Volume 14 · Issue 09 · 2022

Medical nutritional therapy is the basis of comprehensive treatment of diabetes. In recent years, many progress has been made in the research field of medical nutrition and metabolic therapy for diabetes. The Nutrition and Metabolic Management Branch of China Medical Care International Exchange Promotion Association organized experts in relevant fields from Clinical Nutrition Branch of Chinese Nutrition Society, Diabetology Branch of Chinese Medical Association, Parenteral and Enteral Nutrition Branch and Nutritionist Professional Committee of Chinese Medical Doctors Association to update and revise the Guidelines for Medical Nutrition Therapy of Diabetes in China (2013) according to the latest evidence-based medicine, and complete the Guidelines for Medical Nutrition Therapy of Diabetes in China (2022 Edition). The contents of the new version of the guide cover many fields such as diabetes nutritional prevention, treatment and complication prevention, new phytochemicals, parenteral and enteral nutrition support, metabolic surgery and nutrition, etc., and the diagnosis and treatment process is formulated based on expert experience, which is advanced, standardized and practical. This article would like to interpret the key contents of the guide, so as to quickly understand the key points of the update of the guide, aiming at providing clinical reference for the diagnosis, treatment and management of diabetes medical nutrition.

The situation of diabetes prevention and control in China is grim, with a large patient base, low awareness rate, treatment rate and control rate, many elderly diabetic patients, uneven medical development level in urban and rural areas and regions, and multiple obstacles to diabetes management are still faced. In order to solve the problem of a major diabetic country, this paper attempts to put forward the goals, principles and characteristics of a chronic diabetes management model with Chinese characteristics. It is suggested to take the patient as the center, base on the two focal points of the whole population and the whole life cycle, integrate the resources of various medical and health institutions, actively promote the construction of standardized diabetes prevention and control network assisted by digital medical care, build a mature online and offline collaborative diagnosis and treatment model, and promote the implementation of diabetes self-management education and support plan, so as to reduce the prevalence of diabetes, improve the compliance of diabetes management, and improve the clinical outcome, health status and quality of life of diabetes patients.

Medical nutritional therapy (MNT) is the basis of comprehensive treatment of diabetes and is an essential measure for prevention and control at any stage of the course of diabetes. In 2010, the Nutritionist Professional Committee of Chinese Medical Doctors Association and the Diabetes Branch of Chinese Medical Association jointly formulated China's first diabetes MNT guidelines, which were updated in 2015. In the past seven years, many breakthroughs have been made in the fields of diabetes MNT and metabolic therapy. The Nutrition and Metabolic Management Branch of China Medical Care International Exchange Promotion Association organized experts in related fields from Clinical Nutrition Branch of Chinese Nutrition Society, Diabetes Branch of Chinese Medical Association, Parenteral and Enteral Nutrition Branch and Nutritionist Professional Committee of Chinese Medical Doctors Association to initiate the revision of the Guidelines for Medical Nutrition Therapy of Diabetes in China (2013), which covers many fields such as diabetes nutrition prevention, treatment, complication prevention and treatment, artificial sweeteners and new phytochemicals, parenteral and enteral nutrition support, etc. In the process of formulating the guidelines, we strictly followed the requirements of methodology, referred to the requirements of the Guiding Principles for Formulating/Revising Clinical Diagnosis and Treatment Guidelines in China (2022 Edition), adhered to the principle of patient problem-oriented, equal emphasis on evidence level and recommendation, and serving the clinic, combined with Chinese clinical practice to raise questions and collect evidence, and formed the Guidelines for Medical Nutrition Treatment of Diabetes in China (2022 Edition), aiming at guiding and standardizing clinical MNT.

To investigate the role of fatty liver index (FLI) in predicting the risk of developing type 2 diabetes mellitus(T2DM).

