Metabolic syndrome nursing issues

The core contradictions in metabolic syndrome care are essentially "the gap in the adaptability of standardized clinical intervention paths to patients' individual life scenarios and physical tolerance", and "the balance problem in which multiple metabolic abnormalities are superimposed, and a single care goal can easily cause fluctuations in other metabolic indicators" - this is the core issue that our chronic disease care team has summarized after more than 5 years of research and follow-up of nearly a thousand patients.

The 42-year-old middle-level Internet worker who came for a follow-up visit last week is a typical example. His belly was as protruding as a small rubber ball. When he walked in, he was holding half a cup of iced Americano with thick syrup in his hand. He was diagnosed with metabolic syndrome last year: his fasting blood sugar was 6.7mmol/L, which is prediabetes, his blood pressure has been floating in the hypertension level 1 range of 145/95mmHg all year round, his triglycerides were twice the standard, and his uric acid was always hovering at the critical value. The advice given to him by the community nurse before was to "keep your mouth shut and move your legs." He endured starvation for two weeks, cooked vegetables every time, and lost 6 pounds. As a result, his uric acid soared to 580 μmol/L, and he was limping from a gout attack. When he sat down, the first thing he said was, "I did everything as required, why is it worse?"

In fact, the industry has not completely unified the nursing ideas for this type of patients. One group is the "standard group" that strictly follows the evidence-based guidelines, advocating that all interventions must stick to the guideline threshold: daily salt intake should not exceed 5g, cooking oil should be controlled within 25g, at least 150 minutes of moderate-intensity aerobic exercise per week, and the body fat rate should be reduced to less than 24% for men and less than 28% for women. Adjuvant drugs should be prescribed in a timely manner if medication indications are met, leaving no room for patients to "bargain." The advantage of this idea is that the index improvement is extremely certain. As long as it is strictly implemented, all metabolic indicators can basically return to the safe range within 3 months. However, there is also a problem: our department has previously calculated that less than 30% of patients who strictly follow this standard can persist for more than half a year. Most people either suffer from new problems such as hypoglycemia and elevated uric acid, or they can't resist the desire to eat and give up. After two months, the index rebounds to a higher level than before.

The "scenario adaptation school" that has emerged in the past two years takes the completely opposite path, advocating that instead of sticking to the standard, fine-tuning should be made according to the patient's living habits. For example, if you are a delivery person who works in the field every day, it is impossible to bring your own food every day, so I will teach you how to choose take-out first: avoid braised, sweet and sour, and fried dishes, give priority to stir-fried and steamed dishes, eat only two-thirds of the rice, and choose sugar-free drinks. , don’t ask you to eat boiled vegetables every meal; if you are an office worker who is so tired that you slump on the sofa after work, don’t ask you to run 5 kilometers every day. Start by getting off the bus one stop before get off work and walking for 10 minutes every day, and slowly increase the amount. In the small-scale pilot we conducted last year, nearly 70% of the patients who used this program persisted for more than half a year. However, the shortcomings are also obvious: the speed of improvement in indicators is slow, and many patients have almost no change in weight and blood sugar in the first two months, and it is easy for them to give up immediately because they feel "useless".

The 62-year-old Aunt Zhang who I cared for last year is a beneficiary of the adaption school. Her biggest hobby every day after retirement is to go to the community square to dance square. The exercise plan prescribed by other nurses before was to walk briskly for 40 minutes every day. After walking for a week, she found it too boring. She said, "There is no one to talk to while walking, so it is better to watch TV at home." She refused to move. Later, I changed her exercise plan to square dancing for an hour every day. The only requirement was that she should not stand on the side chatting with her old sisters all the time while dancing, and try to keep up with the whole movement. She was so happy that she told me about the new dance she had learned every time she came for a follow-up visit. After three months of persistence, she lost 8 pounds, her blood pressure and fasting blood sugar were stabilized within the normal range, and her triglycerides also dropped significantly.

Of course, this does not mean that the adaptationists are all right. The issue of low-carb diet adaptation that is the most noisy now is a typical example. Domestic and foreign studies have proven that short-term (within 3 months) low-carbohydrate diet can quickly reduce weight, improve insulin resistance, and has a particularly obvious effect on improving blood sugar and triglycerides. However, there are also 5-year cohort studies showing that patients who adhere to very low-carbohydrate for a long time (a daily carbohydrate intake of less than 100g) will have significantly higher levels of low-density lipoprotein cholesterol, which in turn increases the risk of cardiovascular events. Therefore, we will not casually recommend a low-carb diet plan to patients now. If the patient has particularly high triglycerides and no problem with liver and kidney function, he or she can try to appropriately reduce the intake of refined carbohydrates and replace them with whole grains. However, if the patient has renal insufficiency or has excessive low-density lipoprotein, we generally do not recommend such an extreme diet plan.

To be honest, after doing chronic disease care for so long, I feel that there is really no universal formula for metabolic syndrome care. You can't just apply a set of guidelines to everyone. After all, everyone's tastes, work schedules, work nature, and even social habits are different. If you ask an old man who has eaten heavy food all his life to suddenly eat boiled vegetables without salt and taste, he would rather go hungry than eat it. It is better to let him reduce the daily salt amount from 10g to 7g, and then gradually reduce it, which will make him stick to it for a long time. To put it bluntly, the core of nursing care has never been to forcefully break the patient into a "standard template", but to help him find the most comfortable health state in his original life that he can persist in. This is much more important than lowering the indicators to the normal range in the short term.