BIOSKY CLUB
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2022

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Experts talk about early prevention of diabetes


Diabetes mellitus is a common endocrine and metabolic disease, which is caused by the absolute or relative lack of insulin in the blood, resulting in hyperglycemia and glucosuria, which in turn causes fat and protein metabolism disorders.

Hello, all Sina netizens!

Moderator: Famous doctors gathered to talk about people's health. Good afternoon, all Sina netizens! Welcome to pay attention to "Famous Doctors", which is jointly broadcasted by Sina Health and Medical Forum. My name is Cui Yinmo. While the program is live, you can also communicate with our experts through our interactive platform. Nowadays, people's lives are generally improving. With the improvement of the quality of life, there is a disease called "silent killer" that has quietly sneaked into our lives, that is, diabetes. Many people with diabetes will feel very tired, and the accompanying immunity will decline. Diseases such as colds, pneumonia, and tuberculosis infections will also easily trouble everyone and be difficult to cure. In this issue, we have specially invited Professor Li Qiang, director of the Department of Endocrinology and Metabolism Department of the Second Affiliated Hospital of Harbin Medical University, to talk to us about the topic of diabetes prevention and treatment. Hello, Professor Li!

Li Qiang: Hello, all netizens.

Moderator: Professor Li, let's take an example. In March 2011, there was a teacher Zhu, who found out that he had diabetes by his own physical examination. He felt that he was not sick, but he didn't take it seriously. He ate and drank as usual until In September of this year, before the examination, he found that his urine was cloudy, foamy and smelly. He found that diabetes had been complicated by kidney disease, so he received intensive treatment in the hospital for a month. The condition was not under control at all. Now facing various treatment methods, Mr. Zhu suddenly felt that he was very troubled and did not know how to choose. Maybe in our lives, many friends around us will have diabetes problems, and we may also encounter problems like Mr. Zhu. Everyone's understanding of diabetes, in fact, most people are still at a superficial level. What exactly is diabetes, please first ask Professor Li to popularize it for us in ordinary simple language.

Li Qiang: In fact, diabetes is not unique in modern times. With the improvement of living standards, many people around me have been infected with diabetes. In fact, this disease existed in ancient times, as early as the fifth and sixth centuries BC. The monk discovered that some people would attract ants when they urinate on the ground. He tasted the urine and found that the urine was sweet. Only then did he discover diabetes. Not only in India, but also in ancient China, there was a book called "The Yellow Emperor's Classic of Internal Medicine", which also recorded a disease of "fat beauty", which belongs to what is now called diabetes. In addition, the unearthed cultural relics from the tombs of the Egyptian pharaohs also recorded the disease of polyuria, which is now called diabetes. This disease has existed since ancient times. What is diabetes? Simply put, it is a group of endocrine and metabolic diseases characterized by chronic hyperglycemia. It is mainly characterized by chronic hyperglycemia, and the increase in blood sugar during this period can be diagnosed as diabetes mellitus. It is a group of metabolic syndromes, including type I type II, a special type of gestational diabetes mellitus, and there are many common syndromes that we call diabetes.

Host: You just said that type I and type II are staged according to the early stage of the disease?

Li Qiang: It is not related to the early stage, but to the pathogenesis. Types and pathogenesis, for example, type I is mainly related to the autoimmune response. Including acute onset, including slow onset. Acute onset, usually what we call insulin-dependent diabetes mellitus, is particularly acute onset, and the same acid virus may appear at the beginning, requiring insulin treatment.

There are also slow-onset diabetes, autoimmune latent diabetes. The onset of the disease is like type II diabetes. It was effective at the beginning of taking medicine, but gradually it became ineffective. We checked the self-glucose and it was positive, and we classified it as slow onset. Type 1 diabetes usually results from an autoimmune reaction.

There is also a type called type II diabetes. Type II diabetes is that its insulin secretion can be reduced, but it is also accompanied by insulin resistance, which means that it is secreted too much and it does not work. Insulin binds to receptors and does not bind , does not work, this type accounts for the vast majority. At present, 90% of the diabetes that most people get is this type of diabetes.

There is also a third type. The third type is usually a special type of diabetes, which is mainly caused by a certain disease and has a definite cause. For example, drugs, long-term use of glucocorticoids may lead to diabetes, or endocrine diseases. For example, people who are very fat and have fingerprints on their stomachs are also prone to diabetes.