This study was a retrospective cohort study. A number of 1 398 participants from a medical examination center of PLA Rocket Force Characteristic Medical Center from June 2013 to September 2020 were enrolled. The participants were equal or more than 40 years old and without previous T2DM. The general information, physical examination data and laboratory indexes were analyzed, and the occurrence of T2DM was followed up as the research outcome indicator. According to the FLI levels at baseline, the research subjects were divided into FLI<30 group (824 cases), 30≤FLI<60 group (420 cases), and FLI≥60 group (154 cases). Thet test and analysis of variance (ANOVA) were used to compare the means of two or more groups of a categorical variable, and chi-square test was used for testing relationships on categorical variables. Non-parametric test (wilcoxon rank sum test) was used when the continuous variables were not distributed normally. Multivariate Cox regression analysis was used to assess the risk of T2DM in the FLI group with different fasting glucose status at baseline.

The average follow-up time of the study was 5.7 years. During the follow-up period, a total of 240 people (17.17%) were diagnosed with T2DM. Compared with those without T2DM group (1 158 cases), individuals with T2DM were older and had higher waist circumference, body mass index, systolic blood pressure, fasting blood glucose, oral glucose tolerance test 2-hours plasma glucose and FLI levels (P<0.05). Participants with a family history of diabetes were more likely to develop T2DM (P<0.01). After adjusting for baseline age, gender, smoking, drinking, exercise and family history of diabetes, among the participants with normal fasting glucose at baseline, compared with the population with FLI<30 group, the participants who with 30≤FLI<60 group (HR=1.18, 95%CI 0.84-1.64,P>0.05) and FLI≥60 group (HR=1.57, 95%CI 1.01-2.44,P<0.05) had higher risk of developing T2DM. Among the participants with impaired fasting glucose at baseline, compared with the FLI<30 group, participants with 30≤FLI<60 group (HR=1.19, 95%CI 0.44-3.20) and FLI≥60 group (HR=1.32, 95%CI 0.44-3.94) had higher risk of developing T2DM, but the difference was not statistically significant (P>0.05).

In a certain department of physical examination center, without impaired fasting glucose, high FLI has predictive value for the risk of T2DM.

To explore the diagnostic value of quantitative sensory testing (QST) in diabetic peripheral neuropathy in patients with type 2 diabetes mellitus (T2DM).

Patients with T2DM aged 18-70 years in Nanjing Drum Tower Hospital from May 2020 to February 2021 were retrospectively analyzed. QST parameters [warm detection threshold (WDT), cold detection threshold (CDT)], heat pain threshold (HPT) and cold pain threshold (CPT) were collected, and nerve conduction velocity (NCV) parameters of both lower limbs were measured, including common peroneal nerve conduction velocity, sural nerve conduction velocity, tibial nerve conduction velocity, etc. Patients received QST and NCV for allocation into different neuropathy groups according to the diagnostic criteria: nondiabetic peripheral neuropathy (NDPN) group, small fiber neuropathy (SFN) group and mixed fiber neuropathy (MFN) group. The t-test or one-way analysis of variance (ANOVA), Mann Whitney U or Kruskal Wallis H test, or χ² test were used to compare the general clinical data between groups. Multivariate logistic regression analysis was used to analyze the risk factors of DPN. Spearman correlation method was used to analyze the correlation between QST parameters and NCV. Receiver operating characteristic curve (ROC) analysis was used to evaluate the sensitivity, specificity and diagnostic value of QST for MFN.

A total of 279 patients were included, including 111 in NDPN group, 116 in SFN group and 52 in MFN group. Compared with SFN group, MFN group presented lower CDT and CPT, higher WDT and HPT (all P<0.05). The results of correlation analysis showed that the common peroneal nerve conduction velocity, sural nerve conduction velocity and tibial nerve conduction velocity of both lower limbs were positively correlated with CDT (r=0.264, 0.366 and 0.288 respectively) and CPT (r=0.226, 0.253 and 0.236 respectively) (all P<0.05), They were negatively correlated with WDT (r=-0.274, -0.338 and -0.268 respectively) and HPT (r=-0.246, -0.281 and -0.192 respectively) (all P<0.05). The results of ROC model showed that when WDT+CDT was used to diagnose MFN, the product under the curve was 0.840, the sensitivity was 86.3%, and the specificity was 71.8% (P<0.001).

QST was able to exhibit a high early diagnostic value for diabetic peripheral neuropathy.

To investigate the influencing factors and bilirubin levels of diabetic retinopathy (DR) in hospitalized patients with type 2 diabetes mellitus (T2DM).

