Should patients with Hyperosmolar Hyperglycemic State (HHS) diabetes be started on a diet immediately upon admission?

Management of Diet in Patients with HHS Diabetes on Admission

Patients with Hyperosmolar Hyperglycemic State (HHS) should not be started on a diet immediately upon admission, as initial management should focus on fluid resuscitation and insulin therapy.

Initial Management Priorities

• Patients with HHS present with severe dehydration, marked hyperglycemia, and hyperosmolality, requiring immediate fluid resuscitation as the primary intervention 1
• The initial focus should be on restoring circulating volume with intravenous fluids, not on oral intake 2, 3
• Insulin therapy should be initiated for persistent hyperglycemia (≥180 mg/dL), with a target glucose range of 140-180 mg/dL for most hospitalized patients 1
• Fluid replacement alone will cause a fall in blood glucose level, and early use of insulin before adequate fluid resuscitation may be detrimental 2, 3

Progression to Oral Intake

• Oral intake should only be initiated after:

  • Hemodynamic stability has been achieved 2
  • Mental status has improved 4
  • Significant improvement in hyperglycemia and hyperosmolality has occurred 3
  • The patient is able to safely swallow 1

• When transitioning to oral intake:

  • Food intake should be initiated as quickly as possible once the patient is stabilized 1
  • Progression from clear liquids to full liquids to solid foods should be completed as rapidly as tolerated 1
  • A consistent-carbohydrate meal planning system should be implemented to provide consistency in the carbohydrate content of meals 1

Nutritional Considerations During Hospitalization

• For patients requiring clear or full liquid diets during the transition phase, approximately 200g carbohydrate/day in equally divided amounts at meal and snack times is recommended 1
• Liquids should not be sugar-free, as patients require both carbohydrates and calories 1
• Once stable, a regular menu with consistency in the amount and timing of carbohydrate is appropriate 1
• Hospitals should implement a diabetes meal-planning system that provides consistency in the carbohydrate content of specific meals 1

Common Pitfalls to Avoid

• Initiating oral intake too early before adequate fluid resuscitation can worsen dehydration and metabolic abnormalities 2
• Using "ADA diet" or "no concentrated sweets" diets is not recommended and lacks evidence support 1
• Failing to adjust insulin regimens appropriately when transitioning to oral intake can lead to hypoglycemia 1
• Not considering the patient's ability to eat when planning insulin therapy (basal-bolus regimen for patients with good nutritional intake; basal-plus-correction for poor intake) 1

Discharge Planning

• Diabetes discharge planning should start at hospital admission 1
• Nutrition education should be provided before discharge, including:
  • Information on consistent eating patterns 1
  • Carbohydrate counting if appropriate 1
  • Meal planning that accommodates individual preferences 1
• Patients should receive education on the relationship between food intake and insulin dosing 1
• Diabetes self-management education should start as soon as feasible during hospitalization 1

In summary, while nutrition is an important component of diabetes management, the immediate priority for patients with HHS is fluid resuscitation and stabilization of metabolic parameters. Oral intake should be initiated only after the patient is hemodynamically stable with improved mental status and glycemic control.