For example, exocrine diabetes, after suffering from pancreatitis, such a person is very easy to develop diabetes, and needs an endocrinologist to take a look. There is a specific cause of diabetes.

The fourth type is gestational diabetes. Diabetes that occurs during pregnancy, as long as her blood sugar is higher than normal, we can diagnose it, no matter whether diabetes or diabetes is reduced, as long as the increase in blood sugar during pregnancy, we can call it gestational diabetes.

As you can see, there are four types, type I, type II, special type and gestational diabetes, the most common being type II diabetes.

Moderator: Can you understand that type I is congenital and type II is acquired?

Li Qiang: Generally speaking, the occurrence of diabetes is related to genetic factors and environmental factors, including type II diabetes, which is also related to genetic factors. It’s just that on the basis of genetic background, environmental factors cause the onset of this type of diabetes. Environmental factors especially refer to the changes in our lifestyle, including the increase in the level of calories we eat, and the sedentary lifestyle of inactivity. an important factor in the development of diabetes.

Moderator: I often hear a saying that once you get diabetes, your life expectancy will be reduced by ten years. I don't know if there is any real scientific basis for this sentence. What kind of damage does diabetes do to our body?

Li Qiang: We say that after having diabetes, it will not really affect our life expectancy. That is to say, our life expectancy is not reduced by ten years if we have diabetes. This is wrong. But we have to be careful, and the main purpose is that if you don't take diabetes seriously, like the example you just mentioned, if he is not well treated, he will have a lot of complications, then these complications will If you die, your life will be shortened. Diabetes itself does not reduce our lifespan, but if it is not well treated, it will endanger our lifespan if it develops complications.

Moderator: In the example just now, Mr. Zhu, if he had controlled his diabetes when he discovered it a year ago, might it not have such a big impact on his life?

Li Qiang: You are very right. There was a teacher in our school who discovered diabetes when he was in college and started taking insulin. Now the old man is in his 80s and is very healthy. Diabetes is not terrible, the key lies in timely and correct treatment, you can prolong your life.

Moderator: It is often heard that medicines are poisonous. Many people with diabetes often want to try to be conservative for a while. As long as diabetes is diagnosed, we should take medicine in time and control it. We often hear that we usually say, I am hungry today and my blood sugar is low, I am dizzy and eat a candy to top it, and the low blood sugar will have obvious physical feelings. Does the body feel anything about high blood sugar? Usually we say that blood sugar rises, is it diabetes?

Li Qiang: As I mentioned just now, our diabetes is characterized by chronic hyperglycemia, so this blood sugar will definitely increase after diabetes. Then, after the increase, there will be some clinical manifestations. Usually, if we are very typical diabetes, there will be symptoms of "three more and one less". Polyuria, polydipsia, polyphagia, weight loss, typical patients will be like this. When the blood sugar is very high, the sugar will be excreted through the urine first, the urine volume will increase, and the thirst will be caused after the urine is too much, and the drink will be more. After a lot of sugar is excreted, he will still feel hungry, he will eat more, and as the sugar excretes more, he will tolerate it, and typical patients will have symptoms of three more and one less.

If the blood sugar does not reach a certain value in the early stage of the disease, there may be no symptoms, but only a feeling of fatigue, feeling that there is no energy in the recent period of time, and there may be no symptoms of three more and one less. The final diagnosis of diabetes, we have to rely on laboratory tests, not purely by symptoms.

Moderator: We have these symptoms, we should remind us to see if there is such a possibility of such a recessive disease in our living habits.

Li Qiang: Yes. If a person has symptoms such as polyuria, polydipsia, and polyphagia, I suggest that they should go to the hospital to check their blood sugar immediately to see if the blood sugar exceeds the normal value.

Moderator: As you said, maybe he has metabolized the sugar in his body through urination, so he will have this symptom.

Li Qiang: Yes.

Host: Everyone is concerned about whether diabetes can be cured?

Li Qiang: I asked a very critical question. According to our current understanding of the disease, we have not fully understood the pathogenesis of diabetes. Although we have a lot of knowledge about the pathogenesis, It has now been recognized that on the basis of heredity, due to the role of environmental factors, there are many hormones involved, which causes diabetes. But we haven't found a way to cure it yet. Therefore, I also remind all patients not to listen to some misleading propaganda. Then it will affect your correct treatment.

