The "1, 3, 5, 7, 9" principles of the Diabetes Movement and the "Grassroots Diabetes DSMES Consensus" have been released!

To improve the severe situation of diabetes prevention and control in China, "Diabetes Self-Management Education and Support (DSMES)" is an extremely important part
.

In order to effectively carry out DSMES in primary medical institutions, an expert group formed by the Diabetes Professional Committee of the Chinese Research Hospital Association and the Shenzhen Diabetes Prevention and Control Center compiled the Expert Consensus on Self-management Education and Support for Adult Type 2 Diabetes Patients in Primary Medical Institutions, which was recently published in "Chinese Journal of Diabetes"
.

This article shares the "Main Contents of DSMES" section
.

The "Consensus" pointed out that in clinical work, individualized DSMES should be carried out in combination with the specific conditions of patients (including age, course of disease, complications, hypoglycemia risk, treatment plan, occupation, educational level, religious belief, and convenience of medical treatment, etc.
)
.

1.
Introduce the basic knowledge of diabetes in a standardized, systematic and targeted manner 1.
Establish a correct view of the disease and develop scientific medical habits.
Newly diagnosed T2DM patients are the key educational objects
.

It is necessary to clearly inform patients that: ➤Diabetes is a lifelong chronic disease that requires lifelong management and treatment; ➤The function of pancreatic β-cells will decline with the prolongation of the disease course, and the wrong practice of "stopping the drug when the blood sugar drops" should be avoided; ➤Do not misbelieve that "early medication will be dependent", don't go astray such as "I have a remedies to cure"
.

2.
Emphasize the importance of early screening and diagnosis of diabetes ➤ High-risk groups should be aware of the typical "three more and one less" symptoms of diabetes, and understand the atypical symptoms of diabetes, such as itching of the skin or genitals, difficult wound healing, foamy urine, finger (toe) ) numbness, blurred vision, easy infection, etc.
; ➤ clearly inform patients that the diagnosis of diabetes by symptoms alone will cause a delay in diagnosis; ➤ regular physical examination and blood sugar testing (including fasting blood sugar, 2 h postprandial blood sugar and HbA1c) are indispensable
.

3.
Warn the hazards of complications, and establish a treatment concept of "prevention and cure" so that patients can understand the severity of diabetes hazards and the main manifestations of acute and chronic complications
.

If the blood sugar does not meet the standard, the program should be adjusted in time to prevent acute complications; when the patient's disease course exceeds 5 years, attention should be paid to the prevention and treatment of chronic complications
.

4.
Establish a behavioral model of individualized treatment goals and "governance must meet the target".
Blood sugar targets cannot be "one size fits all", but high-quality sugar control and safety compliance must be pursued; comprehensive targets for individualized treatment of blood sugar, blood lipids, and blood pressure should be jointly formulated and urged patients perform
.

2.
The grassroots diabetes care team must master and implement basic diabetes education (1) Healthy living 1.
Healthy diet: formulate a diet plan through patient participation and consultation; pay attention to the operability and compliance of the plan
.

Individualized nutritional therapy should be implemented in combination with the patient's ethnicity, culture, taste preference, overweight/obesity or weight loss, cognition and education level, complications and comorbidities, and family support
.

➤Principles: individualized and reasonable total energy intake; reasonable and balanced distribution of various nutrients; following the principles of healthy eating, meet individual dietary preferences as much as possible
.

➤ Purpose: Maintain a healthy body weight, meet nutritional and trace element requirements, maintain ideal blood sugar, and reduce the risk of cardiovascular disease
.

2.
Regular exercise: Helps to control blood sugar, reduce cardiovascular risk factors, maintain an appropriate weight, improve well-being, and reduce the incidence of diabetes in high-risk groups
.

The amount of exercise and the way of exercise should be individualized and gradual; when conditions permit, a qualified physician should be asked to formulate an individualized exercise prescription
.

