Five solutions to "reverse" diabetes, and the first "Consensus of Chinese Experts on Relieving Type 2 Diabetes" was released!

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Guide: 5 options for early intervention, early benefit, and remission of type 2 diabetes! At present, the incidence of type 2 diabetes (T2DM) in China is high.
Patients are under psychological, physical, social, economic and other pressures.
If diabetes can be relieved, it will be of great significance to patients, their families, and society as a whole
.

Therefore, Professor Zou Dajin, Professor Zhang Zheng, and Professor Ji Linong led domestic experts to organize a "Chinese Expert Consensus on Type 2 Diabetes Mitigation" that meets the health needs of Chinese diabetic patients based on domestic and foreign research evidence and the consensus report of the ADA, with a view to Guide clinicians to standardize the diagnosis and treatment of T2DM relief, and help T2DM patients obtain safe, effective and economic intervention measures
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The definition and mechanism of T2DM remission 1.
The definition of T2DM remission.
In 2021, the ADA released a consensus report on the "Definition and Interpretation of Type 2 Diabetes Remission", suggesting that HbA1c<6.
5% should be considered as T2DM remission after discontinuation of hypoglycemic drugs for at least 3 months Diagnostic criteria
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In some cases, such as the presence of hemoglobin variants, disease affecting the survival time of red blood cells, and irregular HbA1c detection methods, HbA1c cannot reflect the true blood glucose level.
Fasting blood glucose (FPG) <7.
0 mmol/L or estimated by dynamic glucose monitoring can be used Glycated hemoglobin (eA1c) <6.
5% is used as a surrogate criterion for diagnosing T2DM remission.
After confirming that the diabetes is in remission, HbA1c still needs to be reviewed every year
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2.
The mechanism of T2DM remission T2DM remission is related to correcting obesity or significantly improving body mass, improving fatty liver and fatty pancreas, improving insulin resistance and hyperinsulinemia, correcting high glucose toxicity, and dedifferentiation and transdifferentiation of pancreatic β-cells
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In terms of weight control: Actively carry out body weight control.
The goal of body weight control is to reach a normal level of BMI
.

For those with T2DM and obesity, it is recommended to lose at least 10kg or more of body weight (preferably 15kg or more) or to lose more than 10%
.

To assess the basic conditions for diabetic remission, use the "ABCD" method.
The "Consensus" recommends the use of the "ABCD" evaluation method to determine the basic conditions for T2DM remission, as shown in Table 2
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(Level of Evidence: 4, Level of Recommendation: D) Explanation: ➤ First, it is necessary to exclude special types of diabetes, including hypercortisolism, growth hormone tumors, glucagon tumors, and diabetes caused by some genetic factors.
These diseases need to be targeted at It is possible to relieve diabetes by correcting the cause of the disease
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➤Exclude autoimmune diabetes.
In this type of diabetic patients, pancreatic β-cells are progressively decreased due to continuous autoimmune attacks, and the proportion of overweight and obese patients is relatively low
.

There is no clinical evidence that diabetes can be relieved in this population
.

➤Exclude patients with longer course of disease, severe complications, and poorer islet function in T2DM (fasting C-peptide <1.
0ug/L when blood glucose reaches the target)
.