T2DM patients who were hospitalized in the Department of Endocrinology from January to December 2021 in Xuanwu Hospital of Capital Medical University were retrospectively enrolled. All included patients underwent non-mydriatic fundus photography. The data of duration of diabetes, body mass index (BMI), creatinine, total bilirubin, direct bilirubin, indirect bilirubin, glycated hemoglobin A_1c (HbA_1c), high-sensitivity C-reactive protein (hs-CRP) and urinary albumin to creatinine ratio (UACR) were collected. The patients were divided into non-diabetic retinopathy (NDR) group and DR group according to the diagnostic and staging criteria of DR. The t-test, Mann-Whitney U test and χ² test were used to compare the general clinical data between the two groups; multivariate logistic regression analysis was used to analyze the risk factors of DR.

A total of 1 027 patients were enrolled, including 245 patients with DR and 782 patients with NDR. The prevalence of DR in hospitalized T2DM patients was approximately 23.9% (245/1 027). Compared with the NDR group, the DR group had a longer duration of diabetes, higher HbA_1c, creatinine, UACR, hs-CRP levels, and lower total bilirubin, direct bilirubin and indirect bilirubin concentrations. The differences were statistically significant (all P<0.05). Multivariate logistic regression analysis showed that after adjusting for gender, age and BMI, HbA_1c (OR=1.199, 95%CI 1.112-1.293), duration of diabetes (OR=1.063, 95%CI 1.034-1.093), creatinine (OR=1.007, 95%CI 1.002-1.013), UACR (OR=1.389, 95%CI 1.280-1.507) and hs-CRP (OR=1.260, 95%CI 1.108-1.432) were the main risk factors for DR, total bilirubin (OR=0.927, 95%CI 0.873-0.983), direct bilirubin (OR=0.831, 95%CI 0.701-0.985) and indirect bilirubin (OR=0.898, 95%CI 0.825-0.976) were protective factors for DR; after further adjustment for HbA_1c, diabetes duration (OR=1.063, 95%CI 1.033-1.093), creatinine (OR=1.008, 95%CI 1.002-1.013), UACR (OR=1.382, 95%CI 1.272-1.502) and hs-CRP (OR=1.214, 95%CI 1.065-1.384) were still independent risk factors for DR, total bilirubin (OR=0.922, 95%CI 0.867-0.980), direct bilirubin (OR=0.827, 95%CI 0.694-0.984) and indirect bilirubin (OR=0.889, 95%CI 0.815-0.969) were still protective factors for DR.

HbA_1c, duration of diabetes, creatinine, UACR and hs-CRP are risk factors for DR, and bilirubin may be a protective factor for DR.

To explore the correlation between uric acid/high-density lipoprotein cholesterol ratio (UHR) and visceral fat area (VFA) in patients with type 2 diabetes mellitus (T2DM).

A total of 909 patients with T2DM treated in National Metabolic Management Center (MMC) of the Affiliated Hospital of Jiangsu University from May 2018 to July 2020 were enrolled in this study. The general clinical information and physical examination [including height, weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), neck circumference, waist circumference, hip circumference, VFA and subcutaneous fat area (SFA)] were collected. Body mass index (BMI), waist hip ratio (WHR) and VFA/SFA ratio (V/S) were calculated. And glucose metabolism indexes [fasting plasma glucose (FPG), fasting insulin (FINS), 2 hour postprandial plasma glucose (2hPG), 2 hour postprandial insulin (2hINS) and glycated hemoglobin A_1c (HbA_lc)], biochemical indexes [total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyl transpeptidase (GGT), blood urea nitrogen (BUN) and serum creatinine (Scr)] and thyroid hormone [free triiodothyronine (FT3), free thyroxine (FT4), sensitivity thyrotropin stimulating hormone (sTSH)] were conducted on all subjects. Homeostasis model assessment of insulin resistance (HOMA-IR), homeostasis model assessment of β-cell function (HOMA-β) and UHR were calculated. Meanwhile, according to UHR, all patients were divided into tertiles, which included groupQ₁ (UHR≤21.10%, 303 cases), group Q₂ (21.10%<UHR≤31.06%, 303 cases) and groupQ₂ (UHR>31.06%, 303 cases). Based on VFA, patients were divided into control group (VFA<100, 597 cases) and visceral obesity (VO) group (VFA≥100, 312 cases). The differences between groups were compared by one-way analysis of variance (ANOVA), Kruskal-Wallis nonparametric test andχ² test. Spearman correlation analysis was used to analyze the correlation between UHR and various indicators, and multiple linear regression analysis was used to analyze the influencing factors of VFA in T2DM patients.