Moderator: So when you see this so-called propaganda that can cure and cure, there may be problems, and you have to think twice. Does it mean that if I have diabetes, I need to take medication for life?

Li Qiang: After getting diabetes, we say that in most cases, lifelong medication may be required. But in some cases, it may be possible to get rid of the drug. For example, if you are sick, you may find it very early, and you may have a lot of islet cells in your pancreas. In this case, if you go through a short-term intensive insulin treatment, usually we mean two weeks, it is possible to restore your islet function, so that you may not need drug treatment in the future.

Moderator: Many people don’t like it. They say that it’s not a big deal for me to take medicine and injections every day. Can't control diabetes? But what is the principle, can you tell us about it?

Li Qiang: In fact, there are four ways to lose weight. The first is the adjustable gastric bag, the second is the bromine resection, the third is the diversion surgery, and the fourth is the gastric bypass. Intestinal shunt surgery, also known as bypass surgery. Why can these four methods attract everyone's attention and can treat diabetes? Mainly, there are many experiments that have been confirmed, especially famous is an article in the New Medical Journal this year, which compares the treatment of drugs, then brominated gastrectomy, and gastrointestinal bypass surgery. With three methods, he can see after the operation that after the operation, whether it is glycosylated hemoglobin, fasting blood sugar, or body weight, there is a significant reduction after the operation, especially for the group who underwent gastrointestinal bypass surgery, the reduction was even greater. Is this operation completely universal to all our diabetic patients, as a way to treat diabetes? Maybe not yet.

Because you read those articles and their experiments, he still has some requirements for selecting patients. For example, the BMI value he chooses, we call it a body mass index above 35, which is a very fat person. For example, the course of the disease is 5 years, and then the glycated hemoglobin is 7%. You can see that the glycated hemoglobin value is not too severe for the patient, the course of the disease is also relatively short, and the effect of surgery may be better for such people. Some.

If your disease course is particularly long and your blood sugar levels are particularly high, for example, we often see patients with glycated hemoglobin of 9%, 10%, and 11% in outpatient clinics, it may not be suitable. In other words, for people of normal weight like us, if we go for weight loss surgery, the possibility of curing diabetes may be relatively less. So when it comes to this surgery, I suggest that we usually say that in terms of BMI, it should be larger. According to the requirements of the Asia-Pacific Society, it should be at least 30 or more. It may be more appropriate for us to do this weight loss surgery.

Moderator: So maybe if the main cause of diabetes is obesity, he is more suitable for this kind of surgery.

Li Qiang: Yes.

Moderator: You said that these four types of operations are basically the same, but in fact, they all help the person to control this weight by himself?

Li Qiang: Yes. Mainly speaking, the amount of food intake is reduced. After reducing the amount of food intake, some hormones secreted by the gastrointestinal tract will be reduced. For example, the secretion of hormones such as receptors will be reduced, which will affect the metabolism of blood sugar. But I think these surgeries still need some evidence of evidence-based medicine, what is the long-term effect, whether he can get rid of drug treatment for a long time, and whether the other will cause obstacles to the absorption of other substances, we also need to observe.

Moderator: I just mentioned that a certain type of people are particularly prone to diabetes. For example, those who have undergone these operations are relatively obese. In addition to this fat person, who else is particularly prone to diabetes?

Li Qiang: In some cases, the first time he checked his blood sugar in the past, his blood sugar increased. During our physical examination, for example, when the blood sugar exceeded 6 or 6 o'clock, maybe the medical examiner did not remind him, nor did he pay attention. Such people should Note, the first category of people.

The second category of people is over 40 years old, middle-aged and elderly people need to pay attention.

The third type of people we mentioned just now are overweight and obese people. In particular, those with waist circumferences over 90 cm for men and 85 cm for women should be particularly concerned.

The fourth type of people, we say, someone in the family has diabetes. For example, if your parents have diabetes, or if your siblings have diabetes, you may have the same genetic background and have this susceptibility gene. Such people need to pay attention.

The sixth type is a person who gives birth to a fat child. You are also very heavy at birth. Usually we say a child with more than 8 pounds. Chinese tradition says that having a fat boy is especially good, but it's not.

