50 %. Therefore, it is recommended to consider and initiate the assessment, diagnosis, and treatment of malnutrition as diabetes is diagnosed in the patient.