One of the questions that many diabetic patients are very concerned about when they visit the hospital is, “How serious is my diabetes now, and is my diabetes progressing?” So how exactly should you determine the severity of your diabetes condition.
First of all, let’s explain how to determine the severity of diabetes, mainly from four aspects.
The higher the blood glucose, the more serious the diabetes is.
②The possibility of acute complications of diabetes, diabetes if only high blood sugar, no complications we are not very worried. The reason why we need to control blood sugar is that the higher the blood sugar, the greater the possibility that we will develop complications from diabetes. The complications of diabetes are mainly divided into acute complications and chronic complications. Most of our diabetes is type 2 diabetes, especially in the elderly, and acute complications are less likely to occur, but if we do not pay attention to blood sugar control for a long time, acute complications may occur, most notably diabetic ketoacidosis, and diabetic hyperosmolar state. Although acute complications are rare, they can be very serious and can even lead to death, so it is important to pay attention to the possibility of acute complications in patients with high blood glucose.
(3) Chronic complications and comorbidities of diabetes. Diabetes mellitus can have chronic complications if the blood glucose is not well controlled for a long time, mainly affecting the eyes, kidneys, nerves, heart vessels, cerebrovascular and lower limb vessels, etc. It is the main cause of disability and death in diabetic patients. Complications in diabetes are not only related to blood sugar, but also to comorbidities such as hypertension, hyperlipidemia and obesity, and we also need to understand the severity of these comorbidities. The judgment of chronic complications and comorbidities of diabetes is the most important aspect to determine the severity of the disease in diabetic patients.
The main mechanism for the development of type 2 diabetes is the inability of pancreatic islet cells to secrete enough insulin (decreased islet cell function) and the inability of insulin to effectively lower blood glucose (insulin resistance). The worse the function of the islets, the more severe the insulin resistance, and relatively speaking, the more severe the diabetes condition. Blood insulin and C-peptide measurement will be performed in the hospital for diabetic patients, which is to evaluate these two aspects. Since this part is more specialized and usually performed by doctors, it requires less participation from patients, so I will not go into details in this lecture.
Now that we know the indicators to determine the severity of the disease, who do we rely on to determine the severity of the disease? Is it the doctor or the patient? First of all, it is very important that diabetic patients can initially determine the severity of their disease through self-monitoring. We say that 70% of diabetic patients rely on themselves and the remaining 30% rely on their doctors. Self-monitoring is also a very important aspect of self-management of diabetic patients, including diet control and appropriate activity. At the same time, self-monitoring by diabetic patients also provides hospital doctors with very useful information, such as recent blood glucose and blood pressure. If the patients themselves know how to monitor their condition, such as glycated hemoglobin once every 3 months and urine microalbumin once a year, they can take the initiative to remind the doctor when it is time to test their condition and monitor it more effectively.
The first aspect of condition monitoring is the level of blood glucose control. We have three ways to determine the level of blood glucose control, including.
① blood glucose.
② urine glucose.
③ glycated hemoglobin.