The seventh person with high blood pressure. People with high blood pressure have insulin resistance, especially those with blood pressure above 140/90 mmHg.

The following are people with abnormal blood lipids, people with abnormal cholesterol, whether cholesterol or triglycerides, people with cardiovascular diseases, such as angina pectoris, myocardial infarction, people who have passed the stent, people who do not exercise every day for long periods of time, Such people should be careful.

Then there are medicines. Some people have used certain medicines, such as glucocorticoids. Some people have a cold and fever. It is not advisable to take some prednisone. Such people are very likely to develop diabetes in the future. Therefore, these groups of people I just mentioned should be checked regularly. If the fasting blood sugar exceeds 6, or the blood sugar after meals exceeds 7.8, you should go to the hospital for a diabetes test to confirm whether you have diabetes.

  host

:: After listening to your explanation, I may be over 40 years old, I am relatively obese, and someone in my family has a diabetes gene. I meet a few criteria, should I go to the hospital to check if I have diabetes?

Li Qiang: Normally, if you take part in a physical examination every year, the physical examination items include blood sugar, fasting blood sugar, and blood sugar two hours after meals. I think it is fine. If you do not take part in the physical examination every year, and you have not had your blood sugar checked for many years, and you are still a risk factor, I suggest you go to the hospital for a blood sugar check. Moreover, I suggest that the blood sugar check should not say that the fasting blood sugar is normal, we will be fine, but also check the blood sugar two hours after the meal. is an increase in fasting blood sugar. And don't see the doctor with a report, my fasting blood sugar is normal, I'm OK, no. Be sure to check your blood sugar two hours after eating.

Moderator: Let's see how your metabolism is two hours after a meal. I have these two tests, is it possible to know if I am sick?

Li Qiang: Yes.

Moderator: During the physical examination, we often see many words that we don't quite understand, such as "fasting blood sugar", which may be easier to understand, and what are the words "glucose tolerance", "urine sugar" and "glycated hemoglobin" What exactly does that mean?

Li Qiang: There is no doubt about fasting blood sugar. The normal value of blood sugar measured when we do not eat in the morning is usually less than 6. If it exceeds 6, we should be careful and do a glucose tolerance test. Another thing that a doctor often checks for you is that the blood sugar two hours after a meal is counted from the first bite of the meal and calculated for you two hours later. The normal value is less than 7.8 mmole. Do a glucose tolerance test, draw blood sugar on an empty stomach, drink glucose, and collect blood one or two hours after drinking. If the fasting blood sugar exceeds 11 mmol, and the fasting blood sugar exceeds 11.1 mmol, we can diagnose diabetes. During the physical examination, the blood sugar is higher than that of normal people. Such people, or the ten dangerous situations just mentioned, are suitable for this kind of examination, and it can be judged whether they have diabetes.

The fourth test is what we usually call glycated hemoglobin. The glycated hemoglobin reflects the average blood sugar level of two to three months. As a means of monitoring, I have treated it for a period of time, and the fasting blood sugar is well controlled even after meals. Very good, I have met the standard during this period of time. By measuring this indicator, you can see my average blood sugar level in three months. Usually, we require that it is less than 7 to be considered qualified for your treatment. If it is very high, as just mentioned, 9, 10, and 11 indicate that the control is very poor, and you need to find a doctor to adjust your treatment plan.

There are also doctors who suggest that you check the islet function in the hospital. Islet function usually refers to the insulin release test and the C-peptide excitation test. Drink glucose on an empty stomach, then draw blood. The difference is that it measures insulin and C-peptide, which can reflect islet function. After drinking sugar, the secretion of insulin doubles, reaching 5 or 6 times, indicating that the function is very good. If it is not doubled, it will be doubled, so people need to take insulin, and the front group is treated with oral medicine.

Also, see if there are ketone bodies and protein in the urine. In the example just now, whether Mr. Zhu has diabetic nephropathy, and whether the protein exists at the beginning, these indicators are some routine examinations for diabetes.

Moderator: If protein exists, do you usually see cloudy urine?

Li Qiang: Yes.

Moderator: The fasting blood sugar you just said should be below 7, is it normal?

Li Qiang: If the fasting blood sugar is below 6, if it exceeds 7, diabetes is diagnosed.

Moderator: So between 6 and 7.

Li Qiang: Diabetes experiments should be done.

