对控制餐后血糖的再认识

对控制餐后血糖的再认识•餐后血糖与糖尿病诊断•餐后血糖与胰岛素抵抗和分泌缺陷•餐后血糖与心血管并发症•餐后血糖与动脉粥样硬化•餐后血糖与强化血糖控制餐后血糖的重要性根据静脉血浆葡萄糖值的初步诊断ADA1997/WHO1999糖尿病及其他类型高血糖诊断的标准糖尿病:空腹或7.0mmol/L(126mg/dl)葡萄糖负荷后2h/或随机11.1mmol/L(200mg/dl)糖耐量低减(IGT):葡萄糖负荷后2h7.8mmol/L(140mg/dl)且11.1mmol/L(200mg/dl)空腹(如果测定)和7.0mmol/L(126mg/dl)空腹血糖受损(IFG):空腹6.1mmol/L(110mg/dl)且7.0mmol/L(126mg/dl)2h(如果测定)7.8mmol/L(140mg/dl)1、ReportoftheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitus.DiabetesCare2001,24(Suppl1):S5-S202、ReportofWHOConsultant.Definition.Diagnosisandclassificationofdiabetesmellitusanditscomplications(Part1).GenevaWHO1999美国糖尿病协会专家委员会对糖尿病分型和诊断标准的报告•餐后血糖11.1mmol/l能够最好地体现微血管并发症发生危险增加的临界值•餐后血糖7.8-11.1mmol/L（IGT）时已经存在大血管病变餐后血糖越高，大血管病变的危险性越高•以餐后血糖11.1mmol/L为标准诊断糖尿病，敏感性更高，漏诊率低餐后血糖与糖尿病诊断－－检测餐后血糖的重要性ReportoftheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitus.DiabetesCare2001,24(Suppl1):S5-S20餐后血糖与糖尿病诊断－－餐后血糖作为诊断标准敏感性更高以ADA1997/WHO1999为标准评估美国40-74岁人群中糖尿病患病率糖尿病患病率%6.344.35024682h-PGFPGReportoftheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitus.DiabetesCare2001,24(Suppl1):S5-S20餐后血糖与糖尿病诊断－－无症状人群中筛查餐后血糖的标准所有年龄超过40岁者均应检测，如果正常3年内应复查一次。有以下特征者检测频率增加，即使年龄小于40岁肥胖糖尿病患者直系亲属生产超重儿或曾被诊断为妊娠糖尿病高血压高脂血症曾检测出IGT或IFGReportoftheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitus.DiabetesCare2001,24(Suppl1):S5-S202型糖尿病胰岛素分泌缺陷胰岛素抵抗餐后高血糖毒性作用糖耐量低减（IGT）餐后高血糖加重胰岛素抵抗和分泌缺陷胰岛细胞内葡萄糖转运体减少胰岛细胞膜K通道异常抑制胰岛素基因表达减少胰岛素的合成加重餐后高血糖（IGT）的重要性及防治陈家伦.中华内分泌代谢杂志.1998;14:327-329研究目的:评估拜唐苹对老年2型糖尿病患者胰岛素分泌和敏感性的作用研究方法：随机、双盲、历时12个月45例2型糖尿病患者，平均年龄69岁随机分为拜唐苹组（n=23）和安慰剂（n=22）MeneillyGS,etal.DiabetesCare2000;23(8):1162-1167拜唐苹对老年糖尿病患者胰岛素敏感性的影响拜唐苹全面降低老年糖尿病患者空腹和餐后血糖MeneillyGS,etal.EffectofAcarboseoninsulinsensitivityinelderlypatientswithdiabetes.DiabetesCare2000;23(8):1162-1167拜唐苹增加胰岛素敏感性、改善胰岛素抵抗MeneillyGS,etal.EffectofAcarboseoninsulinsensitivityinelderlypatientswithdiabetes.DiabetesCare2000;23(8):1162-1167PPbloodglucoselevelisabetterpredictorforthedevelopmentoftype2diabetesthanfastingbloodsugarTelephoneCompanyStudy(1,285individuals)n=25IFGIFGIGT+n=11IGTn=5044.4%Progressionratetotype2diabetesafter11.5years:32.5%9.1%modif.accordingtoVaccaroOetal.,DiabCare1999;22:1490modif.accordingtoTominagaMetal.,DiabCare1999;22:920AnincreaseinfastingbloodsugarisnoriskfactorforCHDFunagataDiabetesStudy(7yearsfollow-up,n=2,651)MortalityduetoCHDorstrokeatincreasedppbloodglucoseatincreasedfastingbloodglucose1.000.980.960.940.920.0*p0.05*p0.050.00.940.950.960.970.980.991.00Years01234567Years01234567NormalglucosetoleranceNormalfastingbloodglucose**********DiabetesDiabetes****Impairedglucosetolerance(2hbloodglucose141-199mg/dL)(2hbloodglucose7.8-11.1mmol/L)Increasedfastingbloodglucose(110-125mg/dL)(6.1-6.9mmol/L)0.850.800.750.70Meanintima-mediathickness(mm)7.0DiabetesHanefeldMetal.,DiabMed2000;17:835-40Notfastingbutpostprandialhyperglycemiaincreasesintima-mediathicknessindiabeticsandindividualswithIGTRIADStudy6.1-7.0IGT6.1NormalFastingbloodglucose(mmol/L)0.901.000.95Bloodglucose2hpp(mmol/L)7.8normal7.8-11.1IGT11.1diabetes****1.51.00.50Intima-mediathickness(mm)n=2,02030-39years40-49years50-59years60-86years2hbloodglucoselevelNormalAnisolatedpp-hyperglycemiaincreasesintima-mediathickness(carotis)inmensignificantlyinallagegroups********Diabetes120-139mg/dL6.7-7.7mmol/L140-200mg/dL7.8-11.1mmol/Lmodif.accordingtoKawamoriR,DiabRes&ClinPract1998;40Suppl:S35modif.accordingtoDonahueRPetal.,Diabetes1987;36:689Anisolatedpp-hyperglycemiaincreasestheriskofcardiacinfarctionanddeathfromcardiovasculardiseasesHonoluluHeartProgram(n=6,394,12yearsfollow-up)Bloodglucosestatus(mean1h-valueaccordingtoOGTT,fastingbloodglucoseinthenormalrange)DeathfromcardiovasculardiseaseDeathfromcardiovasculardiseaseplusnon-fatalcardiacinfarctionsIncidence(rate/1000)1.quintile040-1142.2-6.32.quintile115-1336.4-7.33.quintile134-1567.4-8.64.quintile157-1898.7-10.45.quintile190-53210.5-29.56050403020100PPglucose(mg/dL)PPglucose(mmol/L)血糖水平和心血管事件的关系临床荟萃分析研究目的:评估血糖与心血管疾病危险性的相关性研究方法：荟萃分析20项临床试验囊括95783例患者年龄20-84岁平均随访12.4年CoutinhoM,etal.Therelationshipbetweenglucoseandincidentcardiovascularevents.DiabetesCare.1999;22(2):223-240餐后高血糖是2型糖尿病心血管并发症的独立高危因素空腹血糖6.1mmol/L餐后血糖7.8mmol/L心血管疾病相对危险211.331.58相关性P=0.0006相关性P0.05心血管事件危险性只与餐后血糖高度相关CoutinhoM,etal.Therelationshipbetweenglucoseandincidentcardiovascularevents.DiabetesCare.1999;22(2):223-240餐后高血糖与心血管并发症糖尿病干预研究(DIS)研究目的:评估餐后血糖与心血管并发症的相关性研究方法：德国16家医学中心入选1139例患者(男性635例;女性504例)年龄30-55岁随访11年HanefeldM.etal.Multi-interventiontrialinnewlydiagnosedNIDDM.DiabeticMedicine1991,14:308-317心血管并发症发病率只与餐后血糖高度相关250200150100500******心肌梗塞发病率()死亡率()*p0.05好一般差好一般差千分率空腹血糖餐后血糖HanefeldM.etal.Multi-interventiontrialinnewlydiagnosedNIDDM.DiabeticMedicine1991,14:308-317葡萄糖耐量和死亡率：比较WHO和ADA诊断标准－－DECODE研究研究目的:评估ADA推荐的单纯以空腹血糖为标准对糖尿病的诊断作用研究方法：欧洲13家医学中心入选25,364例患者年龄17-92岁随访10年(中位数7.3年)Glucosetoleranceandmortality:comparisonofWHOandAmericanDiabetesAssociationdiagnosticcriteria.Lancet1999:354:617-621未知糖尿病个体中所有原因死亡率的相对危险(DECODE)调整年龄、中心和性别6.16.1–6.97.011.17.8–11.07.8空腹血糖(mmol/l)2.52.01.51.00.50.0危险率Ad