Diabetes care issues and diagnosis

Patients have a disconnect between knowledge and practice in self-management, insufficient personalized adaptation of clinical care, and a high rate of missed diagnosis in early screening of complications. Diagnosis needs to break the single standard of "blood sugar theory" and take into account biochemical indicators, behavioral assessment and risk stratification, so as to truly achieve early intervention and control progress.

Leaving aside the clinical issues, patients’ own misunderstandings alone are enough to cause headaches for medical staff. Last week I met 62-year-old Aunt Zhang at the outpatient clinic. She has been diagnosed with type 2 diabetes for 3 years. She has never missed taking anti-diabetic drugs. Every time she tests her fasting blood sugar at home, it is around 6.2mmol/L. She seems to be under very good control. When she checked, her glycosylated hemoglobin (HbA1c) was actually 7.9%, which is far beyond the qualified line. After questioning for a long time, she figured out that she had heard people say "you can't eat sweets with diabetes." She usually didn't touch cakes and milk tea, but she drank two large bowls of white porridge every meal and ate steamed sweet potatoes as a side dish. Her carbohydrate intake had long exceeded the standard. Her fasting blood sugar seemed normal, but it could soar to 13mmol/L two hours after a meal. She had no idea.

Interestingly, there is currently no unified standard answer in the industry regarding dietary guidance for patients. The traditional school adheres to the general principle of "carbohydrates accounting for less than 50% of total calories and giving priority to low-GI foods", which is suitable for most elderly patients and patients with many underlying diseases; the low-carb ketogenic school, which has been popular in recent years, advocates reducing the proportion of carbohydrates to less than 20% and relying on fat to provide energy to stabilize blood sugar. Many young patients have indeed controlled glycation to the normal range by using this method, but many people have experienced elevated uric acid and signs of ketoacidosis after eating for three months. My own experience is that you don’t have to stick to standards. For example, some old people love to eat noodles all their lives. If you insist on letting them eat brown rice all the time, they will have to eat it secretly if they can’t persist for half a month. Instead, it is better to teach them to eat a small bowl at a time, paired with half a catty of green leafy vegetables, and walk for 20 minutes after eating. The blood sugar can be stabilized. After all, sugar control is a lifelong matter, and if you have to go against human nature, the patient will suffer in the end.

When it comes to clinical care issues, the most prominent one now is that "standardized follow-up is useless." In many communities, follow-up visits are just a one-step process, where they call and ask, "Have your blood sugar been tested?" and "Have you taken your medicine?" without understanding the actual difficulties of the patients at all. A while ago, we went to the community in our jurisdiction to conduct a survey and found that nearly 30% of the elderly living alone had wrong blood sugar monitoring methods: some were afraid of pain, and only adjusted the blood collection needle to the lightest setting. If the blood was not enough, they squeezed their fingers hard to mix tissue fluid into the blood sample, and the measured value was 2 to 3 m lower than the actual value. mol/L, I thought I had very good control, until I developed peripheral neuropathy and numbness in my hands and feet before I came to the hospital. Some elderly people have poor eyesight and cannot see the insulin scale clearly. They need to take more or less medicine every time, and they alternate between hypoglycemia and hyperglycemia, so the risk is particularly high. These problems cannot be solved by a standardized nursing form. You have to go to the patient's home and touch the patient's living habits to find the crux.

The diagnosis issue has become more controversial in the past two years. The traditional diagnostic criteria are fasting blood glucose ≥7.0mmol/L, OGTT (oral glucose tolerance test) ≥11.1mmol/L 2 hours after a meal, and glycosylated hemoglobin ≥6.5%. Diabetes can be diagnosed if any one of these criteria is met. However, one group of scholars now proposes that as long as there is abnormal glucose tolerance (fasting 6.1~7.0mmol/L, postprandial 7.8~11.1mmol/L), it should be included in the scope of nursing intervention for people at high risk of diabetes, which can reduce the probability of developing diabetes by 60%; another group of scholars opposes "over-diagnosis" and believes that many people with abnormal glucose tolerance can return to normal as long as they adjust their diet and exercise. If they are labeled as "pre-diabetic" too early, it will cause unnecessary anxiety. Last year, I met a 30-year-old young man whose physical examination revealed abnormal glucose tolerance. He was so scared that he didn't even dare to eat rice. He only ate boiled vegetables. He lost 20 pounds in three months. When he finally came for a follow-up examination, his glycation was normal, but his albumin was extremely low. He was already suffering from malnutrition, and even his normal work was affected.

I have been doing endocrinology nursing for almost 8 years, and my biggest feeling is that the care and diagnosis of diabetes is never as simple as prescribing medication based on a laboratory test sheet. Some patients have poor family conditions and cannot afford long-acting insulin that is not covered by medical insurance. If you insist on prescribing him the expensive one, he will verbally agree, then go to the pharmacy to buy cheap short-acting insulin and inject it himself. You cannot just say that his compliance is poor, and you have to switch him to an affordable plan and teach him how to adjust the injection time. The effect will be better.

To put it bluntly, diabetes care is like tuning an old radio. You can’t adjust the frequency just by twisting it. You have to try it slowly and slowly find the rhythm that suits the patient. After all, this disease will follow a person for a lifetime. No matter how good the care plan is, no matter how precise the diagnostic standards are, they must eventually be implemented in the patients' daily eating, walking, and sleeping. Only those that can be implemented are useful.