Compared with group Q₁, the proportions of males, smoking, drinking, the proportion of hyperlipidemia, FINS, HOMA-β, TG, GGT, Scr, BMI, neck circumference, waist circumference, hip circumference, WHR, VFA, SFA and V/S in groups Q₂ and Q₃ were all increased, while SBP, DBP, 2hINS, HOMA-IR, ALT, AST, FT3 only increased in group Q₃. Age, TC, LDL-C only decreased in group Q₃. Compared with group Q₂, the proportion of males, hyperlipidemia, DBP, HOMA-IR, TG, ALT, γ-GT, BMI, waist circumference and VFA in group Q₃ were increased, while age and LDL-C decreased (P<0.05). Spearman correlation analysis indicated that UHR was positively correlated with VFA and V/S(r=0.328, 0.205,both P<0.001）. Multiple linear regression analysis indicated that UHR was independently correlated with VFA (β=0.241, 95%CI 0.097-0.384,P<0.01). Compared with control group, UHR in VO group was statistically significantly higher (P<0.01).

There is a positive correlation between UHR and VFA as well as V/S in patients with T2DM, and it has clinical value for early warning of VO in the T2DM.

To investigate the interaction of dyslipidemia and hypertension on glycemic control in patients with type 2 diabetes mellitus (T2DM).

This study was a cross-sectional study. T2DM patients in the "Three-High Co-Management" project survey in Xuzhou City, Jiangsu Province from March to December 2021 were selected as the research participants. Blood pressure, blood lipids [including total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C)], glycated hemoglobin A_1c (HbA_1c) and other indicators were collected. HbA_1c<7.0% was defined as good blood sugar control, otherwise poor blood sugar control. Dyslipidemia was defined as TC≥6.2 mmol/L, or TG≥2.3 mmol/L, or HDL-C<1.0 mmol/L, or LDL-C≥4.1 mmol/L, or self-reported history of dyslipidemia or within the past 2 weeks internal use of lipid-lowering drugs. Hypertension was defined as systolic blood pressure≥140 mmHg (1 mmHg=0.133 kPa) and/or diastolic blood pressure≥90 mmHg, or self-reported history of hypertension and taking antihypertensive drugs within the past 2 weeks. The multivariate analysis of blood sugar control used unconditional logistic regression, and the interaction indicators were calculated by the Excel table prepared by Anderssonet al including relative excess risk of interaction (RERI), attributable proportion of interactin (AP), the synergy index (SI).

A total of 2 485 T2DM patients were included, of which 55.5% (1 379/2 485) had poor blood sugar control, 62.1% (1 544/2 485) had dyslipidemia, and 55.0% (1 367/2 485) had hypertension. Taking patients without hypertension and normal blood lipids as the reference group, the factors without hypertension but with dyslipidemia might affect the blood sugar control of patients (OR=1.275, 95%CI 0.987-1.648, P=0.010). However, patients who had normal blood lipids with hypertension and were able to be affected by the level of glycemic control (OR=1.383, 95%CI 1.054-1.814, P=0.019. When hypertension and dyslipidemia coexisted, the glycemic control of patients was more difficult (OR=2.735, 95%CI 2.117-3.532, P<0.001). The harm of dyslipidemia and hypertension to glycemic control in patients with T2DM was greater than that of the two factors alone. The OR (95%CI) of RERI, AP and SI were 1.077 (0.558-1.595), 0.394 (0.230-0.558) and 2.637 (1.268-5.486), respectively.

There is an additive interaction between dyslipidemia and hypertension on poor glycemic control in patients with T2DM.

To evaluate the cost-utility of insulin degludec (IDeg) versus insulin glargine U100 (IGlar U100) and insulin glargine U300 (IGlar U300) in Chinese patients with type 2 diabetes.