Blood glucose reflects the level of blood glucose at the time of measurement. According to the time of measurement, we can divide it into fasting blood glucose, pre-meal blood glucose, post-meal blood glucose and 2-3 am blood glucose. Fasting blood glucose refers to the blood glucose measured in the morning before eating breakfast. Here we need to pay attention to two points, the first one is the time of measuring fasting blood glucose, generally speaking, the blood glucose measured at 6-8 am is the standard fasting blood glucose. Some patients may say, “Fasting, as long as I didn’t eat anything after waking up from breakfast is fasting, I went to the hospital a little late but didn’t eat breakfast, the blood sugar measured at ten o’clock should also be considered fasting blood sugar.” This statement is not very accurate. Even if you don’t eat anything in the morning, your blood sugar is not constant, but gradually increases. In other words, the blood sugar at ten o’clock will be higher than the blood sugar at eight o’clock. In order to avoid the influence of testing time on blood glucose, we stipulate that the blood glucose measured at 6-8 am is the real fasting blood glucose. Some patients often feel that the fasting blood glucose measured in hospital is higher than that measured at home, for example, the blood glucose measured at home is a few millimoles per liter at 6:00, but once measured in hospital, it is a few millimoles per liter at 7:00 or even 8:00, part of the reason is related to the time of measuring fasting blood glucose, which is usually measured earlier at home, at 6:00 or 7:00, while in hospital, it is usually measured at 8:00 when the clinic opens, plus some procedures, it may be measured at 9:00. The blood glucose measured at 9 o’clock may be higher than that measured at 7 o’clock, causing the illusion that the blood glucose in the hospital is higher than that at home, and we still take the blood glucose at home as the standard for our blood glucose control. When comparing whether the blood glucose measured at home is accurate, we must measure it at the same time, for example, bring the blood glucose meter to the hospital and use our own blood glucose meter to measure the blood glucose at the same time in the hospital. The second aspect to pay attention to is the fasting time, that is, how long you can’t eat before measuring blood glucose. Patients often ask, “What time should I eat in the evening when I measure fasting blood glucose the next day? Can I add a meal before bedtime?” The standard fasting blood glucose refers to the blood glucose measured after 8-10 hours of overnight fasting. In other words, you should not eat after 10:00 pm the night before. If you have an extra meal very late, after 10 pm, the next day’s blood glucose will not be considered fasting blood glucose.
Monitoring the progress of diabetes is a very important part of diabetes treatment. Depending on the time of measurement, we can classify blood glucose as fasting, pre-meal, post-meal and 2-3 am. In the previous section, we have introduced some considerations for fasting blood glucose monitoring.
Now let’s look at preprandial blood glucose and postprandial blood glucose. Pre-meal blood glucose refers to the blood glucose before each main meal, i.e. before breakfast, before lunch and before dinner, and if breakfast is conducted before 8:00 a.m., then pre-breakfast blood glucose is also fasting blood glucose. Postprandial blood glucose we generally refer to 2 hours postprandial blood glucose, 2 hours means counting two hours from the first bite of food, not from the end of the meal. Many people will ask why it must be 2 hours after meal, in fact, this is an agreed habit, the first studies are measured 2 hours after meal blood glucose, so after many studies, we know how much 2 hours after meal blood glucose should be controlled is appropriate. If you measure the blood sugar 1.5 or 3 hours after meal, unfortunately there is no unified standard to determine whether the blood sugar measured at this time is normal (except for pregnant women, who can also measure the blood sugar 1 hour after meal). Pre-meal glucose and 2-hour post-meal glucose are both criteria to determine whether our blood glucose is well controlled or not, and people often ask which one is more useful, but in fact they each have their own significance. The 2-hour postprandial blood glucose is generally the highest blood glucose, and Chinese people are more likely to have elevated postprandial blood glucose, and the pre-meal blood glucose may have been well controlled, but the 2-hour postprandial blood glucose is obviously elevated. This is also a mistake that many patients make, that is, they only measure fasting blood sugar. The main significance of preprandial blood sugar is not to judge the peak of blood sugar, but mainly to judge whether there is hypoglycemia, because preprandial is the time when hypoglycemia is easy to appear, so if there is often preprandial panic, hunger and other symptoms of hypoglycemia, also pay attention to monitoring preprandial blood sugar. In some patients who use insulin, when fasting blood sugar is high, it is often necessary to measure blood sugar at 2-3 a.m. to determine whether insulin can be increased, because some fasting hyperglycemia may be due to rebound hyperglycemia after nighttime hypoglycemia, when insulin not only cannot be increased, but also may need to be reduced. In these patients, the blood glucose at 2-3 a.m. should be measured intermittently to determine whether the insulin dosage is appropriate.