There is no clinical evidence that diabetes can be relieved in this group of people
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1.
"Strengthen life>
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Intensive life>
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The basic recommended plan is shown in Table 3
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1.
Diet and nutrition treatment In T2DM patients with obesity, energy-restricted diet (CRD) combined with exercise, low-carbohydrate diet (LCDs), very low-energy diet (VLCD), intermittent fasting, and ketogenic diet can all promote early T2DM Ease
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Several dietary patterns for weight loss are recommended
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➤It is recommended to use limited energy diet (CRD) and limited energy Mediterranean diet with exercise as the basic plan to alleviate T2DM
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There are currently three main types of CRD: (1) Reduce energy intake by a certain percentage (30%-50% reduction) based on the target energy intake; (2) Reduce energy intake by 500 per day based on the target intake Energy intake of about kcal; (3) Daily intake of 1,000 to 1,500 kcal
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➤Short-term (4-12 weeks) periodic special diet patterns (including high-protein diet, ketogenic diet, VLCD, LCDs, VLCDs) can help reduce weight and relieve T2DM
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➤The use of supplementary sugar control foods or functional foods evaluated can increase satiety, assist sugar control, and reduce the difficulty of diet management, which is conducive to weight loss and alleviation of T2DM
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In the process of weight loss, auxiliary weight loss foods, semi-meal replacements, and phased meal replacement packages can be used to achieve the effects of improving satiety, delaying carbohydrate absorption, supplementing nutrients and assisting in sugar control
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Nutritionists (physicians) need to evaluate the rationality and safety of the formulas of such products, and make a good match with ordinary diets
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Meal replacement should provide protein, fiber and trace elements to ensure the basic needs of nutrients and control energy intake
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There are mainly 3 common meal replacement varieties: (1) Meal replacement powder with 80% starch removed (used to make buns, bread, noodles, etc.
) to replace daily staple food; (2) Meal replacement biscuits; (3) Meal replacement soup
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Appetite management of patients: (1) Slow down the meal speed: increase the frequency of chewing, chew each bite 20-40 times; pause between meals, reduce the volume of each bite, and use non-dominant hand-held chopsticks or forks
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(2) Drink water before meals and eat a small amount of nuts before meals (such as 10 almonds, 20 peanuts): Nuts contain unsaturated fatty acids, which can stimulate the secretion of cholecystokinin after eating, and reduce appetite through the vagus nerve and non-vagus nerve pathways
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(3) Reasonably arrange the order of meals: ① Drinking soup before meals can easily produce a feeling of fullness
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②Vegetables and low-sugar fruits are large in size and low in energy, slowing down the rate of absorption and inducing satiety
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③ Meat dishes and meat are high in energy, so eat them in the third place to further increase the feeling of fullness
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④ Eat a small amount of staple food and carbohydrates at the end of the meal, slow absorption to reduce blood glucose fluctuations after a meal
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(4) Increase foods rich in dietary fiber: Dietary fiber is slow to empty in the stomach, and it is easy to produce a feeling of fullness
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It can increase the intake of oats, whole wheat bread made from meal replacement powder with 80% starch removed, green leafy vegetables, low-sugar fruits and other foods
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2.
Exercise intervention The "Consensus" recommends that aerobic exercise is the best fat-reducing program, which can reduce body fat.
It is recommended that no less than 150 minutes of moderate-intensity aerobic exercise per week is recommended
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Resistance exercise should be performed no less than 2 times a week at the same time
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Exercise is one of the best ways to control body mass
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Exercise is the basis of T2DM treatment.
Diabetic patients can directly consume part of their energy through exercise to achieve the goal of blood sugar control
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Exercise can also increase muscle volume and make insulin sensitivity continuously improve
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In addition, exercise can also improve the patient's blood lipids, blood pressure and cardiovascular health, and increase their sense of pleasure
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Table 4 shows the recommended exercise weight loss for prescribing exercise prescription for T2DM relief
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Prescription of exercise should follow the process of "evaluating health, setting goals, selecting items, setting intensity, exercise training, evaluating effects, and adjusting in time"
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(1) Evaluation of health: ①Understand the medical history: hyperglycemia, hypertension, hyperlipidemia, obesity, cardiovascular disease and other diseases that affect exercise
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②Methods for assessing athletic ability: a.
Endurance: Choose a fixed route and record how long it takes to walk each time? b Upper limb strength: How many presses can be done in 2 minutes? c Lower limb strength: How many times can you finish sitting on a chair and stand up and then sit down in 2 minutes? d Balance ability: stand on one foot (it is recommended to practice at the armrest) for a few minutes? e Flexibility: Sit on a stable chair, stretch out one leg and place it on the opposite chair, with the heel facing the ground, and the stretched leg with your hands.
How far can it be stretched? ③Assess exercise safety and cardiorespiratory endurance: usually exercise stress test can be used to assess the most serious cardiovascular ischemic hazards during exercise and avoid sudden death
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While carrying out the load exercise test, the appropriate heart rate range corresponding to the aerobic exercise intensity can be calculated to guide the formulation of exercise prescriptions
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(2) Set goals: How long do you exercise for the exercise plan from Monday to Friday and weekends? What kind of sport do you want to do? (3) the choice of sports: select your favorite, right project the best, consider walking, jogging, swimming, gardening, sports, dance, fitness, dumbbell and so on
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(4) Set intensity: Try to insist on aerobic exercise of at least 30 minutes a day at a moderate intensity.
If you can’t take out the entire 30 minutes every day, you can do it for 10 minutes at a time and exercise 3 times a day
.

Do strength training more than 2 times a week, each lasting 30 minutes
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In the process of exercise, it is necessary to avoid injury, adjust in time, choose suitable exercise mode, suitable intensity, suitable exercise environment and equipment, and monitor the effect in time to avoid sports injury
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When the body mass declines too fast, the body fatigue and the function decline, the exercise load should be appropriately reduced.
When the body mass change is not obvious, the exercise load should be increased to accelerate the fat loss
.

2.
"Weight loss drugs" to achieve T2DM relief.
The "Consensus" mentions that orlistat can be used briefly (12 to 24 weeks) as an auxiliary method for BMI≥27kg/m^2 combined with T2DM relief
.

It is recommended to be used in the short to medium term (half a year) in obese patients with T2DM whose body weight is not improved after intensive life>
.

Orlistat is a lipase inhibitor that inhibits the lipase in the gastrointestinal tract, prevents the hydrolysis of triacylglycerols into free fatty acids and monoacylglycerides, reduces the absorption of dietary fat (triacylglycerol) by the intestinal mucosa, and promotes Fat is eliminated from the body
.

Orlistat is the only weight loss drug approved for weight management in China
.

Orlistat was approved by the National Medical Products Administration as an over-the-counter drug for weight loss in 2007 and is recommended for T2DM patients with BMI ≥ 27 kg/m^2
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The drug has the effects of reducing body mass, maintaining body mass and preventing rebound
.