➤Adult T2DM patients can use the "1, 3, 5, 7, 9" exercise principle, that is, exercise 1 hour after a meal, each exercise for at least 30 minutes, at least 5 times a week, and the pulse does not exceed (170) during each exercise.
-age) times/min, insist on exercising and persevere; ➤ increase daily physical activity and change sedentary habits; ➤ patients suffer from acute metabolic complications such as severe hypoglycemia, diabetic ketoacidosis, acute infection, proliferative retinopathy, Exercise is contraindicated in cases of severe cardiovascular and cerebrovascular diseases (unstable angina pectoris, severe arrhythmia, transient ischemic attack), etc.
, and exercise can be resumed gradually after the condition is controlled and stabilized
.

Be careful not to cause new injuries or aggravate "strains" with exercise
.

3.
Active smoking cessation (including e-cigarettes): Smoking increases the risk of cardiovascular disease in patients, and it is necessary to encourage and help them to quit smoking
.

4.
Regular work and rest: It is recommended to sleep at least 7 hours a day, try to reduce staying up late, and adjust the sleeping time according to the four seasons and solar terms
.

(2) Cooperate with the diagnosis and treatment to regularly go to legal medical institutions for medical treatment
.

Follow the doctor's orders to take medication and comprehensive treatment to prevent complications
.

When adverse drug reactions occur or the drug regimen needs to be adjusted, you should communicate with your doctor in time
.

(3) Active management and a trusted medical and nursing team to customize a personal management plan
.

Monitor blood sugar, blood pressure, blood lipids and body weight regularly as recommended by your physician
.

Screen and assess the risk of chronic complications annually, including foot, eye, heart, kidney, and blood vessels
.

Give full play to the patient's subjective initiative, improve ability and enhance efficiency
.

(4) Peace of mind Maintain optimism and a good attitude
.

Blood sugar fluctuates, which may cause the patient to experience ups and downs, but there is no need to be overly anxious about it
.

As a chronic disease, if the condition changes, the patient should be encouraged to adjust their mentality and actively cooperate with the physician to adjust the treatment plan
.

When the condition requires, patients can be recommended to seek the support of professional institutions and teams for psychological state assessment and intervention
.

(5) Seeking support for the prevention and treatment of diabetes should not be alone, but should be a team effort, including the support of family members, friends, patients, and medical care teams
.

Promote peer support education and seek trusted people to assist in disease management
.

3.
Actively carry out education on the theme of diabetes (1) In the process of rational drug use diagnosis and treatment, primary-level physicians should educate patients about rational drug use
.

Choose the most needed, most beneficial, safest and easiest drug treatment plan, do not abuse drugs, do not use health care products at will, and do not interrupt drug treatment by yourself
.

Adjust educational content for specific treatment plans
.

1.
Oral drug treatment plan: focus on educating the frequency of drug use, the time of drug administration, adverse reactions and treatment methods, introducing the hypoglycemic mechanism, the focus of self-monitoring of blood glucose (SMBG), the method of drug use under special circumstances, and reviewing whether the combination drug is standardized, liver Whether renal function affects drug use,
etc.

2.
Insulin treatment plan: focus on educating the type of insulin, action time, dosage adjustment according to SMBG, insulin dosage under special circumstances, focusing on the correct injection method, preservation of insulin, adverse reactions of insulin treatment and countermeasures, etc.
, confirming the patient's injection technique Is it standard
.

(2) SMBGSMBG is a compulsory course for diabetic patients, which can promote their behavioral changes and blood sugar safety standards
.

Instruct patients to master the correct operation method of SMBG and the relevant knowledge of rapid blood glucose meter calibration, know the common factors that affect the results of SMBG, observe the implementation and recording of SMBG in patients during the follow-up process, instruct patients to write blood glucose logs, and record blood glucose and other information.
Information on diet, exercise and more
.

Educate patients to understand the significance of blood glucose detection at different time points (before meals, after meals, random, before bedtime, and nighttime) and its main applicable objects (Table 1), and at the same time understand the three levels of blood sugar monitoring: point, line, and surface, namely capillaries Significance and applicability of blood glucose monitoring, HbA1c measurement and continuous glucose monitoring reflecting blood glucose fluctuations
.

It is recommended to introduce a continuous glucose monitoring system suitable for patient self-monitoring, and to carry out targeted education when patients have adopted continuous glucose monitoring technology
.

Inform patients that they should follow up or refer patients in a timely manner when they have significantly elevated blood sugar, excessive blood sugar fluctuations, or repeated hypoglycemia
.