At present, blood glucose can be measured by drawing blood from a hospital to test intravenous blood glucose, or by measuring finger blood glucose with a blood glucose meter (or at the hospital). Venous blood glucose is more accurate than finger blood glucose because the method chosen to measure it is more precise, and a 10-15% error is allowed in finger blood glucose measured by a blood glucose meter. When we diagnose diabetes, we must diagnose it through venous blood glucose, but not by finger blood glucose. However, some patients feel that intravenous blood glucose is more accurate, so they usually have to go to the hospital to draw blood for blood glucose monitoring, which is unnecessary because the determination of blood glucose usually does not need to be so accurate, for example, 6.7mmol/l blood glucose and 6.3mmol/l blood glucose may not have much influence on our decision of quality program, and it is too much trouble to draw intravenous blood glucose every time, which is not worthwhile. As said fasting blood glucose generally refers to the blood glucose at 6-8 o’clock, going to the hospital to draw blood is often past 8 o’clock, not strictly fasting blood glucose, and also hospital blood draws are usually only done in the morning, and blood glucose in the afternoon and evening cannot be monitored. Therefore, we recommend only checking venous blood glucose when diagnosing diabetes, and only monitoring finger blood glucose after the diagnosis of diabetes is confirmed.
How often to monitor blood glucose is also a question that patients often ask. Generally speaking, patients with good blood glucose control should have their fasting blood glucose and 2-hour postprandial blood glucose measured every 1-2 weeks or more, while patients with poor blood glucose control should increase the number of daily monitoring and monitor every other day or even several times a day, including bedtime blood glucose. The following conditions should be closely monitored (measured 3-7 times a day), including
① When the condition is unstable (such as co-infection or very high blood glucose).
②when changing medication.
③Patients on intensive insulin therapy (patients with ≥4 injections a day or with an insulin pump).
④Patients with type 1 diabetes. In terms of choosing when to measure blood glucose, it is better to monitor blood glucose several times at different points of the day than at the same point of the day, because the former is more likely to reflect the pattern of blood glucose changes throughout the day, while if you measure blood glucose at the same time every day, you will not know the blood glucose control at other times. For example, if you only measure the blood sugar after dinner every day for three days, the latter will have a more comprehensive response to the blood sugar control compared with the blood sugar after breakfast on the first day, after lunch on the second day and after dinner on the third day. In addition, it is better to monitor pre-meal blood glucose and night blood glucose if hypoglycemia occurs frequently recently.
The standard of blood glucose control is set with reference to normal human blood glucose, and the ideal fasting blood glucose is 4.4-6.1mmol/l and non-fasting blood glucose is 4.4-8.0mmol/l. However, it must be remembered that the target of blood glucose control varies from person to person. The control standard for the elderly can be relaxed appropriately. Generally speaking, fasting blood sugar at 6-7mmol/l and postprandial blood sugar at 8-10mmol/l is fine, and if the general condition is bad and combined with more serious complications, the target value of blood sugar control can be more relaxed. The main reason is that elderly people are more worried about the risk of hypoglycemia, the better the blood sugar control, the higher the risk of hypoglycemia, and in order to avoid hypoglycemia, the blood sugar can be appropriately high. In contrast, pregnant women and the elderly have stricter blood sugar control requirements than normal people.
There are three ways we can judge the level of blood glucose control, including.
① blood sugar.
② urine glucose.
③ Glycosylated hemoglobin.
In the previous section, we introduced the precautions in blood glucose monitoring and the goals of blood glucose control. What time points does blood glucose monitoring include and what is the significance of each? Should we monitor venous blood glucose or finger blood glucose? How often is it appropriate to monitor blood glucose? What is the goal of blood glucose control? Is there any difference in the goal of blood glucose control for different patients? Patients can recall the answers to these questions. If you can’t remember, you can read the previous part again to deepen your memory, as these are very practical questions in daily life.
Once you know how to monitor blood glucose, and you have done so as required, the next very important note is that you must record the results of your blood glucose monitoring.
