Metabolic syndrome nursing rounds

The care of this disease has never been a single-indicator competition of "how much to lower blood pressure and how much to control blood sugar." The essence is a long-term care plan tailored based on the patient's occupation, living habits, and psychological acceptance. There is no one-size-fits-all template, and a plan that patients are willing to stick to is truly effective.

For example, Zhang Ge, a 42-year-old freight driver who was admitted last week, had a waist circumference of 102cm, blood pressure of 148/96mmHg, fasting blood sugar of 6.9mmol/L, triglyceride of 3.2mmol/L, and moderate fatty liver. He fully meets the diagnostic criteria of the 2023 Chinese Metabolic Syndrome Prevention and Treatment Guidelines - abdominal obesity is a must-have, and any two of hyperglycemia, hypertension, and dyslipidemia can be diagnosed. He bought anti-hypertensive pills at a drug store before, and only took one when he remembered. When he was running long distances, he stayed up for more than ten hours, munching on braised food with cold beer in the service area, and moving sweet drinks in boxes to the cab. He had previously found abnormalities in physical examinations, and felt that he was young and had no discomfort, so he never took it seriously. This time, he felt dizzy and almost hit the guardrail while carrying goods, and was forced to be hospitalized by his family members.

When it came time to discuss his care plan, Corey's two factions were far apart. The evidence-based team led by the old head nurse directly read the guidelines and said that they must strictly follow the standards: daily salt intake should not exceed 5g, at least 150 minutes of moderate-intensity exercise per week, waist circumference must be reduced to less than 90cm in 3 months, and complete abstinence from added sugar and alcohol. If the indicator cannot be reduced, add medication directly. Xiao Luti, who had just returned from a higher-level hospital for further training, had a completely different idea. He said that it was difficult for Brother Zhang to eat on time even after running a long distance. It was impossible for him to eat low-salt meals every time, and he couldn't spare a whole time for running. With so many hard targets given at the beginning, he would definitely fail in half a month, so why not start first? Change the small things he can do: For example, replace the iced black tea stored in the car with sugar-free sparkling water, walk around the car for an extra 5 minutes every time he stops at the service area to unload, and replace the salty braised food with plain-cut braised food. He will get used to it for half a month, and then add new requirements when he no longer feels the burden.

What’s interesting is that we conducted follow-up data on 120 patients last year. For the group that strictly followed the evidence-based guidelines, the compliance rate at the 3-month follow-up was only 32%. However, for the patients who really gritted their teeth and persevered, the target compliance rate reached 81%.； The group that made slight adjustments had a compliance rate of 67%, but the final compliance rate was only 49%. There is no absolute good or bad between the two ideas, it all depends on the patient's acceptance. I met a 38-year-old primary school Chinese teacher a while ago. She weighed only 51kg and looked very thin. She usually sat in the office all day long to change homework. Her waist circumference was measured at 87cm. She was found to be insulin resistant and had high triglycerides. She was also diagnosed with metabolic syndrome. She herself thought before that "I am not fat, so I can't have this disease." So the first misunderstanding I want to correct during my current ward rounds is that this disease is not exclusive to fat people. Metabolic syndrome is like a tire slowly deflating. You don’t feel anything at first. By the time you feel something is wrong, visceral fat has been accumulated for almost half a year, and the reference value of waist circumference is much higher than weight.

There is still a controversial point in the industry: whether to use weight loss drugs early as an aid. Some experts believe that as long as the BMI exceeds 27 and there is metabolic abnormality, drugs such as GLP-1 receptor agonists can be used as early as possible to quickly help patients lose weight and build confidence in intervention. ； However, some experts believe that lifestyle intervention must be given priority, otherwise it will be very easy to rebound after stopping the medication, and patients will feel that "they can get better without changing their habit of taking medication." The current compromise plan in our department is to give the patient a one-month lifestyle intervention first. If the weight loss is less than 2%, then we will fully communicate the benefits and risks of medication with the patient and let the patient make his own choice. After all, the core of nursing is to respect the patient's autonomy. If you force him to change, he will turn around and secretly break the habit, which is useless.

I have been caring for this type of patients for almost five years. The most regrettable thing is that the patients who think "I'm just a little fat, have a high blood pressure, and don't feel anything, don't need to take care of it." When complications such as myocardial infarction and diabetic nephropathy really occur, it will be too late to intervene. So now I read out the indicators without even coming up for ward rounds. First, I ask a few household questions, asking whether I am tired from work recently and whether the children at home are well-behaved. Then I talk about physical matters, and the patients are willing to tell the truth. Last time, an aunt secretly told me that she ate half a box of the "sugar-free biscuits" her son bought for her a day. When I looked at the ingredient list, although there was no added sucrose, maltodextrin was ranked first, which raises blood sugar faster than white rice. If I were to criticize her for not following the doctor's advice, she would definitely not tell me this.

After today’s ward rounds, I plan to form a small group for Brother Zhang’s patients who are running freight. Every Wednesday when I have a break, I will hold a 10-minute online meeting. I will talk about how to choose meals while driving and how to find time to move around. After all, nursing is not about sitting in the hospital and giving medical orders. It has to follow the patient’s life scenes to be useful. During the next ward round, we will take out the follow-up data of several patients who took weight loss drugs to see which plan is suitable for more people.