American ssociation ofDiabetes Educators
2003年美国糖尿病协会(ADA)PAD治疗指南
Peripheral Arterial Disease in People With DiabetesA MERICAN D IABETES A SSOCIATIONP eripheral arterial disease(PAD)is a condition characterized by athero-sclerotic occlusive disease of the lower extremities.While PAD is a major risk factor for lower-extremity amputa-tion,it is also accompanied by a high likelihood for symptomatic cardiovas-cular and cerebrovascular disease.Al-though much is known regarding PAD in the general population,the assessment and management of PAD in those with diabetes is less clear and poses some special issues.At present,there are no established guidelines regarding the care of patients with both diabetes and PAD.On the7–8of May2003,a Con-sensus Development Conference was held to review the current knowledge regarding PAD in diabetes.After a series of lectures by experts in thefield of endocrinology,cardiology,vascular surgery,orthopedic surgery,podia-try,and nursing,a vascular medicine panel was asked to answer the following questions:1)What is the epidemiology and im-pact of PAD in people with diabetes?2)Is the biology of PAD different in people with diabetes?3)How is PAD in diabetes best diag-nosed and evaluated?4)What are the appropriate treat-ments for PAD in people with diabetes?1)WHAT IS THEEPIDEMIOLOGY ANDIMPACT OF PERIPHERALARTERIAL DISEASE INPEOPLE WITH DIABETES?PAD is a manifestation of atherosclerosischaracterized by atherosclerotic occlusivedisease of the lower extremities and is amarker for atherothrombotic disease inother vascular beds.PAD affectsϳ12mil-lion people in the U.S.;it is uncertain howmany of those have diabetes.Data fromthe Framingham Heart Study(1)revealedthat20%of symptomatic patients withPAD had diabetes,but this probablygreatly underestimates the prevalence,given that many more people with PADare asymptomatic rather than symptom-atic.As well,it has been reported that ofthose with PAD,over one-half are asymp-tomatic or have atypical symptoms,aboutone-third have claudication,and the re-mainder have more severe forms of thedisease(2).The most common symptom of PADis intermittent claudication,defined aspain,cramping,or aching in the calves,thighs,or buttocks that appears repro-ducibly with walking exercise and isrelieved by rest.More extreme presenta-tions of PAD include rest pain,tissue loss,or gangrene;these limb-threatening man-ifestations of PAD are collectively termedcritical limb ischemia(CLI).PAD is also a major risk factor forlower-extremity amputation,especially inpatients with diabetes.Moreover,even forthe asymptomatic patient,PAD is amarker for systemic vascular disease in-volving coronary,cerebral,and renal ves-sels,leading to an elevated risk of events,such as myocardial infarction(MI),stroke,and death.Diabetes and smoking are the stron-gest risk factors for PAD.Other well-known risk factors are advanced age,hypertension,and hyperlipidemia(3).Potential risk factors for PAD includeelevated levels of C-reactive protein(CRP),fibrinogen,homocysteine,apoli-poprotein B,lipoprotein(a),and plasmaviscosity.An inverse relationship hasbeen suggested between PAD and alcoholconsumption.In people with diabetes,the risk ofPAD is increased by age,duration of dia-betes,and presence of peripheral neurop-athy.African Americans and Hispanicswith diabetes have a higher prevalence ofPAD than non-Hispanic whites,even afteradjustment for other known risk factorsand the excess prevalence of diabetes.It isimportant to note that diabetes is moststrongly associated with femoral-popliteal and tibial(below the knee)PAD,whereas other risk factors(e.g.,smokingand hypertension)are associated withmore proximal disease in the aorto-ilio-femoral vessels.The true prevalence of PAD in peoplewith diabetes has been difficult to deter-mine,as most patients are asymptomatic,many do not report their symptoms,screening modalities have not been uni-formly agreed upon,and pain perceptionmay be blunted by the presence of periph-eral neuropathy.For these reasons,a pa-tient with diabetes and PAD may be morelikely to present with an ischemic ulcer organgrene than a patient without diabetes.While amputation has been used by someas a measure for PAD prevalence,medicalcare and local indications for amputationversus revascularization of the patientwith critical limb ischemia widely vary.The nationwide age-adjusted amputationrate in diabetes isϳ8/1,000patient yearswith a prevalence ofϳ3%.However,re-gional patterns differ—there is nearly a●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●From the American Diabetes Association,Alexandria,Virginia.Address correspondence to Nathaniel Clark,MD,MS,RD,American