The main adverse reactions of orlistat are steatorrhea and increased stool frequency
.

Long-term use for more than 1 year will reduce the absorption of fat-soluble vitamins and β-carotene, and there are rare reports of liver damage
.

3.
"Non-insulin hypoglycemic drugs" to achieve T2DM relief.
The "Consensus" recommends that for T2DM patients whose HbA1c does not meet the standard and who cannot effectively implement enhanced life>
.

Glucagon-like peptide-1 (GLP-1) receptor agonist and its combination program: ➤ A meta-analysis based on a placebo-controlled study showed that the body weight of patients can be reduced by 1.
69 kg after exenatide treatment.
Body weight decreased by 2.
51 kg after treatment with liraglutide, and 0.
90 kg after treatment with lixisenatide
.

DURATION series of studies have shown that 2 mg of Exenatide weekly preparation, once a week, subcutaneous injection, 28 weeks of body weight can reduce 1.
2~1.
5 kg
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The weekly smeglutide preparation (2.
4 mg) combined with life>
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A study by Sustain China shows that the application of smeglutide in overweight and obese T2DM patients can reduce HbA1c by 1.
8% and body weight by 4.
2 kg, which can be used as an auxiliary method to improve body weight
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➤A study by a Danish scholar showed that the combined treatment of metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitor, and GLP-1 receptor agonist, compared with other combined treatments, has the most weight loss, the least occurrence of hypoglycemia, and the The incidence of cerebrovascular disease and all-cause death is the lowest
.

➤Combined therapy with metformin, thiazolidinedione, and GLP-1 receptor agonist is a reasonable adjuvant relief treatment plan for pathophysiological changes
.

Studies have shown that this combination therapy has a higher proportion of HbA1c<5.
7%
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4.
"Insulin" to achieve T2DM relief.
The "Consensus" recommends that for HbA1c≥10% and FPG≥11.
1 mmol/L, adjuvant short-term (2 weeks) early intensive insulin therapy will help relieve T2DM
.

Specific recommendations: ➤Overweight and obese patients with T2DM, if the blood sugar level is high (HbA1c≥10%, FPG≥11.
1 mmol/L) at the first diagnosis, accompanied by obvious symptoms of hyperglycemia or ketoacidosis, insulin therapy can be given for a short period of time
.

➤After the patient undergoes short-term insulin therapy, the hyperglycemia has been significantly improved, and the ketoacidosis has been corrected, the clinical evaluation can be repeated
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If the patient meets the basic conditions for remission of T2DM, the non-insulin treatment measures recommended in this consensus to improve body mass can be used to continue to improve body mass to promote the long-term remission of T2DM
.

5.
"Metabolic Surgery" for T2DM Remission The "Consensus" recommends that for T2DM patients with BMI≥32.
5 kg/m^2, if non-surgical treatment measures cannot significantly improve body mass and metabolic disorders, metabolic surgery can be considered to relieve T2DM
.

Specific recommendations: ➤ADA recommends that for adult T2DM patients with BMI>35 kg/m^2, especially those with diabetes or related complications that are difficult to control through life>
.

➤Asian people, when BMI≥32.
5 kg/m^2, should be actively operated; when 27.
5 kg/m^2≤ BMI<32.
5 kg/m^2, it is difficult to control body weight and blood sugar after changing life>
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➤The recommended age for surgery is 16 to 65 years old
.

➤The recommended standard surgical procedures are LRYGB and LSG
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LSG can improve the glucose metabolism and other metabolic indexes of obese patients better, the operation is simple, and the complications are few; LRYGB can improve the glucose metabolism and other metabolic indexes in addition to the significant weight loss effect.
The remission rate for T2DM is higher, but the operation is complicated.
, There are more complications
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Minimally invasive laparoscopic surgery is recommended because the early postoperative mortality and complication rate are significantly lower than that of open surgery
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It is very important to do a good job in the perioperative period.
For patients with BMI ≥ 37kg/m^2, the preoperative weight loss is 10%, which is conducive to the safe implementation of the operation
.

Effect evaluation and prognosis improvement of T2DM remission 1.
T2DM remission evaluation criteria for T2DM remission: HbA1c<6.
5% after stopping hypoglycemic drugs or pure life>
.

After confirming that the diabetes is in remission, it is still necessary to review HbA1c or FPG every 3 or 6 months or use dynamic glucose monitoring to calculate eA1c
.

Other evaluation indicators: (1) BMI ≤ 24 kg/m^2, weight loss ≥ 10 kg or weight loss ≥ 10%; (2) Body fat rate reduction, reaching male ＜ 25%, female ＜ 30%; (3) Fatty liver improved, ultrasound showed fatty liver disappeared, liver function indicators returned to normal; (4) muscle content reached the standard, male ≥ 40%, female ≥ 35%
.

2.
Improve the prognosis of T2DM remission The "Consensus" recommends that the longer the duration of early remission of diabetes is, the more diabetic complications and all-cause mortality can be reduced
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The "5-000-111 rule" put forward by Daqing Research has strong guiding value for life>
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The 30-year follow-up of the Daqing study showed that early life>
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