Theoretically, blood glucose should be measured at multiple points per day
.

But the reality is that patients are both excruciatingly painful and unable to afford the financial burden of multiple tests
.

Therefore, "targeted" testing is particularly critical, including individualized testing time points and frequencies to meet treatment needs and goals
.

In addition, factors such as diabetes type, blood sugar control, type of drug, risk of hypoglycemia, and whether short-term adjustment of the treatment plan and other special circumstances (such as pregnancy and pregnancy, sudden other diseases and undetected hypoglycemia) should be fully considered.

.

➤Generally speaking, the time points of SMBG are before three meals (among which no carbohydrates are eaten more than 8 hours before breakfast is fasting), 2 hours after three meals and before going to bed, a total of 7 blood glucose points; ➤In special time points, such as before and after exercise, suspected Blood sugar should be checked at any time during times of low blood sugar, before performing critical tasks (such as driving, traveling long distances, or preparing to work for long hours), and when you want to know your blood sugar status
.

➤When life>
.

➤ Those who use oral hypoglycemic drug regimens can monitor fasting or 2 h postprandial blood glucose 2 to 4 times a week
.

➤ For those on insulin therapy, corresponding monitoring strategies should be adopted according to different protocols: usually, fasting blood glucose should be monitored for those on basal insulin therapy, and fasting and pre-dinner blood glucose should be monitored for those on premixed insulin therapy
.

(3) Prevention of hypoglycemia Diabetic patients face the risk of hypoglycemia, especially when insulin or insulin secretagogues are included in the hypoglycemic program.
Therefore, they must be aware of hypoglycemia and learn to deal with hypoglycemia
.

Severe hypoglycemia occurs when blood sugar is so low that it requires the help of another person to treat it and there is a disturbance of consciousness or/and physical symptoms
.

Severe hypoglycemia can lead to abnormal autonomic function, brain dysfunction or induce cardiac, cerebrovascular accidents and sudden death
.

Both doctors and patients must learn to deal with the occurrence of hypoglycemia.
It is necessary to avoid patients from stopping normal hypoglycemic therapy due to fear of hypoglycemia, and to avoid doctors' behaviors of clinical inertia and relaxation of blood sugar control goals because of fear of hypoglycemia
.

Every time a patient sees a doctor, the doctor should educate and guide the patient: ➤ Adhere to the concept of "prevention is greater than cure" of hypoglycemia, emphasizing the danger of hypoglycemia and the importance of preventing hypoglycemia; ➤ Knowing whether there are symptoms of hypoglycemia, whether there is Monitor the patient's unaware hypoglycemia (blood glucose ≤3.
9 mmol/L), the presence or absence of severe hypoglycemia, and the frequency and incentives of hypoglycemia episodes; ; ➤ The amount of exercise should be relatively constant, measure blood sugar before exercising, and carry candy with you when you go out to exercise; ➤ Follow the doctor's order to take regular and quantitative medicines, and do not increase or decrease the dosage at will; master the characteristics of the insulin used and the correct injection techniques,
etc.

Inform patients of common causes of hypoglycemia
.

Including: use of insulin or insulin secretagogues, not eating on time or eating less, increased physical activity, alcohol intake, especially on an empty stomach, combined with diseases such as pituitary or adrenal insufficiency
.

After the correction of hypoglycemia, the cause of hypoglycemia should be analyzed together with the patient, and practical improvement measures should be proposed
.

Teach patients how to implement self-help and first aid when hypoglycemia occurs
.

➤ To master the "15/15 rule", that is, immediately ingest 15 g of sugary foods (preferably glucose solution) when the blood sugar is low, and re-measure the blood sugar after 15 minutes; ➤ If the low blood sugar is still not corrected, repeat the above "15".
/15 guidelines" until the hypoglycemia is corrected
.

All diabetics are instructed to wear a first aid card, indicating name, address, emergency contact person and contact information, disease and treatment medication, allergy medication and other information
.

Impaired consciousness and unable to eat, should seek medical attention as soon as possible, intravenous infusion of glucose, and referral if necessary
.