Diabetes Association,1701N. Beauregard St.,Alexandria,VA22311.E-mail:nclark@.Received and accepted for publication8September2003.This consensus statement has been reviewed and endorsed by the Vascular Disease Foundation.Abbreviations:ABI,ankle-brachial index;CABG,coronary artery bypass graft;CAPRIE,Clopidogrel versus Aspirin in Patients At Risk of Ischemic Events;CLI,critical limb ischemia;CRP,C-reactive protein; eNOS,endothelial cell nitric oxide synthase;FDA,Food and Drug Administration;FFA,free fatty acid;MI, myocardial infarction;MRA,magnetic resonance angiogram;NF-B,nuclear factor-B;PAD,peripheral arterial disease;PAI-1,plasminogen activator inhibitor-1;PI,phosphatidylinositol;PKC,protein kinase C; PVR,pulse volume recording;RAGE,receptor for advanced glycation end products;UKPDS,U.K.Prospec-tive Diabetes Study;VSMC,vascular smooth muscle cell.A table elsewhere in this issue shows conventional and Syste`me International(SI)units and conversion factors for many substances.©2003by the American Diabetes Association.R e v i e w s/C o m m e n t a r i e s/P o s i t i o n S t a t e m e n t sninefold variation of major amputations in people with diabetes across the U.S. Therefore,the incidence and prevalence of amputation may be an imprecise mea-sure of PAD.The reported prevalence of PAD is also affected by the methods by which the diagnosis is sought.Two commonly used tests are the absence of peripheral pulses and the presence of claudication.Both, however,suffer from insensitivity.A more accurate estimation of the prevalence of PAD in diabetes should rely upon a vali-dated and reproducible test.Such a test is the ankle-brachial index(ABI),which in-volves measuring the systolic blood pres-sures in the ankles(dorsalis pedis and posterior tibial arteries)and arms(bra-chial artery)using a hand-held Doppler and then calculating a ratio.Simple to perform,it is a noninvasive,quantitative measurement of the patency of the lower extremity arterial pared with an assessment of pulses or a medical his-tory,the ABI has been found to be more accurate.It has been validated against an-giographically confirmed disease and found to be95%sensitive and almost 100%specific(4).There are some limita-tions,however,in using the ABI.Calci-fied,poorly compressible vessels in the elderly and some patients with diabetes may artificially elevate values.The ABI may also be falsely negative in symptom-atic patients with moderate aortoiliac ste-noses.These issues complicate the evaluation of an individual patient but are not prevalent enough to detract from the usefulness of the ABI as an effective test to screen for and to diagnose PAD in patients with ing the ABI,one recent survey(5)found a prevalence of PAD in people with diabetesϾ40years of age to be20%,a prevalence greater than antici-pated using less reliable measures,such as symptoms or absent pulses.Moreover, another survey of patients with diabetes Ͼ50years of age showed a prevalence of PAD of29%(6).Thus,the prevalence of PAD in diabetes appears higher than pre-viously estimated.Impact of PADThe impact of PAD can be assessed by its progression,the presence of symptoms, and the excess cardiovascular events asso-ciated with systemic atherosclerosis.Ap-proximately27%of patients with PAD demonstrate progression of symptoms over a5-year period,with limb loss oc-curring inϳ4%.While the majority ofpatients remain stable in their lower-limbsymptomatology,there is a striking excesscardiovascular event rate over the same5-year time period,with20%sustainingnonfatal events(MI and stroke)and a30%mortality rate(7).For those withCLI,the outcomes are worse:30%willhave amputations and20%will diewithin6months(8).The natural historyof PAD in patients with diabetes has notspecifically been studied longitudinally,but it is known from prospective clinicaltrials of risk interventions that the cardio-vascular event rates in patients with PADand diabetes are higher than those of theirnondiabetic counterparts.Diagnosis of PADDiagnosing PAD is of clinical importancefor two reasons.Thefirst is to identify apatient who has a high risk of subsequentMI or stroke regardless of whether symp-toms of PAD are present.The second is toelicit and treat symptoms of PAD,whichmay be associated with functional disabil-ity and limb loss.PAD is often more subtlein its presentation in patients with diabe-tes than in those without diabetes.Incontrast to the focal and proximal athero-sclerotic lesions of PAD found typically inother high-risk patients,in diabetic pa-tients the lesions are more likely to bemore diffuse and distal.Importantly,PADin individuals with diabetes is usually ac-companied