Netizen: 45 years old, male, the blood sugar was 6.38 in the physical examination in November last year, and the blood sugar was 6.51 in the physical examination on November 1 this year. How to prevent and treat? Do I need to take medicine?

Li Qiang: This netizen should go to the hospital for examination. His blood sugar exceeded the normal value twice, both exceeding the upper limit of 6 we say is normal. We need him to go to the hospital for a glucose tolerance test to see if his fasting blood sugar can exceed 7, and whether his blood sugar can exceed 11.1 after two hours of drinking sugar. If it exceeds, it will be diagnosed as diabetes. If it is not exceeded, his fasting blood sugar is between 6 and 7, and his blood sugar is between 7-11.1 two hours after drinking sugar, he can be diagnosed as impaired glucose tolerance, which also requires intervention, especially lifestyle adjustments.

Netizen: 46 years old, male, blood sugar between 10-12 after meal, 7-9 before meal, a little fat, especially like to eat fat, how to treat and prevent it?

Li Qiang: In terms of his blood sugar, he has reached the diagnostic criteria for diabetes, because his fasting blood sugar is above 7. If the fasting is more than 7, we can diagnose this patient as diabetes. His postprandial blood sugar occasionally reached 12, and his diagnosis was no problem.

A slightly obese person, according to our preliminary judgment, should have type II diabetes. Obese people generally have insulin resistance. For him, he should control his diet first. He said that if he often eats fatty meat, he must change this eating habit. . Second, exercise should be strengthened to reduce the weight. Third, medication. Because he is a little fatter, I suggest that if his liver and kidney functions are normal, he can use biguanide drugs. For specific treatment, insulin experiments and C-peptide experiments can be done to confirm whether the idea just now is correct and decide which drug to use is more appropriate. .

Moderator: There are many kinds of medicines, which should be prescribed according to the type of diabetes.

Li Qiang: Yes.

Netizen: My mother is 54 years old this year. She has been suffering from diabetes for a long time and has not paid attention to it. She went to check it in the past two years. Due to her lack of knowledge, she has never controlled her diet. Now her mother's diabetes level is 1.8 and she is taking insulin. . I want to know if there is any way to save the diabetes, and can my mother's body recover again?

Li Qiang: This netizen also suggested that you can take your mother to the hospital for an insulin test and a glycosylated hemoglobin test, so that you can judge the current level of your mother's islet function.

If after drinking sugar, the secretion of insulin is very large, it can be changed to oral medication. If you drink sugar, you should do a diabetes test to determine whether he is diabetic or not.

Moderator: So the control at this time may be more important than any of the other several forms of diabetes.

Li Qiang: Yes.

Moderator: Can we say that if the child is a huge child, he may have a much higher chance of developing this type of diabetes than ordinary children?

Li Qiang: Yes. Just now we talked about the risk groups of diabetes. We have already mentioned that if the birth weight is more than 8 pounds, both the child and his mother are a dangerous group. should focus on monitoring.

Moderator: So we actually often talk about giving pregnant women more care, and often let her eat this and that. I suddenly found that the diet really needs a balanced state. Maybe too much nutrition is not a good thing, maybe there is diabetes. The hidden danger is. And we just saw that many netizens are asking this question, they are asking themselves whether they can diagnose diabetes and how to treat it. At present, we have several treatment methods for diabetes?

Li Qiang: There are actually three types of methods for diabetes, the first is the adjustment of lifestyle. Such as diet control, exercise, this is the most basic. If your total calories are not well controlled by diet, then weight gain will cause obesity, which is not conducive to the control of the disease. The second is to strengthen exercise, exercise will increase insulin sensitivity and reduce weight. The control of the disease is very beneficial. This is the first one we talk about, that is, lifestyle changes.

Moderator: We often say keep your mouth shut and open your legs.

Li Qiang: Yes. The second is oral drugs that increase insulin secretion, sulfonylureas, non-sulfonylurea secretagogues, metformin including non-insulin injectable GRPY, incretin hormones, these are the second class of drugs. The third category is insulin, which includes fast-acting insulin, intermediate-acting insulin, long-acting insulin analogs, and premixed insulin. These three types of drugs constitute the main weapons for the treatment of diabetes.

Moderator: We sometimes feel that diabetes is not a serious problem as long as it is well controlled, as you said, but we are particularly worried about complications caused by diabetes. How can we prevent complications in general?

