高危人群的筛查和2型糖尿病的预防

预防2型糖尿病的初级方案应包括：1)针对社会中高危人群(如IGT患者或肥胖患者)的方案;2)一般人群(如计划增加运动、进行健康饮食的成人或儿童)的方案。一般人群和高危亚组人群相关危险因素目前正在评估，需要进一步研究;高危人群的危险因素主要包括：年龄老化、易感人种、肥胖(特别是腹部肥胖)、静坐生活方式、妊娠糖尿病病史、明确的冠心病、空腹胰岛素水平升高和IGT[138]。糖尿病前期是最重要的2型糖尿病高危人群，全球每年约有1.5%~10%的IGT患者进展为2型糖尿病。

一、糖尿病前期人群的干预和预防2型糖尿病

热量摄入过多和体力活动减少引起的肥胖是2型糖尿病在全世界流行的最重要的因素，大庆市629例非糖尿病人群6年随访发现，在基线血糖正常、血糖水平相似的人群中，BMI>27kg/m2者的2型糖尿病发病率为BMI<24kg/m2者的4倍。肥胖2型糖尿病患者体重减轻10%~20%可显著改善血糖控制和胰岛素抵抗，因此，以健康饮食和增加体力活动为主要内容的生活方式干预将有助于高危人群预防2型糖尿病[139，140]。芬兰DPS研究的结果显示，改变生活方式不仅可以减少发生2型糖尿病的风险，也可以降低血压及血甘油三酯水平，因此也会起到预防心血管疾病的作用。

二、强化生活方式干预预防2型糖尿病

许多研究显示，给予2型糖尿病高危人群(IGT、IFG或IGT+IFG)患者适当干预可显著延迟或预防2型糖尿病的发生。美国预防糖尿病计划(DPP)生活方式干预组推荐，患者摄入脂肪含量<25%的低脂饮食，如果体重减轻未达到标准，则进行热量限制;50%的生活方式干预组患者体重减轻了7%，74%的患者可以坚持每周至少150min中等强度的运动;生活方式干预3年可使IGT进展为2型糖尿病的风险下降58%。中国、日本和芬兰的大规模研究也证实了生活方式干预的有效性。在芬兰的研究中，随访4年生活方式干预组2型糖尿病的发病率为11%，而对照组为23%。因而应建议IGT、IFG患者减轻体重和增加运动，并定期随访以确保患者能坚持下来;进行血糖监测;同时密切关注心血管疾病危险因素(如吸烟、高血压和血脂紊乱等)，并给予适当治疗。具体目标是：1)使BMI达到或接近24，或体重至少减少5%~7%;2)至少减少每日总热量400~500cal;3)饱和脂肪酸摄入占总脂肪酸摄入的30%以下;4)体力活动增加到250~300分钟/周。

三、药物干预预防2型糖尿病

高危人群如IGT患者，仅靠生活方式干预往往不能达到100%预防2型糖尿病发生的目标，因而药物治疗可能会有所帮助。有证据表明二甲双胍、阿卡波糖、罗格列酮和减肥药奥利司他都可以降低糖尿病前期人群2型糖尿病的发生危险性。大力提倡强化生活方式干预，但对于难以进行生活方式治疗或生活方式干预效果不佳的患者，可考虑药物干预。

四、糖尿病前期人群的筛查：

筛查方法：推荐应用OGTT，进行OGTT有困难的情况下可仅监测空腹血糖。但仅监测空腹血糖会有漏诊的可能性。

重点筛查人群为年龄≥45岁者，特别是≥45岁伴超重(BMI≥24)者。若筛查结果正常，3年后重复检查。年龄小于45岁者，如有其他危险因素：肥胖(BMI≥28);2型糖尿病者的一级亲属;高危种族;有巨大儿(出生体重≥4Kg)生产史或妊娠糖尿病史;有高血压(血压≥140/90mmHg);HDL-C≤35mg/dL(0.91mmol/L)及TG≥250mg/dL(2.75mmol/L);有糖耐量受损及(或)空腹血糖受损史亦应进行OGTT筛查;如果筛查结果正常，3年后重复检查(参见“2型糖尿病的一级预防”部分)。