by peripheral neuropathywith impaired sensory feedback.Thus,aclassic history of claudication may be lesscommon.However,a patient may elicitmore subtle symptoms,such as leg fatigueand slow walking velocity,and simply at-tribute it to getting older.It has beenreported that patients with PAD and dia-betes experience worse lower-extremityfunction than those with PAD alone(9).Also,diabetic patients who have beenidentified with PAD are more prone to thesudden ischemia of arterial thrombosis(10)or may have a pivotal event leadingto neuroischemic ulceration or infectionthat rapidly results in an acute presenta-tion with critical limb ischemia and risk ofamputation.By identifying a patient withsubclinical disease and instituting preventa-tive measures,it may be possible to avoidacute,limb-threatening ischemia.PAD in diabetes also adversely affectsquality of life,contributing to long-termdisability and functional impairment thatis often severe.Patients with claudicationhave a slower walking speed(generallyϽ2mph)and a limited walking distance.This may result in a“cycle of disability”with progressive deconditioning and lossof function.Finally,there are significanteconomic costs of health care,reducedproductivity,and personal expenses asso-ciated with a chronic manifestation of ath-erosclerotic disease such as PAD.2)IS THE BIOLOGY OF PADDIFFERENT IN PEOPLEWITH DIABETES?Diabetes affects nearly every vascular bed;however,the pervasive influence of dia-betes on the atherothrombotic milieu ofthe peripheral vasculature is unique.Theabnormal metabolic state accompanyingdiabetes results in changes in the state ofarterial structure and function.The onsetof these changes may even predate theclinical diagnosis of diabetes.Relativelylittle is known about the biology of PADin individuals with diabetes in particular.However,it is felt that the atherogenicchanges observed with other manifesta-tions of atherosclerotic disease,such ascoronary and carotid artery disease,aregenerally applicable to patients with bothPAD and diabetes.The proatherogenic changes associ-ated with diabetes include increases invascular inflammation and derangementsin the cellular components of the vascu-lature,as well as alterations in blood cellsand hemostatic factors.These changes areassociated with an increased risk for ac-celerated atherogenesis as well as pooroutcomes.Given the large size of the pe-ripheral vascular bed,the potential im-pact of these abnormalities is great.Diabetes,inflammation,and risk forPADInflammation has been established asboth a risk marker and perhaps a risk fac-tor for atherothrombotic disease states,including PAD(11).Elevated levels ofCRP are strongly associated with the de-velopment of PAD(12).In addition,lev-els of CRP are abnormally elevated inpatients with impaired glucose regulationsyndromes,including impaired glucosetolerance and diabetes.In addition to being a marker of dis-ease presence,elevation of CRP may alsobe a culprit in the causation or exacerba-tion of PAD.CRP has been found to bindto endothelial cell receptors promotingapoptosis and has been shown to colocal-Peripheral arterial disease in people with diabetesize with oxidized LDL in atherosclerotic plaques.CRP also stimulates endothelial production of procoagulant tissue factor, leukocyte adhesion molecules,and che-motactic substances and inhibits endo-thelial cell nitric oxide(NO)synthase (eNOS),resulting in abnormalities in the regulation of vascular tone.Finally,CRP may increase the local production of com-pounds impairingfibrinolysis,such as plasminogen activator inhibitor(PAI)-1.Diabetes and endothelial cell dysfunctionThe endothelial cell lining of the arterial vasculature is a biologically active organ. It modulates the relationship between the cellular elements of the blood and the vas-cular wall,mediating the normal balance between thrombosis andfibrinolysis,and plays an integral role in leukocyte/cell wall interactions.Abnormalities of endo-thelial function can render the arterial system susceptible to atherosclerosis and its associated adverse outcomes.Most patients with diabetes,including those with PAD,demonstrate abnormalities of endothelial function and vascular regula-tion(13).The mediators of endothelial cell dysfunction in diabetes are numerous,but an importantfinal common pathway is de-rangement of NO bioavailability.NO is a potent stimulus for vasodilatation and lim-its inflammation via its modulation of leu-kocyte-vascular wall interaction. Furthermore,NO inhibits vascular smooth muscle cell(VSMC)migration and prolifer-ation and limits platelet activation.There-fore,the loss of normal NO homeostasis can result in