As the saying goes, “A good memory is better than a bad pen”. It is very important to record the results of blood glucose monitoring in time, so that we can find the pattern of blood glucose changes in the future and communicate with the doctor during the consultation. Sometimes you may feel that you can remember the blood glucose results, and it is “quite troublesome” to think of recording them every time. But try to think back, can you still remember the blood glucose you took last week? How about last month? Timely recording can save this very valuable information. Nowadays, there are some blood glucose meters that can record the results of blood glucose measurement in the recent period, but if you record it yourself, on the one hand, the information recorded will be more comprehensive, and on the other hand, the process of recording actually gives you the opportunity to analyze the pattern of blood glucose changes, so that you can have a better understanding of your diabetes.
What items should be included in a blood glucose record book or blood glucose monitoring diary?
A detailed blood glucose monitoring diary should include the time of blood glucose monitoring, the relationship between monitoring and meal (whether it is before or after meal, how long after meal, generally speaking after meal is two hours after meal, but if it is not two hours after meal, it can be specially indicated), the specific monitoring results, the time, type and dose of insulin injection or oral hypoglycemic drugs, any factors affecting blood glucose, such as the type and quantity of food eaten, the amount of exercise, the sickness, and the amount of food eaten. amount, amount of exercise, illness, when hypoglycemia occurred, relationship to medication, eating or exercise, and experience of symptoms. There are many readily available blood glucose record books that are easy to use. You can also use these record books as a template to make the most suitable blood glucose record book for yourself.
On the one hand, you can often look through the blood glucose record book and think about the effect of diet, exercise and medication on your blood glucose, especially when you have to do something different from your usual habits, such as eating some special diet, like pizza, or doing some heavy exercise, like playing badminton, which may have a big impact on your blood glucose. The blood sugar changes when carrying out similar things can be adjusted in time to avoid the situation of too high or too low blood sugar. On the other hand, every time you go to the hospital, be sure to bring your monitoring diary, which is very helpful for the doctor to quickly grasp the pattern of your blood sugar changes and formulate a reasonable treatment plan. Therefore, in addition to your doctor’s card and medical record, you should also bring your blood glucose monitoring diary with you to each visit.
The above is a detailed description of the considerations for blood glucose monitoring, and the following is a brief introduction to urine sugar.
Many patients take the name diabetes literally and think that only a positive urine sugar can diagnose diabetes. This idea is actually a misconception, because in the early days, blood glucose could not be measured quickly and accurately, and only urine sugar could be used to indirectly determine blood glucose, but since blood glucose can now be measured quickly and accurately and at a small cost, the main criterion for diagnosing diabetes is blood glucose, and urine sugar is no longer recommended as a method of determining blood glucose. Although urine glucose has the advantages of being simple, painless and inexpensive, the disadvantages of urine glucose are obvious. However, the disadvantages of urine glucose are also very obvious, including.
①It is affected by the elevated or lowered renal glucose threshold, and the urine glucose monitoring results are not accurate when the renal glucose threshold is not normal.
(2) Urine glucose does not reflect immediate blood glucose.
③ Urine glucose test strips are semi-quantitative and not as accurate as blood glucose. For example, urine sugar (++++), blood sugar can be 17.0 mmol/L or 30.0 mmol/L.
④Urine glucose measurement cannot detect or predict hypoglycemia.
⑤ Urinary tract infection, menstruation, and certain oral medications can affect the test results. So we must remember that judging diabetes control mainly depends on blood sugar, urine sugar is no longer recommended as a method to judge blood sugar, and urine sugar results can only be used as a reference for blood sugar control.
Another very important method to determine blood glucose control is the measurement of glycosylated hemoglobin. As the name implies, glycated hemoglobin is the product of the combination of blood sugar and hemoglobin in red blood cells. Because glycated hemoglobin has several characteristics, it is of great significance in the monitoring of diabetes.
(1) Parallel to blood glucose values: the higher the blood glucose, the higher the glycosylated hemoglobin, so it reflects the level of blood glucose control.