2型糖尿病的三级预防

一、2型糖尿病的一级预防

2型糖尿病的一级预防是预防2型糖尿病的发生，包括在一般人群中宣传2型糖尿病的防治知识，包括2型糖尿病的定义、症状、体征、常见的并发症以及危险因素，提倡健康的行为，如合理饮食、适量运动、戒烟限酒、心理平衡;在重点人群中开展2型糖尿病筛查，一旦发现有糖耐量受损(IGT)或空腹血糖受损(IFG)，应及早实行干预，以降低2型糖尿病的发病率。

二、2型糖尿病的二级预防

2型糖尿病的二级预防，即对已诊断的2型糖尿病患者预防2型糖尿病并发症，主要是慢性并发症。防治2型糖尿病并发症的关键是尽早和尽可能地控制好患者的血糖，纠正血压、血脂紊乱、肥胖和吸烟等导致并发症的危险因素。应对2型糖尿病患者定期进行2型糖尿病并发症以及相关疾病的筛查，并加强相关的治疗措施，以求全面达到治疗目标。

三、2型糖尿病的三级预防

2型糖尿病的三级预防就是减少2型糖尿病并发症的加重和降低残废率和死亡率，改善2型糖尿病患者的生活质量。通过有效的治疗，早期慢性并发症有可能逆转。

糖尿病初诊和随诊简要方案

初诊

1.为确定个体化的治疗目标，初诊时首先应该进行以下体格检查和化验检查

(1)体格检查：身高、体重、体重指数(BMI)、腰围、血压和足背动脉搏动。

(2)化验检查：空腹血糖、餐后血糖、HbA1c、甘油三酯、总胆固醇、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、尿常规、肝功能和肾功能。

(3)特殊检查：眼底检查、心电图和神经病变相关检查。若条件允许，应检测尿微量白蛋白。

2.制定最初需要达到的目标及应该采取的措施

建议患者进行适当的体力运动，制定饮食方案，减轻体重并要求在规定的时间内达到一定的目标。建议患者戒烟，进行自我血糖监测，并做好纪录。

随诊

查看糖尿病记录手册，分析化验结果包括空腹和餐后血糖、HbA1c、讨论饮食及运动方案的实施情况。确定下一步要达到的目标和下一步的治疗方案。

表16临床监测方案

 

 

附 录

附录1 常用口服降糖药

 

 

附录2 常用胰岛素及其作用特点

 

 

附录3 糖尿病常用降压药

 

 

附录3 糖尿病常用降压药(续)

 

 

附录4 常用调脂药物

 

 

附录5 口服葡萄糖耐量试验(OGTT)方法

1.晨7~9时开始，受试者空腹(8~14小时)后口服溶于300 ml水内的无水葡萄糖粉75 g，(如用1分子水葡萄糖则为82.5 g)。儿童则予每公斤体重1.75 g，总量不超过75 g。糖水在5分钟之内服完。

2.从服糖第一口开始计时，于服糖前和服糖后2小时分别在前臂采血测血糖。

3.试验过程中，受试者不喝茶及咖啡，不吸烟，不做剧烈运动，但也无须绝对卧床。

4.血标本应尽早送检。

5.试验前3天内，每日碳水化合物摄入量不少于150 g。

6.试验前停用可能影响OGTT的药物如避孕药、利尿剂或苯妥英钠等3~7天。

附录6 常用体质指标

BMI(体重指数)= 体重(kg)/ 身高2 (M2)

腰围：肋骨下缘与髂嵴连线中点的腹部周径

臀围：臀部最大周径

腰臀比(WHR)：腰围 / 臀围

附录7 常用化验数据及换算

 

 

附录8 糖尿病的病因分类

 

 

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