Li Qiang: In fact, the occurrence of complications is related to the level of our diabetes control. There are many studies that have confirmed that if your glycated hemoglobin is above 6.5, the risk of all complications is increased. So in this sense, for our diabetic patients, the first goal is to control blood sugar. Usually we say fasting blood sugar is 3.9-7.2, and blood sugar after meal is less than 10 two hours after meal. , glycated hemoglobin is less than 7. This is the first blood sugar target.

The second target is blood pressure, which should be controlled at 130/80 mmHg. This is the second goal.

The third target we usually talk about is blood lipids. The primary target of blood lipids is the low-density lipoprotein cholesterol level, and the low-density lipoprotein cholesterol level is less than 1.8 if there is coronary heart disease, and less than 2.6 if there is no coronary heart disease. We require less than 1.7 for triglycerides other than LDL cholesterol. This is the third category of target lipids.

The fourth category of goals we say is weight. Calculated using the BMI, the BMI should be less than 24. This body mass index is calculated by dividing your weight by the square of your height. Generally speaking, it is a simpler method. We can also calculate it by subtracting 105 from your height, or you can get an approximate standard weight. This is the fourth.

The fifth indicator is the excretion rate of urinary protein. The excretion rate of urinary protein is the ratio of urinary protein, albumin and creatinine, which is less than 1.5 for men and less than 2.5 for women. These indicators are controlled in place, and diabetes is far from complications. But I have taken medicine for diabetes and no matter the control indicators, you may be very close to complications, so for diabetes, one of the keys to preventing complications is to meet the standard of treatment, so it is not only the blood sugar that meets the standard, including blood pressure, blood lipids, Body mass index, including microalbumin in urine, should be on target so that we can avoid complications.

Moderator: I just heard that there are so many indicators, including blood sugar and blood lipids. Many indicators say that I should be less than how much. Many patients have a misunderstanding. Is the smaller the better. They control their weight too much, keep their mouth shut and eat less, stretch their legs and increase the amount of exercise every day. In order to lower their blood sugar, they sometimes become hypoglycemic. If hypoglycemia occurs, will it be harmful to our body?

Li Qiang: Yes. After hypoglycemia, it actually has a very important impact on the activity of brain cells. Very severe hypoglycemia can cause a person to lose consciousness and be life-threatening. Therefore, for diabetic patients, blood sugar should not be overcorrected or cause hypoglycemia. It must be within a suitable range. As mentioned earlier, this range is between 3.9 and 7.2, and cannot be lower than 3.9.

Under what circumstances would cause his hypoglycemia? For example, as you just said, this person stops eating, especially if the staple food is not eaten, it is prone to hypoglycemia. In the second case, I took too much medicine. The doctor ordered me to take one tablet at a time. He said that my blood sugar was high. I took two and three tablets at a time, which resulted in an increase in the effect of the drug. Even some people’s insulin did not follow the doctor’s advice. Increasing the amount may cause hypoglycemia.

The third case has a large amount of activity. Doctors generally instruct him to exercise for half an hour, and he may go out to exercise for two or even three hours, which is particularly likely to cause hypoglycemia. So these are the situations that we should avoid.

Once hypoglycemia occurs, it should be treated in time. First of all, if you feel uncomfortable, check your blood sugar immediately to see if it is low blood sugar. Second, if it is a relatively mild hypoglycemia, it can be improved by eating, such as eating cookies and chocolate candies, and it can be improved. Very severe hypoglycemia, must go to the hospital, by the doctor to deal with.

Moderator: We often find that diabetic patients have to keep their mouths shut and always have some snacks in their bags, which may be to prevent the occurrence of hypoglycemia. Is it necessary to prepare snacks? What kind of snacks do we suggest they should bring?

Li Qiang: Generally speaking, there may be some biscuits or candies in the bag. For mild hypoglycemia, such as hypoglycemia with blood sugar between 3-4, we can let the patient eat something first, which can relieve his symptoms very well, especially severe hypoglycemia, for example, we often If you encounter a few points of low blood sugar, you must be sent to the hospital, so that eating will not increase much.

Exclusive advice in this issue

The occurrence of complications is related to the level of diabetes control. Studies have confirmed that if the glycated hemoglobin is above 6.5, the risk of all complications increases.

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