What Does a Diabetes Educator Do?

Diabetes is a group of metabolic diseases characterized by high blood sugar. Hyperglycemia is due to a defect in insulin secretion or impaired biological effects, or both. The long-term hyperglycemia during diabetes causes chronic damage and dysfunction of various tissues, especially the eyes, kidneys, heart, blood vessels, and nerves.

Basic Information

English name: diabetes mellitus, DM
Visiting department: Internal medicine, endocrinology

Common symptoms: Drink more, drink more, eat more, and lose weight
Contagious: no

Causes of diabetes

1. genetic factors

There is significant genetic heterogeneity in both type 1 and type 2 diabetes. Diabetes has a family tendency, and 1/4 to 1/2 patients have a family history of diabetes. There are at least 60 genetic syndromes clinically associated with diabetes. Multiple DNA sites are involved in the pathogenesis of type 1 diabetes, among which the DQ site polymorphism in the HLA antigen gene is most closely related. A number of definite genetic mutations have been found in type 2 diabetes, such as insulin genes, insulin receptor genes, glucokinase genes, mitochondrial genes, and so on.

2. envirnmental factor

Obesity caused by excessive eating and reduced physical activity is the most important environmental factor in type 2 diabetes, which makes individuals with a genetic susceptibility to type 2 diabetes prone to disease. Patients with type 1 diabetes have abnormal immune systems, which cause autoimmune reactions and destroy insulin beta cells after infection with certain viruses such as coxsackie virus, rubella virus, and mumps virus.

Clinical manifestations of diabetes

1. Drink more, drink more, eat more, and lose weight

Symptoms of "three more and one less" are typical in severe hyperglycemia, which is more common in type 1 diabetes. "Three more and one less" symptoms are more pronounced when ketosis or ketoacidosis occurs.

2. Tiredness, obesity

More common in type 2 diabetes. Type 2 diabetes is often obese before the onset of the disease, and if not diagnosed in time, weight will gradually decrease.

Diabetes test

1. blood sugar

Is the only criterion for diagnosing diabetes. Those with obvious "three more and one less" symptoms can be diagnosed with only one abnormal blood glucose level. Asymptomatic people need two abnormal blood glucose levels to diagnose diabetes. Suspects need to do a 75g glucose tolerance test.

2. Urine sugar

Often positive. Urine glucose was positive when blood glucose concentration exceeded the renal glucose threshold (160-180 mg / dL). When the renal glucose threshold is increased, the diagnosis of diabetes can be negative even if the blood sugar reaches the diagnosis. Therefore, urine glucose measurement is not a diagnostic criterion.

3 Ketone body

Ketones are positive for ketones or ketoacidosis.

4 Glycosylated hemoglobin (HbA1c)

It is the product of the non-enzymatic reaction of glucose and hemoglobin. The reaction is irreversible, and the level of HbA1c is stable, which can reflect the average blood glucose level 2 months before taking blood. It is the most valuable indicator to judge the state of blood glucose control.

5. Glycated serum protein

It is the product of the combination of blood glucose and serum albumin non-enzymatic reaction, which reflects the average blood glucose level 1 to 3 weeks before blood collection.

6. Serum insulin and C-peptide levels

Reflects the reserve function of islet cells. Early type 2 diabetes or obese serum insulin is normal or increased. With the development of the disease, islet function gradually decreases and insulin secretion capacity decreases.

7. Blood lipids

Dyslipidemia is common in diabetic patients, especially when blood glucose is poorly controlled. It shows elevated triglycerides, total cholesterol, and low-density lipoprotein cholesterol. Reduced HDL cholesterol levels.

8. Immune indicators

Islet cell antibodies (ICA), insulin autoantibodies (IAA), and glutamate decarboxylase (GAD) antibodies are three important indicators of humoral immune abnormalities in type 1 diabetes. Among them, the positive rate of GAD antibodies is high and the duration is long. The diagnostic value of type 2 diabetes is great. There is also a certain positive rate among first-degree relatives of type 1 diabetes, which has significance in predicting type 1 diabetes.

9. Urinary albumin excretion, radioimmunoassay or enzyme-linked method

Urinary albumin excretion can be detected sensitively, and urine albumin is slightly elevated in early diabetic nephropathy.

Diabetes diagnosis

The diagnosis of diabetes is generally not difficult. A fasting blood glucose greater than or equal to 7.0 mmol / L and / or a blood glucose greater than or equal to 11.1 mmol / L within two hours after a meal can be confirmed. Typing after diabetic diagnosis:

1.1 type 1 diabetes

The age of onset is young, mostly <30 years old. Sudden onset, obvious symptoms of weight loss, polydipsia and polydipsia, high blood glucose level, many patients with ketoacidosis as the first symptoms, low serum insulin and C peptide levels, ICA, IAA Or GAD antibodies can be positive. Oral medication alone is not effective and needs to be treated with insulin.