(2) Slow generation: as we all know, blood glucose fluctuates constantly, and each blood draw only reflects the blood glucose level at that time, while glycated hemoglobin is generated gradually. A brief increase in blood glucose will not cause an increase in glycated hemoglobin, and conversely, a brief decrease in blood glucose will not cause a decrease in glycated hemoglobin, and meals do not affect its determination, and it can be measured after meals.
(3) Once generated, it is no longer decomposed: glycated hemoglobin is quite stable and not easily decomposed, so although it cannot reflect the short-term fluctuation of blood glucose, it can better reflect the degree of blood glucose control over a longer period of time, and glycated hemoglobin can reflect the average blood glucose level within two to three months before blood collection.
To use an analogy, testing blood glucose at home is like taking a photograph, which can only show a momentary situation. A glycated hemoglobin test, on the other hand, is like taking a 3-month videotape that reflects the average blood glucose over a period of time. Some people say that glycosylated hemoglobin is so good that it can be measured once every three months, so is it possible not to test blood glucose normally? The answer to this question should be that blood glucose and glycosylated hemoglobin each have their own significance and are not interchangeable. Blood glucose changes quickly, and the measurement of fasting and postprandial blood glucose facilitates timely adjustment of treatment, while glycosylated hemoglobin testing is used for the observation and judgment of long-term treatment effects, so as to provide a basis for the formulation of future treatment plans. The normal value of glycosylated hemoglobin should be between 3% and 6%. Most people advocate that glycosylated hemoglobin in diabetic patients should be controlled between 4.0% and 7.5%, too high indicates poor glycemic control, too low should be careful about the occurrence of hypoglycemia. If the glycosylated hemoglobin exceeds 8%, it means that the blood glucose control in the first 6-8 weeks is not satisfactory and the treatment of diabetes needs to be improved, and if it exceeds 11%, the medication needs to be adjusted quickly. In addition to glycosylated hemoglobin, there is also glycosylated serum albumin or fructosamine, which also reflects the average blood glucose level over a longer period of time.
In the previous section, we introduced three ways to determine the level of blood glucose control, including blood glucose, urine glucose, and glycosylated hemoglobin. Finger blood glucose is our main means of monitoring blood glucose, glycosylated hemoglobin reflects the average blood glucose in the last three months and is a very good supplement to finger blood glucose, while urine glucose is now no longer a criterion to judge good or bad blood glucose control. A good glucose monitoring diary is an important helper in our diabetes treatment, and we must make good use of this helper. I hope you have remembered this part of the last time.
The criteria for good and bad diabetes control we mentioned earlier focus mainly on the fact that blood glucose should not be too high. In fact blood glucose control is a two-way street, neither too high nor vigilant not too low. So here we also want to emphasize the need to be alert to hypoglycemia. This is also a problem that some patients tend to ignore in the treatment process. These patients have very strict requirements on blood sugar control, thinking that the lower the blood sugar control, the better, such as fasting requirements to control at 5 mmol per liter, two hours after meal blood sugar control at 7 mmol per liter or less, and each time blood sugar must reach this standard. The result is severe hypoglycemia and even coma, just because of the lack of awareness of the risk of hypoglycemia. There is a saying that we must know about blood sugar control, which is “hypoglycemia is acute damage, while hyperglycemia is chronic damage.” That is, if blood sugar is too low, serious consequences can occur immediately, and in the most severe cases, death can even result, while high blood sugar can take a considerable amount of time, generally years, before complications can occur. A single occurrence of severe hypoglycemia may undermine the benefits of long-term strict blood glucose control. In fact, the high incidence of hypoglycemia also indicates poor control of the disease. We emphasize that good glycemic control should mean that the lower the blood glucose in the absence of hypoglycemia, the better. Generally speaking, fasting blood sugar of 6-7mmol/l and postprandial blood sugar of 8-10mmol/l is enough, and good blood sugar control does not mean that every time the blood sugar reaches the above standard, more than 50% of the blood sugar can reach the above range and it can be said that the standard is basically met. The control target can be relaxed when hypoglycemia easily occurs.