If you have symptoms of hypoglycemia, but do not measure blood sugar in time, you can first deal with hypoglycemia treatment methods and monitor blood sugar as soon as possible
.

(4) Prevention of Diabetic Foot All diabetic patients should carry out preventive education on diabetic foot (DF)
.

Primary prevention is mainly aimed at various risk factors and possible causes of DF, and comprehensive prevention strategies are adopted to correct or remove them to avoid the occurrence of DF
.

Comprehensive prevention and treatment strategies include: blood sugar control, high-risk foot identification and effective follow-up, behavior improvement, weight control, screening and control of DF risk factors, smoking cessation, regular moderate exercise, and control of high-risk factors for cardiovascular disease
.

Prevention of DF is the daily work of primary physicians
.

Primary physicians should be familiar with: (1) Identify high-risk groups for DF and perform risk stratification
.

Patients with any of the following are at high risk for DF: age over 60 years (especially advanced age), disease duration over 5 years, poor glycemic control, diabetic retinopathy or vision defects, chronic kidney disease, foot deformities or calluses, foot trauma or surgery history, previous history of DF, and foot joint mobility impairment
.

Loss of protective sensation and peripheral arterial disease are key factors in risk stratification for DF, according to which frequency of review is determined (Table 2)
.

(2) To educate patients and their families, mainly including: ➤ Improve the knowledge of patients' foot self-care and self-protection behaviors; ➤ Regularly check and evaluate peripheral sensation and circulation; ➤ Choose loose and comfortable shoes to avoid stenosis shoes and pointed-toe shoes; ➤ Develop good foot hygiene habits, such as thoroughly washing your feet, wiping dry, and carefully checking for foreign objects before putting on shoes; ➤ Choose detachable cushioning insoles or self-made simple ➤ Properly trimming toenails; ➤ Treating risk factors for ulcers, such as removing calluses, protecting blisters, treating ingrown or thickened toenails, antifungal treatment for fungal infections, etc.
; ➤ Daily foot examination, including between the toes; ➤ Make sure the patient knows how to contact the appropriate medical professional,
etc.

Primary physicians should establish DF files for diabetic patients, carry out targeted education based on DF screening and diagnosis and treatment, and clearly record the content of education to ensure that patients' behaviors are improved
.

In first-level community institutions or grassroots diabetes demonstration bases, train relatively professional DF grassroots management medical and nursing teams, and establish a standardized and effective DF graded diagnosis and treatment system, two-way referral and remote consultation system
.

(5) Prevention of cardiovascular disease All diabetic patients should carry out atherosclerotic cardiovascular disease (ASCVD) prevention education
.

To improve ASCVD risk factors in a targeted manner, the "ABCDE" program is recommended
.

➤"A" is low-dose aspirin (75-150 mg/d) treatment: selective for primary prevention in patients with high risk of ASCVD; ➤"B" is blood pressure target therapy: control the blood pressure of T2DM patients to 130/80 mmHg as much as possible (1 mmHg=0.
133 kPa) or less; ➤“C” is lipid-lowering therapy and smoking cessation: assess ASCVD risk and achieve individualized cholesterol compliance according to risk intensity; recommend behavioral intervention combined with drug therapy to maximize smoking cessation rate; ➤“D” "For a balanced diet: Emphasize vegetables, fruits, nuts, legumes, fish, and whole grains to maintain ideal body weight
.

Control blood sugar: control blood sugar through diet and exercise, and initiate metformin (for those without contraindications); for patients with multiple risk factors for ASCVD, sodium-glucose co-transporter 2 inhibitors or glucagon-like peptide-1 receptors can be administered Agonist hypoglycemic therapy; ➤ "E" is exercise: recommended weekly ≥150 minutes of moderate-intensity exercise, or ≥75 minutes of vigorous exercise per week; it can also be performed in accordance with the "1, 3, 5, 7, 9" exercise principles
.

Source: Diabetes Professional Committee of Chinese Research Hospital Association, Shenzhen Diabetes Prevention and Control Center.
Expert consensus on self-management education and support for adults with type 2 diabetes in primary medical institutions [J].
Chinese Journal of Diabetes, 2022, 14(4): 307 -315.
DOI: 10.
3760/cma.
j.
cn115791-20220207-00066.