diabetes care literature

First, the benefits of individualized multi-dimensional intervention are significantly better than the universal standardized glucose control plan. Second, for patients throughout the disease course, the priority of long-term complications prevention is higher than the short-term blood glucose level reaching the target.

Last week, I followed Nurse Zhang from the Department of Endocrinology during ward rounds and met Uncle Zhang, a 62-year-old diabetic. He used to follow the "Universal Sugar Control Chart" uploaded online and strictly followed it. He ate a fixed weight of whole-wheat meals and walked 10,000 steps every day. His glycation rate did drop to 6.8%. However, he fainted twice in three months, both caused by hypoglycemia. He also developed corns from walking too much and almost developed diabetic foot. In fact, this kind of "hard work to meet the standard" situation is really too common in clinical practice.

When I sorted out 27 clinical studies related to diabetes care included in Peking University core journals from 2021 to 2024 last month, I found that the academic controversy over sugar control targets has been going on for almost five years. The traditional nursing school insists that all adult patients without underlying complications must have glycated hemoglobin (HbA1c) stably controlled below 7%. This conclusion comes from the long-term follow-up data of the 1993 DCCT study, which can reduce the risk of microvascular complications by more than 40%. It is still the core standard for many primary care education. However, in recent years, the latest guidelines from the American Diabetes Association (ADA) and the Chinese Diabetes Society (CDS) have proposed the concept of layered sugar control. For patients over 65 years old, with cardiovascular and cerebrovascular diseases, and a history of hypoglycemia, the HbA1c target can be relaxed to 7.5%-8.5%. For some elderly and frail elderly people, the HbA1c target can even be relaxed to 9%. The core is to avoid the fatal risk of hypoglycemia first, and then talk about long-term sugar control. There is no absolute right or wrong between these two views, they just apply to different groups of people. Applying rigid standards will cause problems. For example, the 78-year-old Grandma Li who was admitted to our department last year was required by community care to reduce her glycation to less than 7%. She only dared to eat 1 tael of staple food every day. She lost 8 pounds in three months. She fell dizzy when she went downstairs to buy groceries. It was caused by hypoglycemia. Later, we relaxed her sugar control goal to 8% and allowed her to eat staple foods normally, along with sitting Baduanjin for 15 minutes a day. After three months, her glycemic index was 7.8. She felt more energetic and never suffered from dizziness again.

To be honest, I have met many young patients who have just been diagnosed before. They checked one by one against the "diabetic diet blacklist" found on the Internet. They even dared to eat less than half a bowl of rice. They were so hungry that they panicked and still carried it. Instead, they developed hypoglycemic ketosis. It is really unnecessary. In recent years, many nursing studies have mentioned that, on the premise that the total carbohydrate intake reaches the standard, patients who occasionally eat less than 10g of refined sugar, such as a small piece of cake or a piece of fruit candy, will have minimal impact on overall blood sugar. On the contrary, it can relieve the anxiety of sugar control and improve long-term compliance. When we communicate with patients in private, we often say, "sugar control is about living a good life, not meeting KPIs." Living a life just for a few numbers is not fun, but in fact it is more gain than loss.

By the way, another care point that is often ignored is foot care. In the past three years, 11 core documents have mentioned that the cost of early prevention of diabetic foot is only 1/20 of the cost of treatment. Soak your feet in warm water of 37-40°C for 10 minutes every day, wear loose cotton socks, and do not cut the nail groove when cutting nails. These seemingly inconspicuous little things are more effective than taking many nerve-nourishing drugs. I have been in contact with three patients who suffered from early foot numbness. They insisted on following this method of care for half a year. During the reexamination, the nerve conduction velocity improved to varying degrees, and there were no more foot ulcers.

Nowadays, continuous blood glucose monitoring (CGM) is becoming more and more popular. In the past, people thought that only people with type 1 diabetes needed to use it. Now, many people with type 2 diabetes use oral medications. They can also wear them in stages for 3-7 days to understand their own blood sugar fluctuation patterns. For example, some people Eating rice raises blood sugar quickly, while some people eat noodles. Some people exercise better in the afternoon to lower blood sugar, while some people exercise in the evening and have hypoglycemia. Once you understand your own patterns, you can adjust your care plan to get twice the result with half the effort. This is also the core meaning of personalized care.

In fact, the more literature I read, the more I feel that there is no one-size-fits-all standard answer to diabetes care. All guidelines and research data must ultimately be applied to specific people. After all, we are caring for people with diabetes, not the numbers floating on the test sheets. This is probably the core of what all diabetes care literature ultimately wants to convey.