From the perspective of health system, based on the IQVIA CORE diabetes model, the long-term medical costs and health outcomes of treatment with IDeg, IGlar U100 and IGlar U300 were calculated and an incremental cost-effectiveness analysis was performed. Health outcomes included life years and quality adjusted life year (QALY), and medical costs included drug cost, disease management cost and complication treatment cost. The price of insulin adopted the price of national volume-based procurement. The simulation model runs for 30 years at a discount rate of 5%. The robustness of the results was evaluated by one-way sensitivity analysis and probabilistic sensitivity analysis.

Compared with the IGlar U100 group, the quality of life in IDeg group was gained by 0.060 QALY, the direct medical cost was increased by RMB 158 Yuan, and the ICER was RMB 2 639 Yuan/QALY. Compared with the IGlar U300 group, the quality of life in IDeg group was gained by 0.085 QALY, the direct medical cost was reduced by RMB 1 402 Yuan. Sensitivity analysis verified the robustness of the results.

Compared with IGlar U100 and IGlar U300, IDeg was likely to be a cost-effective treatment in Chinese patients with type 2 diabetes mellitus.

This paper reports the clinical diagnosis and treatment of rhabdomyolysis (RM) caused by diabetic ketoacidosis (DKA) combined with hyperosmolar hyperglycemia (HHS), and discusses the pathogenesis of RM caused by DKA and HHS. The patient had DKA complicated with hyperosmolarity. During the course of the disease, the peak creatine kinase exceeded the upper limit of normal by 300 times, and was accompanied by tawny urine. He was diagnosed with rhabdomyolysis. He was treated with a large amount of fluid rehydration, insulin hypoglycemia, correction of electrolyte disorder, and alkalization of urine. The prognosis was good. By arranging the diagnosis and treatment process of this case, the aim is to improve clinicians' understanding of RM caused by acute complications of diabetes, strengthen the routine screening of muscle enzyme spectrum, avoid misdiagnosis and misdiagnosis, and improve the survival rate of patients.

Alström syndrome (AS) is a rare monogenic genetic syndrome with diabetes mellitus, and esophagogastric variceal bleeding is even rarer in patients with AS. This article reports a case of AS patient with main clinical manifestations of photophobia, poor vision, sensorineural deafness, mental retardation, short stature, early onset obesity, insulin resistance, type 2 diabetes, abnormal liver function and hyperlipidemia.ALMS1There are compound heterozygous variants of c.10825C>T (p.R3609X) and c.11107C>T (p.R3703X). However, only 14 months after diagnosis, the child developed cardiac enlargement, pulmonary hypertension, and esophagogastric variceal rupture and bleeding, and the condition was severe and progressed rapidly. At the same time, this paper also discusses the progress of diagnosis and treatment of AS in combination with the literature, so AS to improve the understanding of endocrinologists on this disease.

Report-Hemoglobin variation allows HbA to be determined by high performance liquid chromatography (HPLC)_1cThe values did not match the blood glucose monitoring results. Proband HbA by HPLC_1cThe value was 5.6%, which was inconsistent with the blood glucose monitoring results, whereas HbA was measured by capillary electrophoresis_1cThe value was 7.8%, which was consistent with the results of blood glucose monitoring. The Hb spectrum obtained by capillary electrophoresis indicated that the proband had abnormal hemoglobin. Sanger method for HbA β-globin (HBB) Gene sequencing, confirming probandsHBBThere is a heterozygous mutation in the gene (HBB: C. 68A>C), supporting the presence of the Hb G-Coushatta variant. Family data showed that the Hb of the proband's younger brother and sister contained the same variant andHBBGene sequence. It is difficult to completely isolate the Hb G-Coushatta variant by HPLC, making HbA_1cValues were inconsistent with blood glucose monitoring results, while the capillary electrophoresis method completely separated the variants and yielded an accurate HbA_1cValue. Clinically, HbA_1cWhen the value is inconsistent with the blood glucose monitoring, different methods should be used to detect HbA, taking into account the possibility of hemoglobinopathy_1cProvide accurate guidance for diabetes diagnosis and condition monitoring.