a cascade of events in the vascula-ture leading to atherosclerosis and its con-sequent complications.Several mechanisms contribute to the loss of NO homeostasis,including hyper-glycemia,insulin resistance,and free fatty acid(FFA)production.Hyperglycemia blocks the function of endothelial eNOS and boosts the production of reactive ox-ygen species,which impairs the vasodila-tor homeostasis fostered by endothelium. This oxidative stress is amplified because, in endothelial cells,glucose transport is not downregulated by hyperglycemia.In addition to hyperglycemia,insulin resistance plays a role in the loss of normal NO homeostasis(14).One consequence of insulin resistance is excess liberation of FFAs.FFAs may have numerous deleteri-ous effects on normal vascular homeostasis, including activation of protein kinase C (PKC),inhibition of phosphatidylinositol(PI)-3kinase(an eNOS agonist pathway),and production of reactive oxygen species.The sum effect of all these leads to the loss ofNO homeostasis.The effects of endothelial cell dys-function,along with activation of the re-ceptor for advanced glycation endproducts(RAGE),increase the local in-flammatory state of the vascular wall,me-diated in part by increased production ofthe transcription factors,nuclear fac-tor-B(NF-B),and activator protein1.Local increases in these proinflammatoryfactors,together with the loss of normalNO function is associated with increasedleukocyte chemotaxis,adhesion,transmi-gration,and transformation into foamcells.This latter process is further aug-mented by increased local oxidative stress(15).Foam cell transformation is the ear-liest precursor of atheroma formation.Diabetes and the VSMCThe presence of diabetes is also associatedwith significant abnormalities in VSMCfunction.Diabetes stimulates pro-atherogenic activity in VSMC via mecha-nisms similar to that in endothelial cells,including reductions in PI-3kinase,as wellas local increases in oxidative stress and up-regulation of PKC,RAGE,and NF-B.Thesum total of these changes might be ex-pected to promote the formation of athero-sclerotic lesions.These effects may alsoincrease VSMC apoptosis and tissue factorproduction,while reducing de novo syn-thesis of plaque stabilizing compounds,such as collagen.Thus,the above events ac-celerate atherosclerosis and are also associ-ated with plaque destabilization andprecipitation of clinical events(16).Diabetes and the plateletPlatelets play an integral role in the con-nection between vascular function andthrombosis.Abnormalities in platelet bi-ology may not only promote the progres-sion of atherosclerosis,but also influencethe consequence of plaque disruption andatherothrombosis.As in the endothelialcell,platelet uptake of glucose is un-checked in the setting of hyperglycemiaand results in increased oxidative stress.Consequently,platelet aggregation isenhanced in patients with diabetes.Plate-lets in diabetic patients also have in-creased expression of glycoprotein Ib andIIb/IIIa receptors,which are important inthrombosis via their role in adhesion andaggregation.Diabetes,coagulation,and rheologyDiabetes leads to a hypercoagulable state(17).It is associated with the increasedproduction of tissue factor by endothelialcells and VSMCs,as well as increasedplasma concentrations of factor VII.Hy-perglycemia is also associated with a de-creased concentration of antithrombinand protein C,impairedfibrinolytic func-tion,and excess production of PAI-1.Finally,abnormalities in rheology areseen in diabetic patients as an elevation inblood viscosity andfibrinogen.Elevatedviscosity andfibrinogen are both correla-tive with abnormalities in ABI among pa-tients with PAD,and elevatedfibrinogen(or its degradation products)has been as-sociated with the development,presence,and complications of PAD.In summary,diabetes increases therisk for atherogenesis via deleterious ef-fects on the vessel wall,as well as effectson blood cells and rheology.The vascularabnormalities leading to atherosclerosisin patients with diabetes may be evidentbefore the diagnosis of diabetes,and theyincrease with duration of diabetes andworsening blood glucose control.Furtherstudies of the diabetes-specific mecha-nisms responsible for the development ofatherosclerosis,as well as the specificpathways responsible for PAD in this pop-ulation,are needed.3)HOW IS PAD INDIABETES BESTDIAGNOSED ANDEVALUATED?Clinical evaluation:history andphysicalThe initial assessment of PAD in patientswith diabetes should begin with a thor-ough medical history and physical exam-ination to help identify those patientswith PAD risk factors,symptoms of clau-dication,rest pain,and/or functional