The goals of diabetes treatment are to control hyperglycemia, correct metabolic disorders, eliminate diabetic symptoms, prevent or delay complications, maintain good health and work capacity, safeguard the growth and development of children, prolong life expectancy, and reduce morbidity and mortality. At present, the principles of early treatment, long-term treatment, comprehensive treatment and individualization of treatment measures are emphasized. Specific measures to diet therapy, physical exercise, drug therapy, blood glucose monitoring and diabetes patient education five aspects.
I. Diet therapy
Diet therapy is an important basic treatment measure, which should be strictly and long-term implemented. Especially for obese or overweight patients, diet therapy is beneficial to reduce weight, improve hyperglycemia, lipid metabolism disorders and hypertension.
1.Total calories
First of all, the ideal weight should be calculated according to the patient’s gender, age, height, work nature and living habits, etc.
Ideal body weight (kg) = height cm – 105, and calculate the total calories required daily according to the ideal body weight. Adults should give l25-30 kcal per kg of ideal body weight per day at rest, 130-35 kcal for light physical labor, 35-40 kcal for moderate physical labor
kcal, and 40 kcal or more for heavy physical labor. Children, pregnant women, malnutrition and emaciation, and obese people should increase or decrease as appropriate.
2.Carbohydrate content
About 50-60% of the total calories of the diet, advocate more coarse rice and noodles, but to ensure nutrition and taste. Avoid eating grape enamel, cane sugar, honey sugary drinks, etc.
3.Protein
About 15-20% of total dietary calories, protein intake should be moderate, 0.8-1.2g per kg of ideal body weight per day for adults, and should be increased to 1.5g for children, pregnant women, lactating mothers, malnourished people or people with wasting diseases. 0.6g should be limited for people with elevated blood urea nitrogen.
4.Fat
Fat accounts for about 30% of total calories, 0.6-0.8g per kg of ideal body weight per day for adults.
5.Advocate the consumption of fiber-rich food
6.Rational distribution
After the total daily calories and the composition of carbohydrates, proteins and fats are determined, they should be distributed according to three, five or seven times a day, and it is advocated to eat less and more meals.
Second, physical exercise
Physical exercise should be carried out in a gradual and long-term manner according to different conditions such as age, gender, physical strength, medical condition and the presence of complications. Physical exercise should be carried out after meals, the amount of exercise should not be too large, and the duration should not be too long. It is generally considered that the exercise is effective when the heart rate reaches 170-age after the activity.
Three, oral hypoglycemic drug treatment
1.Sulfonylurea (SU)
These drugs promote insulin release by acting on the receptors on the surface of pancreatic islet B cells, and their hypoglycemic effect depends on the existence of a considerable number (more than 30%) of functional pancreatic islet B cell tissue. The main indications are patients with type 2 diabetes. This class of drugs is not suitable for patients with type 1 diabetes, combined with severe infection, ketoacidosis, hyperosmolar coma, major surgery, with hepatic and renal insufficiency, and combined with pregnancy. The main side effect is hypoglycemic reaction. There are various sulfonylureas. The first generation drugs include methylsulfonylurea (D860) and chlorosulfonylurea, which are used sparingly. The second generation drugs include glibenclamide, glipizide, gliclazide, glibenclamide and gliquidone. They are widely used clinically. The third-generation drugs are long-acting sulfonylureas glimepiride.
2.Biguanide
These drugs improve glucose metabolism by promoting glucose uptake by peripheral tissues such as muscles, accelerating glucose utilization and inhibiting glucose xenobiogenesis, etc. They do not have hypoglycemic effect on normal people. The main indications are obese or overweight diabetic patients. type 1 diabetic patients can also be applied. Common side effects are gastrointestinal reactions, and excessive doses may induce lactic acidosis. Commonly used biguanides are phenelzine and metformin.
3.α-glucosidase inhibitors
Alpha-glucosidase inhibitors can reversibly inhibit the activity of alpha-glucosidase in the upper small intestine after oral administration, which significantly delays the digestion and absorption of carbohydrates and mainly reduces postprandial blood sugar. It can be used in type 1 and type 2 diabetic patients and does not cause hypoglycemia by itself. Adverse reactions include abdominal distension and diarrhea. Contraindicated for chronic intestinal diseases or dyspepsia, abnormal liver and kidney function, etc. Bactrim 50-100mg; Bexin 0.2-0.4mg. three times daily. It should be chewed and swallowed at mealtime.