Diabetic nephropathy is one of the serious diabetic microvascular complications. Ferroptosis is a type of cell death characterized by intracellular iron overload and lipid peroxidation caused by reactive oxygen species accumulation. There is increasing evidence that ferroptosis is involved in the development of various kidney diseases. This article will expound the role and progress of ferroptosis in diabetic nephropathy, explore the important links of ferroptosis, deepen the understanding of diabetic nephropathy, and provide ideas for clinical treatment by using ferroptosis-related regulation.

"Patient-centered" individualized treatment has always been the goal that clinicians relentlessly pursue. The choice of hypoglycemic drugs has already gradually transitioned from a single emphasis on blood sugar control to a new era of individualized treatment with multiple factors such as simultaneous attention to patients' comorbidities. With the advent of new hypoglycemic drugs such as sodium-glucose cotransporter 2 inhibitor (SGLT2i) and the clarification of the evidence and mechanism of their cardiac and kidney benefits, the change of Chinese and foreign diabetes guidelines and the update of treatment concepts have been greatly promoted. The "patient-centered" treatment concept of cardiac and kidney benefits has been further sublimated. This article intends to review the hypoglycemic efficacy, heart and kidney benefits and other related research and medication precautions of the new oral hypoglycemic drug SGLT2i, and explore its current therapeutic status in the guidelines and the possibility of further improvement in the future.

Although hearing loss is one of the complications of diabetes, it attracts less attention in clinical practice. A number of studies have shown that diabetes can lead to hearing loss, and the hearing loss caused by diabetes is mostly progressive mild to moderate sensorineural deafness in both ears, which is mainly related to microvascular disease, neuropathy and mitochondrial damage. It can be detected early by high-frequency audiometry and otoacoustic emission of distortion products, and the hearing loss of diabetic patients can be improved by dietary adjustment and the use of drugs such as improving inner ear circulation and nourishing nerves. This article reviews the relationship between diabetes and hearing loss and the prevention and treatment of hearing loss caused by diabetes, in order to improve the clinical attention to this disease.

Compared to other diabetic complications, the prevalence of diabetic nephropathy (DKD) has not decreased significantly over the past 30 years. Treatment after focused fibrosis or the appearance of proteinuria cannot reverse DKD, and recognition of its initiation mechanism is more meaningful for the treatment of DKD. Damage to glomerular vascular endothelial cells glycocalyx (GEG) in the context of diabetes is an initial and critical step in causing filtration barrier impairment and can be an important target for preventing or delaying the progression of DKD. It is currently believed that the regulation of glycocalyx (EG) in endothelial cells is mainly determined by the balance between mechanisms promoting glycocalyx synthesis and degradation. The changes in EG caused by diabetes may partly reflect that hyperglycemia directly inhibits the renewal of EG components; The expression of proteolytic enzymes such as matrix metalloproteinase 9, hyaluronidase 1 or heparanase is increased in diabetic patients and can be involved in the degradation of GEG in this pathological environment; The increased expression of pro-angiogenic molecules (including inflammatory mediators and vascular endothelial growth factor) leads to increased activation and permeability of glomerular endothelial cells, and also plays an important role in the regulation of GEG. At present, the prevention and control situation of DKD is still grim. In the future, the treatment of DKD should be advanced to the beginning of diabetes diagnosis, rather than the "end of the crossbow" after proteinuria.

With the transformation of hospital diagnosis and treatment mode, the multidisciplinary integration mode centered on systemic diseases will become an important mode of disease diagnosis and treatment in the future. Perioperative blood glucose management urgently needs to break the single or loose collaborative medical model, and needs a multidisciplinary integration management model such as surgery, endocrinology and nutrition. According to the relevant guidelines and research progress at home and abroad, this paper focuses on the establishment of perioperative blood glucose management team and perioperative blood glucose monitoring scheme (including blood glucose monitoring methods, blood glucose control targets and blood glucose monitoring frequency), and briefly introduces the research progress of emerging blood glucose monitoring technology and monitoring indexes in perioperative blood glucose monitoring. On this basis, the current challenges and future development direction of perioperative blood glucose monitoring were discussed, in order to provide reference and reference for further improvement and perfection of perioperative blood glucose monitoring.