im-pairment.Alternative causes of leg painon exercise are many,including spinalstenosis,and should be excluded.PADpatients present along a spectrum of se-verity ranging from no symptoms,inter-mittent claudication,rest pain,andfinallyto nonhealing wounds and gangrene.A thorough walking history will elicitclassic claudication symptoms and varia-tions thereof.As these symptoms are of-American Diabetes Associationten not reported,patients should be asked specifically about them.Two important components of the physical examination are visual inspection of the foot and pal-pation of peripheral pulses.Dependent rubor,pallor on elevation,absence of hair growth,dystrophic toenails,and cool, dry,fissured skin are signs of vascular in-sufficiency and should be noted.The in-terdigital spaces should be inspected for fissures,ulcerations,and infections(18).Palpation of peripheral pulses should be a routine component of the physical exam and should include assessment of the femoral,popliteal,and pedal vessels. It should be noted that pulse assessment is a learned skill and has a high degree of interobserver variability,with high false-positive and false-negative rates.The dor-salis pedis pulse is reported to be absent in8.1%of healthy individuals,and the posterior tibial pulse is absent in2.0%. Nevertheless,the absence of both pedal pulses,when assessed by a person expe-rienced in this technique,strongly sug-gests the presence of vascular disease.Noninvasive evaluation for PAD:ABI In contrast to the variability of pulse assess-ment and the often nonspecific nature of information obtained via history and other components of the physical exam,the ABI is a reproducible and reasonably accurate, noninvasive measurement for the detection of PAD and the determination of disease se-verity(19).The ABI is defined,as noted pre-viously,as the ratio of the systolic blood pressure in the ankle divided by the systolic blood pressure at the arm.The tools re-quired to perform the ABI measurement in-clude a hand-held5–10MHz Doppler probe and a blood pressure cuff.The ABI is measured by placing the pa-tient in a supine position for5min.Systolic blood pressure is measured in both arms, and the higher value is used as the denom-inator of the ABI.Systolic blood pressure is then measured in the dorsalis pedis and posterior tibial arteries by placing the cuff just above the ankle.The higher value is the numerator of the ABI in each limb.The diagnostic criteria for PAD based on the ABI are interpreted as follows:●Normal if0.91–1.30●Mild obstruction if0.70–0.90●Moderate obstruction if0.40–0.69●Severe obstruction ifϽ0.40●Poorly compressible ifϾ1.30An ABI valueϾ1.3suggests poorly com-pressible arteries at the ankle level due tothe presence of medial arterial calcifica-tion.This renders the diagnosis of PAD byABI alone less reliable.Due to the high estimated prevalence ofPAD in patients with diabetes,a screeningABI should be performed in patientsϾ50years of age who have diabetes.If normal,the test should be repeated every5years.Ascreening ABI should be considered in dia-betic patientsϽ50years of age who haveother PAD risk factors(e.g.,smoking,hy-pertension,hyperlipidemia,or duration ofdiabetesϾ10years).A diagnostic ABIshould be performed in any patient withsymptoms of PAD.It should be noted thatin the evaluation of the individual patientthere may be errors and that the reliability ofany diagnostic test is dependent on the priorprobability of disease(Bayes’Theorem).Vascular lab evaluation:segmentalpressures and pulse volumerecordingsIn the patient with a confirmed diagnosis ofPAD in whom an assessment of the locationand severity is desired,the next step wouldbe a vascular laboratory evaluation for seg-mental pressures and pulse volume record-ings(PVRs).These tests should also beconsidered for patients with poorly com-pressible vessels or those with a normal ABIwhere there is high suspicion of PAD.Seg-mental pressures and PVRs are determinedat the toe,ankle,calf,low thigh,and highthigh.Segmental pressures help with lesionlocalization,while PVRs provide segmentalwaveform analysis,a qualitative assessmentof bloodflow.Treadmill functional testingFor patients with atypical symptoms or anormal ABI with typical symptoms of clau-dication,functional testing with a gradedtreadmill may help with diagnosis.Patientswith claudication will typically exhibit aϾ20-mmHg drop in ankle pressure afterexercise.Treadmill testing may also be usedas an evaluation of treatment efficacy and asan assessment of physical function.Additional evaluationIn patients with possible CLI,furthernoninvasive studies may help with clini-cal decision making regarding