Comorbidities of diabetes, metabolic surgery and tertiary prevention strategies

VII. Complications of Diabetes

1. Diabetes mellitus complicated with metabolic syndrome

Metabolic syndrome (MS) is the most common complication of diabetes mellitus, and the two conditions influence and promote each other. Insulin resistance is the main pathogenesis of type 2 diabetes and also a fundamental characteristic of MS. MS is a complex metabolic disorder syndrome caused by disturbances in the metabolism of proteins, fats, and carbohydrates, clinically manifesting as obesity, dyslipidemia, diabetes, hypertension, coronary heart disease, and stroke. The probability of developing type 2 diabetes in non-diabetic individuals with MS is approximately five times that of non-diabetic individuals without MS, while patients with type 2 diabetes are also more likely to develop MS.

2. Diabetes mellitus complicated with pancreatitis or hypotestosterone in men

For patients with medically refractory chronic pancreatitis requiring total pancreatectomy, autologous islet transplantation should be considered to prevent postoperative diabetes. For male diabetic patients with symptoms and signs of hypogonadism, serum testosterone levels should be measured.

3. Management of diabetes mellitus complicated with pregnancy and gestational diabetes mellitus

Both gestational diabetes mellitus (GDM) and diabetes insipidus during pregnancy are associated with maternal and infant complications such as preeclampsia and cesarean section. Therefore, controlling GDM throughout the entire pregnancy is crucial for ensuring maternal and infant safety. Early diagnosis of GDM is essential, and management should follow standard treatment protocols after diagnosis. Medical nutrition principles are the same as for non-pregnant patients, ensuring normal weight gain. Insulin should be used to control blood glucose; currently, no oral hypoglycemic agents are approved for the treatment of gestational diabetes in my country. Closely monitor blood glucose levels, controlling pre-meal blood glucose to 3.3–5.3 mmol/L, 1-hour postprandial blood glucose ≤7.8 mmol/L, and 2-hour postprandial blood glucose ≤6.7 mmol/L; HbA1c should be below 6.0%; and hypoglycemia should be avoided. GDM patients should be screened for permanent diabetes 6–12 weeks postpartum. If blood glucose is normal, diabetes screening should be performed at least every 3 years.

VIII. Other treatment methods for diabetes

1. Metabolic surgical treatment

Clinical evidence shows that metabolic surgery can significantly improve glycemic control in obese patients with type 2 diabetes, and may even lead to remission in some patients. Domestic reports indicate a remission rate of up to 73.5% one year after surgery. Compared with intensive lifestyle interventions and hypoglycemic drug therapy, surgery is more effective in reducing weight and improving blood sugar, while comprehensively controlling metabolic indicators such as blood lipids and blood pressure. It also significantly reduces the risk of macrovascular and microvascular complications of diabetes, significantly improves obesity-related diseases, and significantly reduces the risk of developing diabetes in non-diabetic obese patients after surgery. This treatment has been implemented in my country, but due to various reasons, it is not yet suitable for large-scale promotion.

2. Cell replacement therapy

In recent years, cell-based replacement therapies have demonstrated advantages in the treatment of diabetes, with mesenchymal stem cells (MSCs) considered an ideal candidate cell type for this treatment. Studies on MSCs' effects on glycemic control have shown significant therapeutic efficacy, and some have been applied in clinical trials; however, many potential challenges remain. Furthermore, pancreas transplantation and islet cell transplantation for type 1 diabetes are limited in widespread clinical application due to donor shortages and the need for long-term immunosuppressant therapy.

IX. How to prevent diabetes

In recent years, the incidence of diabetes has been rising year by year, seriously endangering human health and placing a heavy burden on society. Therefore, the prevention and control of diabetes is urgent. From the perspective of the target population, prevention can be divided into prevention for the general population and prevention for individuals. From the perspective of preventing and controlling different stages of disease development, it mainly involves the three levels of prevention for diabetes.

(I) Primary prevention of diabetes

Primary prevention refers to minimizing the occurrence of diseases. Diabetes is a non-communicable disease, and although it has a certain genetic predisposition, environmental factors are the key. Prevention includes prevention in the general population and in key populations.