The severity of the diabetes condition is judged from four main aspects
①The level of blood glucose control.
②The possibility of acute complications of diabetes.
③The condition of chronic complications and comorbidities of diabetes mellitus.
④The severity of pancreatic islet cell function and insulin resistance. Up to now, we have finished the first criterion for determining the severity of diabetes, which is the level of glycemic control. Next we are going to talk about the second criterion which is the possibility of acute complications of diabetes mellitus. The complications of diabetes are mainly divided into acute complications and chronic complications. Most of our diabetes is type 2 diabetes, especially the elderly diabetic patients, the possibility of acute complications is less, but if you do not pay attention to blood glucose control for a long time, there is also the possibility of acute complications. Acute complications simply mean that if they are not detected and treated in a timely manner, there is an immediate risk of serious consequences or even death, so although acute complications are rare, we have to stay alert to them. Acute complications of diabetes include diabetic ketoacidosis, diabetic non-ketotic hyperosmolar state, lactic acidosis and hypoglycemia. We have already talked about hypoglycemia, and the acute complications to be alert for in patients with high blood glucose are diabetic ketoacidosis and diabetic non-ketotic hyperosmolar state.
Diabetic ketoacidosis is mainly caused by an excess of ketone bodies in the blood. Ketone bodies are produced by the massive breakdown of body fat and are excreted in the urine. There is no good method to measure the concentration of ketone bodies in the blood, but generally the measurement of urinary ketone bodies reflects whether the body is producing too many ketone bodies. Excessive ketone bodies can cause symptoms: including nausea, vomiting, accelerated breathing, fruity taste, increased thirst, etc. In severe cases, confusion and coma can occur. We should be alert to the possibility of ketoacidosis when high blood sugar is accompanied by the above symptoms. We should monitor urinary ketone bodies in the following cases: when blood sugar is >15mmol/L, during illness, when vomiting or abdominal pain as well as flushing and shortness of breath occur. This will enable early detection of ketoacidosis and avoid aggravation of the disease and serious consequences.
After talking about the second criterion for judging the severity of diabetes, namely the possibility of acute complications of diabetes, we start to talk about the third criterion, namely the chronic complications and comorbidities of diabetes.
There are many aspects to the examination of chronic complications and comorbidities of diabetes, some of which can be monitored at home, and some of which require regular visits to the hospital with the help of a doctor. Let’s have some preliminary understanding of these items that need to be checked, there are: general examination: blood pressure, weight, waist/hip circumference; blood indicators: blood lipids, liver and kidney function, electrolytes, etc.; urine examination: urine routine, urine microalbumin; special examination: fundus examination, neuromyography, electrocardiogram, cerebral hemogram, arterial ultrasound, etc.
First of all, let’s talk about weight, which can be monitored as long as there is a scale at home. What is the appropriate weight to control? The simpler algorithm is to use the standard weight, which (in kilograms) is equal to the height (in centimeters) minus 105, within ±20% of the standard weight is normal, that is, we want to control the weight within this range. In addition, we can also do a precise calculation, that is, using the body mass index, body mass index = weight (kg) / height (m) 2, body mass index more than 24 is overweight, and more than 28 has reached the range of obesity, so it is best to control the body mass index within 24. As an example, Mr. Li, weighing 80 kg and 1.70 m tall, Mr. Li’s BMI = 80 ÷ (1.7 × 1.7) = 27.7, which is in the overweight range and should be reduced appropriately.
In addition to weight itself, an important indicator in determining whether we are overweight is waist circumference, there is a saying that “the longer the belt, the shorter the life expectancy”, indicating that the longer the waist circumference, the more likely to complicate cardiovascular disease, so the waist circumference should be measured frequently. Waist circumference control standard is 90 cm or less for men and 80 cm or less for women.