revascular-ization.A toe pressureϽ40mmHg or atoe waveformϽ4mm may predict im-paired wound healing and is often used inthe evaluation of ischemic ulcers.Systolictoe pressure is also useful in the evalua-tion of the patient with medial arterial cal-cification,where the ABI is less accurate.Another method of predicting healing isthe measurement of the transcutaneouspartial pressure of oxygen(TcPO2).AvalueϽ30mmHg is associated with poorhealing of wounds or amputations.Anatomic studies:duplexsonography,magnetic resonanceangiogram,and contrastangiographyFor those patients in whom revasculariza-tion is considered and anatomical local-ization of stenoses or occlusions isimportant,an evaluation with a duplexultrasound or a magnetic resonance an-giogram(MRA)may be valuable.Duplexultrasound can directly visualize vesselsand is also useful in the surveillance ofpostprocedure patients for graft or stentpatency.MRA is noninvasive with mini-mal risk of renal insult.It may give imagesthat are comparable with conventional X-ray angiography,especially in occultpedal vessels,and may be used for ana-tomical diagnosis.While MRA is a safe and promising newtechnology,the gold standard for vascularimaging is X-ray angiography,and it is in-dicated primarily for the anatomical evalu-ation of the patient in whom arevascularization procedure is intended.Because it is an invasive test with a small riskof contrast-induced nephrotoxicity,“ex-ploratory”angiography should not be per-formed for diagnosing PAD.For patientswith suspected pedal ischemia,the angiog-raphy should include an aortogram with se-lective unilateral runoff and a magnifiedlateral view of the foot.It should be notedthat the decision to perform an angiogram ismade on a clinical basis and the need forrevascularization,sometimes independentof any prior noninvasive tests.4)WHAT ARE THEAPPROPRIATE MEDICALTREATMENTS FOR PAD INPEOPLE WITH DIABETES?Treatment of systemicatherosclerosis associated with PADMost cardiovascular risk factors for indi-viduals with PAD are similar to those forpeople with diabetes alone.Althoughthere is little prospective data showingthat treating these risk factors will im-prove cardiovascular outcomes in peoplePeripheral arterial disease in people with diabeteswith both PAD and diabetes specifically, consensus strongly supports such inter-ventions,given that both PAD and diabe-tes are associated with significantly increased risks of cardiovascular events. Cigarette smoking.Cigarette smoking is the single most important modifiable risk factor for the development and exac-erbation of PAD.In patients with PAD, tobacco use is associated with increased progression of atherosclerosis as well as increased risk of amputation(20).Thus, tobacco cessation counseling and avoid-ance of all tobacco products is absolutely essential.Glycemic control.Hyperglycemia may be a cardiovascular risk factor in individ-uals with PAD;however,evidence for the benefit of tight glycemic control in ame-liorating PAD is lacking.In the U.K.Pro-spective Diabetes Study(UKPDS), intensive glycemic control reduced diabe-tes-related endpoints and diabetes-related deaths(21).However,it was not associated with a significant reduction in the risk of amputation due to PAD.In fact, the major reduction in adverse end points was due to improved microvascular rather than macrovascular end points.An additional caveat is that,although it is likely that many patients with PAD were included in the UKPDS study,the preva-lence of PAD was not defined,therefore conclusions from this study may not di-rectly relate to patients with diabetes and PAD.Nevertheless,good glycemic con-trol(A1CϽ7.0%)should be a goal of therapy in all patients with PAD and dia-betes in order to prevent microvascular complications.Hypertension.Hypertension is associ-ated with the development of atheroscle-rosis as well as with a two-to threefold increased risk of claudication(22).In the UKPDS,diabetes endpoints and risks of strokes were significantly reduced and risk of MI was nonsignificantly reduced by tight blood pressure control(23).Risk for amputation due to PAD was not re-duced.In general,the effects of treating hypertension on atherosclerotic disease or on cardiovascular events have not been directly evaluated in patients with both PAD and diabetes.Nevertheless,consen-sus still strongly supports aggressive blood pressure control(Ͻ130/80mmHg) in patients with PAD and diabetes in or-der to reduce cardiovascular risk.Results of the Heart Outcomes Pre-vention Evaluation(HOPE)study showed that ramipril,an ACE inhibitor,significantly reduced the rate of cardio-vascular death,MI,and stroke in a broadrange