Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia. Hyperglycemia, in turn, is caused by defective insulin secretion or impairment of its biological action, or both. The long-term presence of hyperglycemia in diabetes leads to chronic damage and dysfunction of various tissues, especially the eyes, kidneys, heart, blood vessels, and nerves.
Etiology
1.Genetic factors
There is significant genetic heterogeneity in both type 1 or type 2 diabetes. There is a tendency for diabetes to develop in families, and 1/4 to 1/2 of patients have a family history of diabetes. There are at least 60 clinical genetic syndromes that can be associated with diabetes. type 1 diabetes has multiple DNA loci involved in the pathogenesis, with the DQ locus polymorphism in the HLA antigen gene being the most closely related. A variety of well-defined genetic mutations have been identified in type 2 diabetes, such as insulin genes, insulin receptor genes, glucokinase genes, mitochondrial genes, etc.
2.Environmental factors
Obesity due to excessive eating and reduced physical activity is the most important environmental factor in type 2 diabetes, making individuals with genetic susceptibility to type 2 diabetes susceptible to the disease. type 1 diabetic patients have abnormal immune system, which leads to autoimmune reaction after certain viruses such as coxsackie virus, rubella virus, mumps virus, etc., and destroys insulin beta cells.
Clinical manifestations of diabetes mellitus
1. Drinking more, urinating more, eating more and losing weight
The typical symptoms of “three more and one less” appear in severe hyperglycemia, mostly seen in type 1 diabetes. When ketosis or ketoacidosis occurs, the symptoms of “three more and one less” are more obvious.
2. Fatigue and obesity
Most often seen in type 2 diabetes. type 2 diabetes is often preceded by obesity, and if not diagnosed in time, weight loss will occur gradually.
Treatment of diabetes
There is no cure for diabetes, but it can be controlled through a variety of treatments. There are five main areas: education of diabetic patients, self-monitoring of blood sugar, diet therapy, exercise therapy and medication therapy.
(I) General treatment
1.Education
It is important to educate diabetic patients to know the basic knowledge of diabetes, establish confidence to overcome the disease, how to control diabetes, and the health benefits of good control of diabetes. Develop appropriate treatment plan according to the characteristics of each diabetic patient’s condition.
2.Self-monitoring of 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 the blood glucose level. type 1 diabetes is monitored at least four times a day (before meals) when intensive treatment is carried out, and eight times when blood glucose is unstable (before and after three meals, before going to bed at night and at 3:00 a.m.). Fasting blood glucose should be controlled below 7.2 mmol/L, blood glucose less than 10 mmol/L two hours after meal and HbA1c less than 7% during intensive treatment. the frequency of self-monitoring blood glucose in type 2 diabetes can be reduced appropriately.
(II) Drug treatment
1.Oral medication
(1) Sulfonylurea type 2 DM patients after diet control, exercise, weight reduction and other treatments, the efficacy is not yet satisfactory can be used sulfonylurea drugs. Because the glucose-lowering mechanism is mainly to stimulate insulin secretion, so the efficacy is better for those who have certain pancreatic function. For some diabetic patients with young age of onset and not fat body shape, they also have certain efficacy in early stage. However, when using sulfonylureas in obese patients, special attention should be paid to diet control to make weight loss gradually, and it is better to combine with biguanides or α-glucosidase inhibitor hypoglycemic drugs. The following are contraindications: first, serious liver and kidney insufficiency; second, severe combined infection, trauma and major surgery, temporary change to insulin therapy; third, diabetic ketosis, ketoacidosis, temporary change to insulin therapy; fourth, pregnant women with diabetes, high glucose in pregnancy has a teratogenic effect on the fetus, high incidence of premature birth and stillbirth, so strict control of blood glucose, fasting blood glucose should be controlled at 105 mg/dL (5.8 mmol/L) or less, and 2 hours after meal blood glucose control at 120 mg/dL (6.7 mmol/L) or less, but control of blood glucose should not use oral hypoglycemic drugs; fifth, allergic to sulfonylureas or obvious adverse reactions.
(2) The main mechanism of hypoglycemia of biguanides is to increase the utilization of glucose by peripheral tissues, increase the anaerobic enzymolysis of glucose, reduce the absorption of glucose by the gastrointestinal tract and reduce body weight.
①Indications obese type 2 diabetes mellitus, unsatisfactory effect of diet alone; type 2 diabetes mellitus with sulfonylurea alone is not effective, can add biguanides; type 1 diabetes mellitus with insulin treatment is unstable, with biguanides can reduce the insulin dose; type 2 diabetes mellitus secondary failure to change to insulin treatment, can add biguanides, can reduce insulin dosage.
② Contraindications serious liver, kidney, heart and lung diseases, wasting diseases, malnutrition, hypoxic diseases; diabetic ketosis, ketoacidosis; with serious infections, surgery, trauma and other stressful conditions when suspending bivalirudin and switching to insulin therapy; during pregnancy.
