For case managers and solicitors working in catastrophic injury litigation, poorly controlled type 2 diabetes can become a significant barrier to rehabilitation. It may delay surgery, prolong dependency on care, and contribute to future health complications.  All of this can influence rehab planning and long-term care costs.

Regardless of whether the diabetes developed pre-injury or post-injury, chronically high blood glucose levels (especially if glucose levels persistently run over 9mmol/L or someone has an HbA1c over 58mmol/mol)1 can undermine rehab in various ways.  Examples include:

• Increased fatigue
• Increased risk of urinary tract infections and sepsis
• Increased risk of wounds becoming infected or healing slowly
• Increased risk of nonunion and/or slow bone healing
• Increased surgical risk for any elective surgeries
• Increased risk of cardiovascular disease and kidney disease
• Increased risk of neuropathy and foot complications

Blood glucose levels can become much more difficult to manage after a major trauma.

Here’s why:

1. Changes to body composition

Most major trauma clients lose significant amounts of muscle mass in hospital.  This is due to a combination of high levels of inflammation in the body, combined with being much less physically active and/or not eating sufficient calories and protein.

Skeletal muscle is the metabolically active tissue which stores and uses glucose in the body.  Less muscle mass means fewer cells requiring glucose.  This can result in higher glucose spikes after eating carbohydrate-rich meals and snacks.

Less muscle also means a slower metabolic rate, and a higher probability of increasing weight and body fat in the future (often around the abdominal region).  High levels of body fat make cells more “resistant” to insulin, meaning the body has to produce more and more insulin to keep blood glucose levels within a healthy range.  Overtime, worsening insulin resistance, combined with reduced pancreatic beta-cell function, can contribute to the development of type 2 diabetes.

2. Cognitive overwhelm, executive function and mental capacity

Major trauma clients are often juggling multiple demands and priorities which are all competing for their mental energy and time.  Having type 2 diabetes is just one more thing to think about.  This can be a struggle when clients are already feeling overwhelmed.

Additionally after a brain injury, executive dysfunction can mean clients struggle with initiation, planning, memory, reduced insight and challenging behaviour.  Food choices can also become a lot more impulsive.  This makes food shopping, meal planning, portion control, timing of meals and medication adherence a lot more tricky and makes blood glucose levels harder to manage.  Clients after a brain injury may also lack the mental capacity to make specific decisions relating to their food choices, and to understand the impact that these food choices can have on their weight, health and blood glucose levels.

3. Lower levels of physical activity

A brain injury, spinal cord injury, amputation or multiple orthopaedic fractures, will all have a negative impact on mobility and physical activity levels, at least initially.   Less physical activity means the cells become more “resistant” to insulin and the cells don’t need as much glucose to fuel them.  In both cases, this can cause glucose levels to rise in the blood.

4. Illnesses

Alongside food intake and physical activity, blood glucose levels are also affected by the hormonal changes which naturally occur due to illness or stress (physical or mental).  Clients with chronic UTI’s or other acute infections for example, will frequently have high blood glucose levels which can be completely independent of their food choices.

5. Medication

Major trauma clients often take many different medications.  Certain medications can increase blood glucose levels or make the body more resistant to insulin, such as corticosteroids, certain anti-psychotic medications (like olanzapine or quetiapine), thiazide diuretics and beta-blockers. 2

6. Food choices

Major trauma clients frequently return to their pre-injury eating habits or they become reliant on support workers and family members to provide food for them.  In both situations, the food they are eating may not always be aligned with what their post-injury body actually needs. Toast or cereal for breakfast, a sandwich and crisps for lunch, a high-carb evening meal with lots of potatoes, pasta or rice and/or biscuits for snacks, can provide too many carbohydrates, particularly when physical activity is limited.

7. Poor sleep

Sleep apnoea and/or chronically poor sleep “stresses” the body, resulting in hormonal and cellular changes that can increase blood glucose levels.3

Top four ways that dietitians can help

a) Arrange and interpret blood tests

An HbA1c blood test checks someone’s average glucose level over the previous 2-3 months.  Dietitians can request or arrange for HbA1c levels to be checked at regular intervals and help the client interpret these results.  It’s not uncommon to come across major trauma clients who have had pre-diabetes for years, but were never told they had the condition.  This means they were never given any advice on diet and lifestyle changes which could prevent further deterioration (into type 2 diabetes).  Additionally, dietitians can arrange for other blood tests to be done at the same time to rule out hypothyroidism, low testosterone levels and/or common nutrient deficiencies (e.g. iron, B12, folate and vitamin D) which can also contribute to fatigue.