of high-risk patients without hyper-tension(24).Of the9,297patients in thisstudy,4,051had PAD.Patients with PADhad a similar reduction in the cardiovas-cular endpoints when compared withthose without PAD,thus demonstratingthat ramipril was effective in lowering therisk of fatal and nonfatal ischemic eventsamong all patients.Nonetheless,the po-tential benefit of ACE inhibitors has notbeen studied in prospective,randomizedtrials in patients with PAD.Such trials areneeded before making definite treatmentrecommendations regarding the use of anACE inhibitor as a unique pharmacologicagent in the treatment of PAD.Dyslipidemia.Although treating dyslip-idemia decreases cardiovascular morbid-ity and mortality in general,no studieshave directly studied the treatment oflipid disorders in patients with PAD.In ameta-analysis of randomized trials in pa-tients with PAD and dyslipidemia whowere treated by a variety of therapies,Leng et al.(25)reported a nonsignificantreduction in mortality and no change innonfatal cardiovascular events.However,the severity of claudication was reducedby lipid-lowering treatment.Similarly,ina subgroup analysis of the ScandinavianSimvastatin Survival Study(4S),the re-duction in cholesterol level by simvastatinwas associated with a38%reduction inthe risk of new or worsening symptoms ofintermittent claudication(26,27).In theHeart Protection Study,adults with coro-nary disease,other occlusive arterial dis-ease,or diabetes were randomly allocatedto receive simvastatin or placebo(28).Asignificant reduction in coronary deathrate was observed in people with PAD,but the reduction was no greater than theeffect of the drug on other subgroups.Thus,although there are no data showingdirect benefits of treating dyslipidemia inindividuals with both PAD and diabetes,dyslipidemia in diabetic patients shouldbe treated according to published guide-lines,which recommend a target LDLcholesterol levelϽ100mg/dl.Followingthis guideline,it is our belief that lipid-lowering treatment may not only decreasecardiovascular deaths,but may also slowthe progression of PAD in diabetes.Antiplatelet therapy.The AntiplateletTrialists’Collaboration reviewed145ran-domized studies in an effort to evaluatethe efficacy of prolonged treatment withantiplatelet agents(in most cases,aspirin)(29).This meta-analysis combined datafromϾ100,000patients,includingϳ70,000high-risk patients with evi-dence of cardiovascular disease.A27%reduction in odds ratio(OR)in the com-posite primary endpoint(MI,stroke,andvascular death)was found for high-riskpatients compared with control subjects.However,when a subset ofϾ3,000pa-tients with claudication was analyzed,ef-fects of antiplatelet therapy were notsignificant.Thus,the use of aspirin to pre-vent cardiovascular events and death inpatients with PAD is considered equivo-cal;however,aspirin therapy for peoplewith diabetes is recommended(30).The Clopidogrel Versus Aspirin in Pa-tients At Risk of Ischemic Events(CAP-RIE)Study evaluated aspirin versusclopidogrel inϾ19,000patients with re-cent stroke,MI,or stable PAD(31).Thestudy results showed that75mg of clopi-dogrel per day was associated with a rel-ative risk reduction of8.7%comparedwith the benefits of325mg of aspirin perday for a composite endpoint(MI,isch-emic stroke,and vascular death).Morestriking,in a subgroup analysis ofϾ6,000patients with PAD,clopidogrel was asso-ciated with a risk reduction of24%com-pared with aspirin.Clopidogrel wasshown to be as well tolerated as aspirin.Based on these results,clopidogrel wasapproved by the Food and Drug Admin-istration(FDA)for the reduction of isch-emic events in all patients with PAD.Inthe CAPRIE study,about one-third of thepatients in the PAD group had diabetes.In those patients,clopidogrel was also su-perior to aspirin therapy.In summary,patients with diabetesshould be on an antiplatelet agent(e.g.,aspirin or clopidogrel)according to cur-rent guidelines(30).Those with diabetesand PAD may benefit more by takingclopidogrel.Treatment of symptomatic PADMedical therapy for intermittent claudica-tion currently suggests exercise rehabili-tation as the cornerstone therapy,as wellas the potential use of pharmacologicagents.Exercise rehabilitation.Since1966,many randomized controlled trials havedemonstrated the benefit of supervisedexercise training in individuals with PADAmerican Diabetes Association。
美国糖尿病学会(ADA)在亚太区公布治疗指南
美国糖尿病学会(ADA)在亚太区公布治疗指南2007年7月曼谷来自美国糖尿病学会新的临床治疗指南,在世界领先的制药公司赛诺菲-安万特公司自由教育资助的支持下, 首次在亚太地区学术培训研讨会上得到公布。
新的 ADA 治疗指南标志着该学会首次阐明了能帮助医生选择最适合的降低2 型糖尿病患者血糖水平的治疗规范。
一些世界该领域最杰出的医学专家应邀出席。
亚太地区的顶尖医学专家集聚曼谷,参加于7月7日至8日的特别学术会议。
此会议名为“齐心协力抵抗糖尿病”,它标志着亚太区医学专家和美国糖尿病学会(ADA)共同对糖尿病研究所进行的学术交流的一个重要的里程碑。