③Adverse reactions one is gastrointestinal reactions. The most common, manifested as nausea, vomiting, decreased appetite, abdominal pain, diarrhea, the incidence of up to 20%. To avoid these adverse reactions, the drug should be taken during, or after, a meal. The second is headache, dizziness, and metallic taste. Third, lactic acidosis, mostly seen in long-term, large amount of application of hypoglycemia, accompanied by hepatic and renal decompensation, hypoxic diseases, acute infection, gastrointestinal diseases, hypoglycemic tablets cause less chance of acidosis.
(3) α glucosidase inhibitors can be used for both type 1 and type 2 diabetes, and can be used in combination with sulfonylureas, biguanides or insulin.
(1) Voglibose is given orally immediately before a meal. ②Acarbose is taken orally immediately before meals. The main adverse reactions are: abdominal pain, intestinal flatulence, diarrhea, and increased anal discharge.
(4) Insulin sensitizers have enhanced insulin action and improved glucose metabolism. It can be used alone or in combination with sulfonylureas, biguanides or insulin. It is not suitable for those who have liver disease or cardiac insufficiency.
(5) Glinolactone insulin secretagogue ① Reglinol is a rapid insulin secretagogue, which is taken orally immediately before meals, at each main meal, and not without meals. ②Naglinide is similar to Repaglinide.
2.Insulin therapy
Insulin preparations include animal insulin, human insulin and insulin analogues. They are divided into short-acting, medium-acting and long-acting insulins according to the duration of action, and have been made into mixed preparations, such as Novolin 30R and Utrolin 70/30.
(1) Type 1 diabetes requires treatment with insulin. Non-intensive treatment is injected 2 to 3 times a day, and intensive treatment is injected 3 to 4 times a day, or treated with insulin pump. The dose needs to be adjusted frequently.
(2) Type 2 diabetes mellitus with oral hypoglycemic drugs failing is first treated with a combination of oral hypoglycemic drugs in the same dose, and medium-acting insulin or long-acting insulin analogs are injected at 10:00 p.m. before bedtime, generally adjusted once every 3 days, with the aim of reducing fasting blood glucose to 4.9-8.0 mmol/L. Those who are ineffective stop using oral hypoglycemic drugs and replace them with insulin injections twice a day.
The biggest adverse effect of insulin therapy is hypoglycemia.
(iii) Exercise therapy
Increasing physical activity can improve the body’s sensitivity to insulin, lower body weight, reduce the amount of body fat, enhance physical strength, and improve work ability and quality of life. The intensity and duration of exercise should be determined according to the patient’s overall health condition, and find the amount of exercise suitable for the patient and the items that the patient is interested in. Exercise can take various forms, such as walking, brisk walking, aerobics, dancing, tai chi, running, swimming, etc.
(iv) Diet therapy
Diet therapy is the basis of treatment for all types of diabetes, and some patients with mild diabetes can control their disease with diet therapy alone.
1.Total calories
The total calorie requirement should be determined according to the patient’s age, gender, height, weight, physical activity, condition and other comprehensive factors. First of all, the standard weight of each person should be calculated, which can be referred to the following formula: standard weight (kg) = height (cm) – 105 or standard weight (kg) = [height (cm) – 100] × 0.9; for women, the standard weight should be reduced by 2 kg, which can also be obtained by checking the table according to age, gender and height. After calculating the standard weight, the caloric requirement per kg 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, adjustments should be made according to the patient’s other conditions. Children, adolescents, lactation, malnutrition, emaciation and chronic wasting diseases should increase the total calories as appropriate. Obese people should strictly limit the total calories and fat content, and give low-calorie diet, with the total calories not exceeding 1500 kcal per day, and it is generally appropriate to reduce 0.5 to 1.0 kg per month, and then calculate the total calories per day according to the aforementioned method when it is close to the standard weight. In addition, older people need fewer calories than younger people, and adult women need fewer calories than men.
2.Carbohydrate
Carbohydrates produce 4 kcal per gram and are the main source of calories. It is now believed that carbohydrates should account for 55% to 65% of the total calories in the diet, which can be calculated by the following formula.
According to the living habits of our people, 250～400g of staple food (rice or noodles) can be entered, and the following preliminary estimation can be made: 200～250g of staple food per day for resting people, 250～300g for light physical laborers, 300～400g for moderate physical laborers, and more than 400g for heavy physical laborers.
3.Protein
Protein produces 4 kcal per gram. It accounts for 12% to 15% of the total calories. The protein requirement is about 1g per kg of body weight for adults, and should be increased to 1.5-2.0g per kg of body weight for children, pregnant women, lactating women, malnourished, emaciated, and those with wasting diseases. 0.8g per kg of body weight for diabetic nephropathy should be reduced, and if there is renal insufficiency, high quality protein should be consumed, and the intake should be further reduced to 0.6g per kg of body weight.
4.Fat
The energy of fat is high, producing 9 kcal per gram. Animal fat mainly contains saturated fatty acids. Vegetable oil contains more unsaturated fatty acids, and diabetic patients are prone to atherosclerosis and should use vegetable oil mainly.
Finally, we should remind diabetic patients that they must not eat food and drinks with sugar, and must self-promote and do more exercise.