2.2 Type 2 diabetes

Common in the elderly, obese people have a high incidence, often accompanied by hypertension, dyslipidemia, arteriosclerosis and other diseases. Insidious onset, no symptoms at early stage, or only mild fatigue, thirst, and insignificant increase in blood glucose require glucose tolerance test to confirm the diagnosis. Serum insulin levels are normal or elevated in the early stages and low in the later stages.

Differential diagnosis of diabetes

1. Liver Disease

Patients with liver cirrhosis often have abnormal glucose metabolism. Typical fasting blood glucose is normal or low, and blood glucose rises rapidly after meals. The course of the elderly can also increase fasting blood glucose.

2. Chronic renal insufficiency

Mild glucose metabolism abnormalities may occur.

3 Stress state

Many stress states such as cardiac and cerebrovascular accidents, acute infections, trauma, and surgery may cause transient rises in blood glucose, which can be recovered within 1 to 2 weeks after the stress factors are eliminated.

4 Multiple endocrine diseases

Such as acromegaly, Cushing's syndrome, hyperthyroidism, pheochromocytoma, and glucagonoma can cause secondary diabetes, in addition to elevated blood sugar, there are other characteristic manifestations, it is not difficult to identify.

Diabetes treatment

There is currently no cure for diabetes, but diabetes can be controlled with a variety of treatments. It mainly includes 5 aspects: education for diabetic patients, self-monitoring blood glucose, diet therapy, exercise therapy and medication.

(A) general treatment

1. education

It is necessary to educate people with diabetes to understand the basic knowledge of diabetes, build confidence to overcome the disease, how to control diabetes, and control the health benefits of diabetes. According to the characteristics of each diabetic patient, an appropriate treatment plan is formulated.

2. Self-monitoring blood glucose

With the gradual popularization of small and fast blood glucose meters, patients can adjust the dose of hypoglycemic drugs at any time according to blood glucose levels. Monitor blood glucose at least 4 times a day (before meals) during intensive treatment of type 1 diabetes, and 8 times when blood sugar is unstable (before meals, after, before bedtime, and at 3:00 am). During intensive treatment, fasting blood glucose should be controlled below 7.2 mmol / L, blood glucose less than 10 mmol / L and HbA1c less than 7% two hours after a meal. The frequency of self-monitoring blood glucose in patients with type 2 diabetes can be appropriately reduced.

(Two) drug treatment

1. Oral medication

(1) Sulfonylureas Type 2 DM patients can be treated with diet sulphate, exercise, and weight loss, and those who are not satisfied with the results can use sulfonylureas. Because the hypoglycemic mechanism is mainly to stimulate insulin secretion, it has a better effect on those with certain islet function. It also has a certain effect on some early-onset, non-obese diabetic patients. However, when using sulfonylurea drugs for obese people, special attention should be paid to diet control to gradually reduce body weight. It is better to combine with biguanide or -glucosidase inhibitor hypoglycemic agents. The following conditions are contraindicated: First, severe liver and kidney dysfunction; second, severe infection, trauma and major surgery, temporarily switch to insulin therapy; third, diabetic ketosis, ketoacidosis, temporarily switch to insulin therapy Fourth, pregnant women with diabetes, pregnancy-induced hyperglycemia has teratogenic effects on the fetus, high incidence of preterm and stillbirth, so blood glucose should be strictly controlled, fasting blood glucose should be controlled below 105 mg / dL (5.8 mmol / l), meal The blood glucose was controlled below 120 mg / dL (6.7 mmol / L) in the next 2 hours, but oral hypoglycemic drugs should not be used to control blood glucose. Fifth, allergic to sulfonylureas or obvious adverse reactions.

(2) Biguanide hypoglycemic drugs The main mechanism of lowering blood sugar is to increase the utilization of glucose in peripheral tissues, increase the anaerobic glycolysis of glucose, reduce the absorption of glucose in the gastrointestinal tract, and reduce body weight. Indications for obese type 2 diabetes, who are not satisfied with the effect of diet alone; type 2 diabetes is not effective with sulfonylurea alone, and can be added with biguanide; type 1 diabetes with insulin is unstable, and biguanide is used Drugs can reduce the dose of insulin; when secondary failure of type 2 diabetes is treated with insulin, biguanide drugs can be added to reduce the amount of insulin. Contraindications Severe liver, kidney, heart, lung diseases, wasting diseases, malnutrition, hypoxic diseases; diabetic ketosis, ketoacidosis; suspension of biguanides with severe infection, surgery, trauma and other stress conditions Medication, insulin therapy; pregnancy. adverse reactions are gastrointestinal reactions. The most common manifestations are nausea, vomiting, decreased appetite, abdominal pain, and diarrhea. The incidence can reach 20%. To avoid these adverse reactions, medication should be taken with or after meals. The second is headache, dizziness, and metallic taste. The third is lactic acidosis, which is more common in long-term and large-scale application of hypoglycemic, accompanied by liver and kidney dysfunction, hypoxic disease, acute infection, gastrointestinal diseases, hypoglycemic tablets have less chance of causing acidosis.

