Diabetes Care Orientation

The current core direction of diabetes care recognized in clinical and public health fields has already moved away from the single logic of "sugar control alone" and shifted to "full-cycle stratified individualized care" centered on the individual needs of patients. There is no universal nursing formula. Blood sugar control goals, diet and exercise plans, and complication screening frequencies must be dynamically adjusted according to the patient's age, underlying diseases, living habits, and even financial capabilities.

I was particularly impressed by Aunt Zhang, whom I met at a community free clinic last month. She was 62 years old. She had suffered from the sequelae of cerebral infarction and had difficulty with her left limbs. Her children checked popular science on the Internet and forced her to control her fasting blood sugar to 4.4-6.1mmol/L. As a result, she fainted twice in three consecutive months. Once she fell in the kitchen and needed three stitches on her forehead, which was why her children came to ask in a panic. Speaking of this, some people may wonder: Is it wrong to strictly control sugar after so many years?

In fact, the concept of intensive sugar control of "glycated hemoglobin lower than 7%" was first proposed, which itself has a solid evidence-based basis: for newly diagnosed patients with diabetes who are younger than 65 years old and have no serious underlying diseases, long-term stabilization of glycation within 7% can reduce the risk of long-term microvascular complications by more than 30%. This is also the standard of care that many endocrinologists still adhere to. However, in the past ten years, scholars in the fields of geriatric medicine and chronic disease care have successively put forward the opposite view: For patients over 65 years old, with a history of severe cardiovascular and cerebrovascular diseases, and repeated hypoglycemia episodes, it is no problem to relax glycation to 7.5%-8.5% or even 9%. On the contrary, it can significantly reduce the risk of hypoglycemia and falls, and the quality of life will be much higher. These two views are never antagonistic, they are just suitable for different people. Later, we adjusted Aunt Zhang’s fasting blood sugar target to 7-9mmol/L. She never fainted again, and she could still go downstairs and slow dance with her old sisters for half an hour every day.

When talking about diabetes care, the first thing most people think of is "shut up", but this is exactly where the most misunderstandings currently occur. The current mainstream diet plans are actually divided into several groups: some advocate the ketogenic diet, which advocates almost cutting off carbohydrates. Short-term sugar control and weight loss are indeed fast, but long-term eating can easily increase blood lipids, and people with poor liver and kidney function cannot use it at all. ； There are low-GI diets that promote whole grains and low glycemic index, which are friendly to most people with diabetes. The disadvantage is that multigrain rice tastes bad, and many young people break the diet after being unable to persist for half a month. ； There is also the balanced dietary pattern that has been promoted by domestic guidelines. It is not necessary to completely give up sugar and meat. It only needs to control the total calories and balance the nutritional ratio, and the acceptance is higher. I met a 30-year-old programmer before who had just been diagnosed with pre-diabetes and prescribed a low GI diet. He said he really couldn't swallow multi-grain rice and couldn't help but drink milk tea. Later we adjusted him to white rice mixed with 1/3 brown rice and set aside 2 grams per week. As long as he drank milk tea and eaten fried chicken as an "indulgence quota", he just walked 2,000 more steps that day. He persisted for half a year, and his glycation dropped from 6.3% to 5.6%. The effect was much better than those who tried hard to quit sugar and ended up overeating. To put it bluntly, there is no best diet plan, only a plan that patients can stick to.

Exercise care tied to diet is actually not as complicated as everyone thinks. You have to walk 10,000 steps a day or go to the gym. Not long ago, there was a 70-year-old diabetic who had degenerative knee disease and it hurt when he walked 500 meters. We gave him an idea: stand for half an hour after eating every day without sitting down, and do upper limb exercises at home with two 500ml bottles of mineral water, three times a week, for 20 minutes each time. Last month, his blood sugar was very stable, and he was in better shape than before when he had to walk 10,000 steps a day and his knees hurt so much that he couldn't sleep. Nowadays, the clinical consensus on exercise care is no longer the pursuit of intensity. Even if it is just mopping the floor or watering the flowers at home, being able to move is better than sitting. What suits you is the best.

As for screening for complications that everyone is most worried about, there is no unified timetable. For those with diabetes who are young, have been diagnosed for a short time, and have stable blood sugar control, it is enough to check their fundus, liver and kidney function, and urine microalbumin once a year. ； But if you are an old diabetic patient who has been ill for more than 10 years and has high blood pressure and high blood lipids, it is best to get screened once every 3-6 months, especially for foot care. Patients with peripheral neuropathy must ask their family members to help test the temperature of the foot water. I met an old man in the emergency department before. He soaked his feet in 45-degree water and didn’t even feel the blisters. In the end, it was so bad that he needed amputation. It was a pity.

Digital care has also been a hot trend in the past two years. Dynamic blood glucose meters, chronic disease management APPs, and family doctor contract services can monitor blood sugar at any time and automatically record diet and exercise, which is really convenient for young people with diabetes. But you want to say this thing is suitable for everyone? No, for many elderly people living alone who cannot use smartphones, it is more reliable to keep a small notebook to record their blood sugar and go to the community health service center to test it once a week. There is no need to follow the trend.

In fact, to put it bluntly, the core of diabetes care has never been to fit patients into a standard answer, but to allow patients to find the most comfortable balance between sugar control and life - after all, the purpose of our sugar control is to make people live a good life, not to suffer by staring at those numbers.