Diabetes Care Pathway Chart

The "Diabetes Care Pathway" is essentially an individualized dynamic management tool for different diabetic patients. Its core function is to replace the general "eat less and move more" requirement, break down the sugar control goals into practical and easy-to-adhere daily actions, and ultimately achieve long-term blood sugar stability and reduce the risk of complications. It has never had a unified national standard answer, and all so-called "universal" path tables are not suitable for direct copying.

I have been doing chronic disease management in a community health service center for almost 8 years, and I have at least hundreds of path lists in my hands. No two are exactly the same. Last month I met a 32-year-old type 1 diabetic who works in Internet operations and travels all year round to catch up on projects. On the chart I made for him, I crossed out the requirement of "eating and taking injections at a fixed time" and replaced it with carrying glycemic candy bars with me and calculating the distance in advance before traveling. Adjusting the insulin dose over time and preferring rice bowls with less oil and sauce for takeout are safer than eating salads with uncertain glycemic index. After three months of implementation, his glycemic index dropped from 8.3 to 6.9, which is much more stable than when he followed the standard path.

The path tables on the market now are actually divided into several schools. There is no absolute right or wrong, it just depends on whether it suits your situation. Most of the path tables of endocrinology departments in traditional hospitals are clinically standardized, especially the version for inpatients. From the examination items on the first day of admission, medication adjustment plan to the daily diet calorie ratio and exercise duration, it is all very detailed. This is mainly to avoid omissions in medical care operations and to suppress excessively fluctuating blood sugar in a short period of time. However, it is easy to get into trouble if you copy it directly after discharge—— There was an old man who ate multigrain rice every meal according to the routine when he was hospitalized. After returning home for half a year, he lost 10 pounds due to indigestion and his blood sugar fluctuated. Later I found out that he had stomach problems. The dietary fiber of multigrain grains was too thick to irritate the gastrointestinal tract and disrupted sugar metabolism. After adjusting to 1/3 millet mixed with 2/3 polished rice and adding a boiled egg every day, the index became stable.

The DSME (Diabetes Self-Management Education) school that has become popular in recent years has a much looser path chart, and the core is to follow the patient's living habits. For example, if you like to eat hot pot, you will not be directly added to the "fasting list". You will only be noted to choose a clear soup pot, do not use sesame sauce and sugar for dipping sauce, rinse half a pound of green vegetables before eating meat, and finally eat the staple food. Measure your blood sugar two hours after eating to record the blood sugar level. Next time, you will know how much tripe and potatoes you eat without exceeding the limit. There is also the highly controversial issue of staple food intake. The traditional approach requires refined carbohydrates to account for no more than 40% of total calories, while the low-carb approach recommends reducing it to less than 20%. We generally ask patients to measure their blood sugar after meals for two days before making a determination. Some people eat steamed buns to raise blood sugar slowly, while others eat rice but it is stable. There is no need to impose a uniform ratio.

Don’t think that this list only has dietary and exercise requirements. There is actually a lot of hidden content in it. When the file was first created, the basic evaluation items took up less than half a page: Basic indicators such as glycated hemoglobin, fasting and postprandial blood sugar, pancreatic islet function, liver and kidney function must be included, and whether you have high blood pressure and high blood lipids, whether there are lesions in the fundus, and whether the foot sensation is normal or not, you must also write down whether you have Smoking and drinking habits, whether your family members support your sugar control, and whether you use a blood glucose meter must be clearly marked. We have met elderly people who live alone who do not know how to set reminders on their smartphones, so we print the time to take medicine and measure blood sugar directly on the top of the watch. The words are printed in large letters and can be seen when posted on the refrigerator.

There is also the adjustment link that is most easily overlooked. The path table is not finalized once it is made. For newly diagnosed patients, we require a follow-up visit once every half month. If there is anything that cannot be directly modified, for example, if you are asked to walk for 30 minutes a day and your knees hurt, then you can switch to sitting at home, tiptoeing, and holding a mineral water bottle. A total of 20 minutes of fragmented exercise will do. After blood sugar is stable, you can adjust it every three months. By the way, mark the time for complication screening, fundus examination once a year, foot sensory test every quarter, and liver and kidney function test every six months. These must be written in advance so as not to forget.

Last time, an aunt came to see me with an "Expert Customized Universal Path Table" that she bought online. It was accurate enough to eat 100 grams of spinach and 200 grams of beef every day. I asked her, do you use a food scale for cooking every day? She laughed to herself and said that after two days of working on it, she just threw it away if it was too troublesome. In fact, this table has never been a strict curse for you. It is essentially to help you find a balance between sugar control and daily life.

Every time I make a path chart for a patient, I handwrite a line at the end: If you can't do any of the requirements, come to me at any time to make changes. Don't force yourself to do it, and don't give up secretly. After all, controlling blood sugar is a lifelong matter. You don’t need to pursue perfect blood sugar every time. Only by staying within the target range for a long time and walking comfortably can you go far.