b) Assist with continuous blood glucose monitoring (if needed and beneficial)

The NHS does not routinely provide blood glucose monitors (finger prick or continuous) to people with type 2 diabetes, unless they are pregnant, on insulin or otherwise at increased risk of hypoglycaemia.1 This can be a real missed educational opportunity.  Many clients don’t “feel” any different when their blood glucose levels are high.  That means that in the absence of any tangible evidence that proves that what they are doing is working, many clients may be less motivated to implement changes to diet and physical activity levels.

The easy solution is to use a continuous blood glucose monitoring device.  This is a sensor that affixes to the back of someone’s arm and transmits real-time glucose data to an app on their phone every ~5 minutes.   This is a quick and easy way to give clients (and their support team) real-time feedback on how their blood glucose levels are affected by different food choices and physical activity.  This can positively impact someone’s confidence in their ability to self-manage the condition, compared to receiving a generic list of “foods to avoid” and being sent on their way.  It’s also a much faster way to identify when things go off track, versus waiting until the next HbA1c blood test. These glucose sensors can be used short-term or long-term, monitored remotely by the dietitian and can be purchased privately if someone is not eligible through the NHS.  Freestyle Libre 3 and Dexcom G7 are the most commonly used sensors in the UK.

Continuous blood glucose monitoring can also give more flexibility with food choices.  Many foods don’t need to be entirely avoided, and someone’s body may be able to tolerate them in smaller amounts or when paired with a certain amount of physical activity.  There is no point restricting food choices just for the sake of it – that isn’t realistic or sustainable.  Plus just because a food is supposed to affect glucose levels in a certain way, doesn’t mean that’s what happens in reality.  Factual data provides a much more reliable basis for decision-making.

c) Liaise with the GP regarding medication

When managing type 2 diabetes, it’s always a delicate balance between food choices, portion sizes, weight management, physical activity, medication and quality of life.  Dietitians are uniquely placed to identify when someone’s high (or low) glucose levels are a food-related issue versus a medication-related issue.  Dietitians can also determine whether the current medication regime is working with the client’s eating habits and lifestyle, or whether a different type or combination of medication would be a better fit for them.  Dietitians will also know if a medication is having a negative impact on someone’s gut function (e.g. metformin; GLP-1 injections).

d) Guide and oversee food choices (in the least restrictive way possible)

Continuous blood glucose monitoring can help give clients more independence with figuring out which foods and dietary habits work best for them.  However, dietitians can also be there to provide advice, suggestions, interpret the data, ensure diets are nutritionally adequate, screen for disordered eating, train support staff, develop meal plans, assist with mental capacity assessments and/or help make best interest decisions on behalf of someone who lacks the mental capacity to understand the consequences of their food choices.  Dietitians can also advise clients on how to manage multiple health conditions which may all require different dietary considerations, such as type 2 diabetes alongside a slow healing wound, bladder stones and the need for a texture-modified diet.  Dietitians can also help clients lose weight in a sustainable way which doesn’t compromise their nutritional health or increase fatigue levels.

Poorly controlled blood glucose levels can quietly undermine rehabilitation.  If you have a client with an HbA1c of 58mmol/mol or higher (or if blood glucose levels are regularly over 9mmol/L), that is a red flag to get a dietitian involved.  Additionally, if the client also has other secondary health issues, like a slow healing wound, nonunion, or fatigue (which will be made worse as a result of these high glucose levels), that further justifies the need for dietetic input.

To refer a case management or litigation client for a comprehensive dietetic assessment and report, contact Specialist Nutrition Rehab at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

References:

1. Type 2 diabetes in adults: Management (2015) National Institute for Health and Care Excellence. 
2. Jain, A. B., & Lai, V. (2024). Medication-induced hyperglycemia and diabetes mellitus: a review of current literature and practical management strategies. Diabetes Therapy, 15(9), 2001-2025.
3. Adeva-Andany, M. M., Domínguez-Montero, A., Castro-Quintela, E., Funcasta-Calderón, R., & Fernández-Fernández, C. (2024). Hypoxia-induced insulin resistance mediates the elevated cardiovascular risk in patients with obstructive sleep apnea: a comprehensive review. Reviews in Cardiovascular Medicine, 25(6), 231.