4.Non-sulfonylurea insulin secretagogues
In addition to SU, there are other insulin secretagogues. Its structure is different from the traditional SU and its binding site on the β-cell is also different from SU, but its action also stimulates insulin release by increasing intracellular calcium ion concentration through the closure of the ATP-sensitive potassium channel and the opening of the calcium channel. The response of insulin secretion occurs 30 minutes after oral administration. It is usually taken at mealtime, and the dose varies according to blood glucose level, generally one dose per meal, 0.5mg per dose.
5.Insulin sensitizer
For patients with type 2 diabetes and obesity, thiazolidinediones (TZD) can promote insulin-mediated glucose utilization and improve β-cell function. tZD can also normalize IGT and delay the development of diabetes in patients. Troglitazone (now discontinued due to liver damage), pioglitazone and rosiglitazone have been used in clinical practice. Pay attention to liver function while taking the drug. Rosiglitazone dose 2-4mg, 1-2 times a day, pioglitazone 15-30mg, once a day.
6.Insulin therapy
(1) Indications are mainly.
①Type 1 diabetes mellitus ;
Diabetic ketoacidosis, hyperosmolar coma and lactic acidosis with hyperglycemia;
(3) Combination of severe infection, wasting disease, retinopathy, nephropathy, neuropathy, acute myocardial infarction, cerebrovascular accident;
④perioperative period when surgical treatment is required due to associated morbidity;
⑤ Pregnancy and childbirth;
(6) Patients who have not achieved good control with diet and oral anti-inflammatory drug therapy;
(7) Secondary diabetes mellitus caused by total pancreatectomy.
(2) Types of preparations: There are three types of insulins currently in use. Animal insulins are single animal source preparations or mixed preparations extracted from the pancreas of pigs and cattle. Human insulin is insulin of recombinant technology and enzyme conversion technology. Insulin analogues are human insulin analogues produced by genetic technology.
The types of insulin preparations are rapid-acting insulin analogues; rapid-acting (short-acting, regular) preparations; medium-acting preparations, long-acting preparations and analogues; premixed preparations, etc. Our commonly used preparations contain 40 and 100 U per milliliter two specifications.
(3) use principles and dose regulation: insulin therapy should be carried out on the basis of general treatment and diet therapy, for patients with type 2 diabetes, medium-acting (NPH) or premixed insulin can be used, injected subcutaneously half an hour before meals twice a day, the amount of insulin before breakfast is about 2/3 of the whole day, the amount of insulin before dinner is 1/3, available medium-acting and rapid-acting insulin (according to the ratio of 2/3 to 1/3) Mixing. The insulin dose should be adjusted every few days according to the results of urine glucose and blood glucose measurement until good control is achieved.
For patients with type 1 diabetes, intensive insulin therapy can be given
①Inject medium-acting and fast-acting insulin before breakfast, fast-acting insulin before dinner, and medium-acting insulin before the evening meal;
②Injections of rapid-acting insulin before breakfast, lunch and dinner, and medium-acting insulin before the evening meal;
③Injecting rapid-acting insulin before breakfast, lunch and dinner, and injecting long-acting insulin before breakfast at the same time.
After using the intensive insulin therapy program, sometimes the fasting blood sugar in the morning is still high, the possible reasons for this are:
①Insufficient insulin action at night;
(2) “Dawn phenomenon”, that is, the blood enamel is well controlled at night and no hypoglycemia occurs, but hyperglycemia only appears in a short period of time at dawn, the mechanism may be due to the increase of corticotropin and other antagonistic hormone secretion;
(3) Somogyi phenomenon, i.e. hypoglycemia before dawn, but the symptoms are mild and transient and not detected, followed by reactive hyperglycemia after the occurrence of hypoglycemia.
Another method of intensive insulin therapy is continuous subcutaneous insulin infusion, where a container for placing rapid-acting insulin is connected to a needle and a pump through a catheter, respectively, and the needle is placed in the subcutaneous tissue of the abdomen, and the insulin infusion is controlled by an adjustable-programmed microelectronic computer, simulating continuous basal secretion of insulin and pulsatile release during feeding.
(4) Insulin resistance and side effects: The main side effects of insulin are hypoglycemic reactions, panic, sweating, hunger, and even coma. Animal insulin can have allergic reactions, lipodystrophy, etc.
IV. Prevention and health education
With the economic development and urbanization of life, diabetes mellitus and its well-developed disease have become more and more serious, endangering people’s health. Therefore, under the leadership of governments and health departments at all levels, social support should be mobilized to participate in diabetes prevention, treatment, education and health care programs. Develop, implement and evaluate a variety of comprehensive programs, with self-care and community support as the main components, for early detection and effective control of diabetes and its complications. Promote non-smoking, less salt consumption, reasonable diet, regular exercise, and prevention of obesity.