Enteral and parenteral nutrition

Hospital malnutrition, hyperglycemia and insulin therapy are three closely related variables that affect the quality of life and the result of treatment in the hospitalized person. They have the characteristic of influencing each other: a bad glycometabolic control worsens the state of nutrition and, on the other hand, malnutrition can cause hyperglycemia (1,2). Inadequate insulin therapy does not allow sufficient metabolic control and does not promote the state of nutrition (3). The prevalence of diabetes in hospitalized patients is not well known; in 2000, 12.5% ​​of hospital discharges in the USA reported diabetes as a diagnosis. Umpierrez has detected a prevalence of diabetes in the hospital of 26%; in this study, an additional 12% of people had unrecognized forms of diabetes or stress hyperglycemia (4). 

The Italian data are scarce, they date back to the introduction of the system of diagnosis related groups (DRG) and tend to underestimate the prevalence because the diagnosis of diabetes is not always included in the hospital discharge card (SDO). However, we know that in Italy in 2014, according to the recent ARNO report, 20% of diabetics had at least one ordinary hospitalization or a Day Hospital compared to 13% of the non-diabetic population (5) and that diabetic patients compared to non-diabetics, comparable for age and sex, they have an increased risk of hospitalization for all causes. We must also consider that diabetes is present in 20-25% of patients for other diseases and that the glycometabolic compensation has a significant impact on the management and duration of hospitalization and consequently on costs incurred by the NHS (6). In Campania, a prevalence of 6% among the discharged was described, while in Emilia Romagna it reached 21%. The presence of diabetes in SDOs is related to a notable lengthening of hospital stays.

 These studies, almost always, do not take into account stress hyperglycemia, ie occurring during hospitalization but regressed to discharge, even if different observational reports show that for glycemic values ​​between 79 and 200 mg / dl the duration of exposure to the highest concentrations glycemia is associated inversely with survival (3). Stress induces an increased secretion of the counter-regulating hormones (mainly adrenaline and cortisol) and an increase in the release of cytokines and fatty acids from the adipose tissue. These factors condition the worsening of glycometabolic control by increasing both peripheral and hepatic insulin resistance. The person with diabetes in a critical situation or with hyperglycemia due to stress, due to the same mechanisms that lead to an increase in blood glucose, is more frequently involved in a state of malnutrition which represents a further negative prognostic factor.

Hospital malnutrition

The current historical moment continues to be characterized by a lively debate on the containment and rationalization of health expenditure. What is incomprehensible is the generalized underestimation of areas of intervention capable of simultaneously meeting the needs of the economic order and total quality of health services (sum of the professional component with the management, perceived and social). 

The strategies aimed at combating hospital malnutrition are, in fact, the main of these areas (7.8). The most representative scientific societies of the sector have recently elaborated a document (9) that inserts the calorie protein malnutrition (MPC) among the top ten Italian challenges for the 2015-2018 three-year period and reiterates that the MPC is a relevant clinical and economic problem, unfortunately often misunderstood, despite a relative simplicity in its motorization. At the European level, the prevalence of MCP at admission, ie the condition of depletion of energy reserves, proteins and other nutrients of the organism that compromise the state of health varies between 20 and 60% and at national level settles on the 30%. The incorrect management of the hospitalized patient from the nutritional point of view can determine a “disease in the disease”.