(3) Alpha glucosidase inhibitors can be used for both type 1 and type 2 diabetes, and can be used in combination with sulfonylureas, biguanides or insulin . Voglibose is taken orally immediately before meals. Acarbose is taken orally immediately before meals. The main adverse reactions were: abdominal pain, flatulence, diarrhea, and increased anal exhaust.

(4) Insulin sensitizers have the effect of enhancing insulin and improving glucose metabolism. It can be used alone or in combination with sulfonylureas, biguanides or insulin. It should not be used in patients with liver disease or cardiac insufficiency.

( 5) Glinate insulin secretagogues Reglinide is a fast-acting insulin secretagogue, which is taken orally immediately before meals. Naglinaide works similarly to riglinai.

2. Insulin therapy

Insulin preparations include animal insulin, human insulin and insulin analogs. According to the action time, it is divided into short-acting, medium-acting and long-acting insulin, and has been made into mixed preparations, such as Novoline 30R, Youbilin 70/30.

(1) Type 1 diabetes needs to be treated with insulin. Non-intensive treatments are given 2 to 3 times a day, and intensive treatments are given 3 to 4 times a day, or treated with an insulin pump. Need to adjust the dose often.

(2) Patients with type 2 diabetes who have failed oral hypoglycemic agents should first adopt combined treatment. The method is to keep the original oral hypoglycemic dose unchanged, and inject mid- or long-acting insulin analogs at 10:00 the night before bed. Adjust once every 3 days, the purpose is to reduce fasting blood glucose to 4.9 to 8.0 mmol / L. Those who do not respond will stop taking oral hypoglycemic drugs, and instead inject insulin twice a day.

The biggest adverse effect of insulin treatment is hypoglycemia.

(Three) exercise therapy

Increasing physical activity can improve the body's sensitivity to insulin, reduce weight, reduce body fat, increase physical strength, improve work capacity and quality of life. The intensity and duration of exercise should be determined according to the overall health of the patient, and find the amount of exercise suitable for the patient and the items that the patient is interested in. There are various forms of exercise, such as walking, brisk walking, aerobics, dancing, Tai Chi, running, swimming, etc.

(D) diet therapy

Diet therapy is the basis of various types of diabetes treatment, and some patients with mild diabetes can control their condition with diet alone.

Total calories

The total caloric requirement should be determined according to the patient's age, gender, height, weight, physical activity, and other comprehensive factors. First of all, to calculate the standard weight of each person, you can refer to the following formula: standard weight (kg) = height (cm)-105 or standard weight (kg) = [height (cm)-100] × 0.9; the standard weight of women should be Subtract 2kg. Can also be obtained according to age, gender, height checklist. After calculating the standard weight, the caloric requirement per kilogram of standard weight is estimated according to the daily physical activity of each person.

After calculating the daily calorie requirement based on the standard weight, the patient's other conditions must be adjusted accordingly. Children, adolescence, lactation, malnutrition, wasting, and chronic wasting diseases should increase total calories as appropriate. Obese people should strictly limit the total calories and fat content, and give a low-calorie diet. The total calories per day should not exceed 1500 kcal. Generally, it is advisable to reduce 0.5 1.0kg per month. When the weight is close to the standard weight, calculate the total daily weight according to the method Heat. In addition, older people need less calories than younger ones, and adult women need less calories than men.

Carbohydrate

Carbohydrates produce 4 kilocalories per gram, which is the main source of calories. It is believed that carbohydrates should account for 55% to 65% of the total calories in the diet, which can be calculated using the following formula:

According to the living habits of our people, you can eat 250 400g of staple food (rice or noodles). You can make a preliminary estimate as follows. The daily staple food for resters is 200 250g. 400g or more for heavy manual workers.

3. Protein

Protein produces 4 kcal per gram. It accounts for 12% to 15% of the total calories. The amount of protein required is about 1 g per kilogram of body weight in an adult. In children, pregnant women, lactating women, malnutrition, weight loss, and those with wasting diseases should increase to 1.5 ~ 2.0g per kilogram of body weight. People with diabetic nephropathy should reduce their protein intake, 0.8g per kilogram of body weight. If they have renal insufficiency, they should consume high-quality protein, and their intake should be further reduced to 0.6g per kilogram of body weight.

4. Fat

Fat has higher energy, producing 9 kcal per gram. About 25% of total calories, generally not more than 30%, 0.8 to 1g per kilogram of body weight per day. Animal fats mainly contain saturated fatty acids, and vegetable oils contain more unsaturated fatty acids. Diabetic patients are susceptible to atherosclerosis, and vegetable oils should be the main factor, which is more conducive to controlling blood cholesterol and low-density lipoprotein cholesterol levels.