1. Prevention in the general population

(1) Strengthen public awareness and understanding of diabetes, such as: What is diabetes? What are the common symptoms, signs, complications, and risk factors of diabetes?

(2) Promote a healthy lifestyle, such as a balanced diet, moderate exercise, quitting smoking and limiting alcohol consumption, and maintaining psychological balance.

(3) Regular physical examinations should be conducted. If impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) is found, intervention should be implemented as soon as possible.

2. Prevention among key populations

(1) Key populations requiring intervention: those aged ≥45 years; those with BMI ≥25; those with a family history of diabetes; those previously diagnosed with IGT or IFG; those with dyslipidemia; those with hypertension and/or cardiovascular and cerebrovascular diseases; those with a history of gestational diabetes; those who have given birth to large babies (birth weight ≥4kg); those with unexplained prolonged labor; women with polycystic ovary syndrome; and those using certain special medications (such as glucocorticoids, diuretics), etc.

(2) Lifestyle interventions can benefit this population. Specific goals for lifestyle changes include: achieving or approaching a BMI of 24, or reducing it by 5%–7%; reducing daily total calorie intake by 400–500 kcal; ensuring saturated fatty acid intake accounts for less than 30% of total fatty acid intake; and increasing physical activity to 250–300 minutes per week. To achieve these goals, it is essential to "control your diet and increase physical activity."

How to "control your diet"? Dietary therapy is the foundation of diabetes prevention and treatment, and should be adhered to long-term regardless of the type of diabetes. The general principle of diabetic dietary therapy is to achieve nutritional balance within a fixed calorie limit. This includes moderate amounts of staple foods (approximately 100g per meal); avoiding sweets and oily foods; eating fruit sparingly; and consuming plenty of fish, shrimp, soy products, whole grains, and vegetables. The following points should be noted:

a. Eat small amounts of fruits with relatively low sugar content between meals, such as tomatoes, apples, strawberries, cherries, etc., but avoid fruits and dried fruits such as bananas, pineapples, pomegranates, cantaloupes, and raisins.

b. Foods with high starch content should be eaten less, such as sweet potatoes, potatoes, and yams.

c. Eat less or avoid eating sunflower seeds, pine nuts, and walnuts.

d. It is best not to drink alcohol. If you must drink alcohol, consume a small amount of low-alcohol beverage (no more than 50g per day).

e. Gradually increase your intake of dietary fiber.

f. Eat meals at regular times and in fixed quantities.

How to "get moving"? Exercise therapy is the best partner for diet therapy and also the foundation of diabetes treatment. The benefits of exercise for diabetes are undeniable, especially for type 2 diabetes. Regular exercise can not only reduce the incidence of type 2 diabetes but also lower blood sugar, improve insulin sensitivity, and delay the onset and progression of its chronic complications. It is generally recommended that diabetic patients engage in aerobic exercise such as walking, jogging, swimming, cycling, Tai Chi, and dancing. To achieve the therapeutic effect of exercise, it is necessary to ensure an appropriate amount of exercise (at least three times a week, with an effective exercise time of 45 minutes each time), and safety must be ensured during exercise. To prevent exercise-induced hypoglycemia, the following points should be noted:

a. Avoid exercising on an empty stomach; it is best to do so 1 to 2 hours after a meal.

b. When engaging in prolonged, moderate-intensity or higher exercise, it is advisable to eat an appropriate amount of food before exercising.

c. Before exercise, the pre-meal insulin injection site should preferably be the abdomen, avoiding the muscle groups being exercised as much as possible.

d. When exercising, you should carry your diabetes card and sugary foods with you.

(II) Secondary prevention of diabetes

The key to preventing and treating diabetic complications is to detect diabetes as early as possible and to control and correct risk factors such as hyperglycemia, hypertension, dyslipidemia, obesity, smoking, and alcohol consumption in diabetic patients as much as possible.

Patients with type 1 diabetes should start insulin therapy as early as possible, and control their blood sugar throughout the day by strengthening blood glucose monitoring, while also paying attention to protecting the remaining pancreatic β cells; patients with type 2 diabetes should be screened regularly for diabetic complications and related diseases to understand their condition, strengthen relevant treatment measures, and fully achieve the treatment goals.