与会代表将回顾ADA 有关糖尿病筛查和预防的要点,及其在最佳的治疗实践中的地位, 包括近期发表的对 2 型糖尿病人的处理治疗规范。
所有代表将配备学术教育资料, 使他们能将 ADA 的信息带给他们国家的医生。
近些年出现了多种不同的治疗2型糖尿病的药物疗法,ADA的临床治疗要点树立了一个治疗糖尿病的先例,它是通过为医护人员提供一种便利的治疗方案,以帮助确定针对2型糖尿病人的最适合的治疗方法。
与会的 ADA 专家是:• John Buse 博士,医学教授,北卡罗来纳大学内分泌科主任(很快将成为 ADA 主席) • Richard Kahn 博士,美国糖尿病学会科学和医学主管官员• Anne Peters 博士,临床医学教授,洛杉矶-加州大学糖尿病计划负责人• Charles Burant 博士,医学博士、理学博士,来自密歇根大学。
关于美国糖尿病学会( ADA):美国糖尿病学会(ADA)是美国领先的非营利性的卫生组织,提供糖尿病研究、信息和宣传的支持。
它的主旨是预防和治疗糖尿病,并提高所有患糖尿病病人的生活质量。
ADA关于基础胰岛素的治疗指南推荐是对于糖尿病人一系列长期有效的研究为基础的全部的A D A 临床实践要点可以在A D A 网站获得( w w w . d i a b e t e s . o r g :“ 针对医疗专家和科学家”,“临床实践要点”)。
国内外的糖尿病管理
美国糖尿病教育项目认证标准1 美国糖尿病教育项目认证标准1
• 医院提供的书面支持和证明材料
Letter of Support Example
支持材料举例
April 15, 2005 2005年4月15日 American Diabetes Association 美国糖尿病协会 Education Recognition Program 教育项目认证部门 Dear Sir or Madam: 尊敬的先生或女士 The application for Education Recognition for the diabetes self-management program at Loma Linda University Medical Center will be submitted May 1, 2005. I verify that the information contained in the application is correct.罗马琳打大学医 学中心的糖尿病自我管理教育项目申请将于2005年5月1日递交。我证明申请中的 内容属实。 Loma Linda University Medical Center supports the Diabetes Treatment Center. 罗马琳达大学医学中心支持糖尿病治疗中心 Sincerely, Liz Dickinson, RN, MSN Senior Vice President, Patient Care Services 病人医疗质量资深副院长
美国糖尿病教育项目的规范认证
• 认证机构: ADA 认证机构: • 认证要求: 10大标准, 收集6个月资料 认证要求: 10大标准 收集6 大标准, • 认证有效期3年 认证有效期3
儿童青少年1_型糖尿病发病现状及血糖管理进展
儿童青少年1型糖尿病发病现状及血糖管理进展祖丽胡玛尔·日夏提，米热古丽·买买提新疆医科大学第一附属医院儿科，新疆乌鲁木齐830054[摘要]1型糖尿病是严重影响儿童和青少年健康的疾病之一，发病率从世界范围内看呈上升趋势。
儿童和青少年作为特殊群体，其血糖控制与成年人不同，多数1型糖尿病患儿的血糖控制水平不佳，长期血糖控制不佳会导致多种慢性并发症的发生，其在1型糖尿病中的管理面临着挑战。
本文综述了国内外儿童青少年1型糖尿病的发病情况和血糖控制状况，为1型糖尿病患儿的血糖管理提供参考。
[关键词] 1型糖尿病；血糖控制；儿童；青少年[中图分类号] R587.1 [文献标识码] A [文章编号] 1672-4062（2023）06（b）-0194-05 Current Status of Type 1 Diabetes Mellitus in Children and Adolescents and Progress of Blood Glucose ManagementZulihumaer Rixiati , Mireguli MaimaitiDepartment of Pediatrics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Au‐tonomous Region, 830054 China[Abstract] Type 1 diabetes is one of the diseases that seriously affect the health of children and adolescents, and the incidence is on the rise from the world. As a special group, children and adolescents have different glycemic control from adults. Most children with type 1 diabetes have poor glycemic control levels, and poor long-term glycemic con‐trol leads to the development of multiple chronic complications, and their management in type 1 diabetes faces chal‐lenges. This paper reviews the incidence and glycemic control status of type 1 diabetes in children and adolescents at home and abroad, and provides a reference for the glycemic management of children with type 1 diabetes.[Key words] Type 1 diabetes mellitus; Blood glucose control; Children; Adolescents糖尿病是由于胰岛素绝对或相对不足所致的糖、脂肪、蛋白质代谢紊乱症。
中国糖尿病医学营养治疗指南(2010年版)
中国糖尿病医学营养治疗指南(2010)主要缩略语-汉语对照表2中国糖尿病医学营养治疗指南(2010)目录前言 (4)制定2010年中国糖尿病医学营养治疗指南的方法学 (4)一、糖尿病医学营养治疗的循证基础 (6)1.MNT的目标 (6)2.推荐意见 (6)3.证据 (6)二、营养素推荐 (8)1.能量 (8)2.蛋白质 (9)3.脂肪 (10)4.碳水化合物 (12)5.膳食纤维 (14)6.无机盐及微量元素 (15)7.维生素 (17)8.植物化学物 (19)9.甜味剂 (21)10.膳食结构 (22)三、糖尿病并发症的医学营养治疗 (24)1.糖尿病肾病及透析 (24)2.糖尿病视网膜病变 (26)3.糖尿病合并肝功能损害 (26)4.糖尿病合并高血压 (28)5.糖尿病合并神经病变 (29)6.糖尿病合并脂代谢紊乱 (29)7.糖尿病合并高尿酸血症 (30)8.糖尿病合并肥胖 (31)9.应激性高血糖 (32)四、特殊状态下的医学营养治疗 (34)1.儿童糖尿病 (34)2.妊娠期糖尿病 (35)3.患糖尿病的老年人 (36)4.糖尿病前期 (37)5.糖尿病与肠外肠内营养支持 (38)五、医学营养治疗的执行与贯彻 (41)1.营养教育 (41)2.糖尿病医学营养治疗管理 (42)3中国糖尿病医学营养治疗指南(2010)4中国糖尿病医学营养治疗指南(2010)5中国糖尿病医学营养治疗指南(2010)6一、糖尿病医学营养治疗的循证基础医学营养治疗（Medical Nutrition Therapy,MNT ）对预防糖尿病的发生、治疗已发生的糖尿病、预防或至少延缓糖尿病并发症的发生均有非常重要的作用。
同时MNT 也是糖尿病自我教育中一个不可或缺的部分, MNT 应该贯穿于糖尿病预防的所有阶段。
本“指南”总结了糖尿病MNT 近15年的循证依据和干预模式，并参照WHO 的《WHO 指南编写指南》和AGREE 协作网发展的临床指南编写方法学原则，结合中国糖尿病营养治疗共识实践现况，建立“指南”制定的方法学原则。
授权教育在糖尿病健康教育中的研究进展
授权教育借鉴了动机性访谈的技术，动机性访谈［１４１（ｍｏ－ ｔｉｖａｔｉｏｎａｌ ｉｎｔｅｒｖｉｅｗｉｎｇ，ＭＩ）在西方国家已得到比较广泛的应 用，成为行为改变的主要技术之一ｎ５】。开放式提问、反馈式倾 听、及时确认、阶段性小结，以及引导自我动机性陈述是５步 基本教育和咨询技能。动机访谈技术与授权教育有紧密的联 系，能够促进患者对治疗的合作和落实ｍ］。ＭＩ技术与授权教 育的共同特点是合作和授权、支持并尊重患者的自主支持和 自我解决问题的能力，发展行为改变的内在动机【１７］。与传统 的教育方法不同，ＭＩ中出现不依从并不意味着患者反对改 变，相反，它是患者对行为改变持有不同看法的一个信号。倘 若发生不依从，教育者要避免和患者对行为改变进行争论， 合适的教育原则是邀请患者一同探讨新的解决问题的办法。
授权教育的行为改变方法是一个行之有效的体系Ⅲ］，每 一个环节都有体现授权教育策略的互动，如在第１步明确问 题的评估是“仕么是你在管理糖尿病时最困难的事情？”在第 ２步表达感情时讨论“你对糖尿病有什么感受？”在第３、４步设 立目标时提出“你打算怎么做？”让我们一起制订一个计 划。”在第５步评价结果时进行引导：“你是怎么解决遇到的障 碍的？”通过授权教育中的讨论，可以促进患者的思考，明确 在自我管理中存在哪些障碍，从而提高其自我管理糖尿病的 能力‘矧。 ３．３授权教育在团队式教育的应用
糖尿病神经病变甲古胺系列
糖尿病与糖尿病神经病变
Diabetes and Diabetic Neuropathy
1
Contents
主要内容
• • • • • • • •
糖尿病相关的学会组织 糖尿病定义 糖尿病流行病学 糖尿病分类 糖尿病临床表现 糖尿病诊断标准 糖尿病神经病变概述 Neuropathy screening and treatment
糖尿病周围神经病变，远端对称性多神经病变
因诊断标准不同，糖尿病并发神经损害率报道不一。 若以周围 神经传导速度或临床判断，糖尿病性多发性神经病损害几乎可占糖 尿病患者的47%~91%
18
糖尿病性神经病变
(Diabetic Neuropathy, DN) • 糖尿病诊断后的十年内常有明显的临床糖尿病神经病变的 发生，其发生率与病程和检查手段相关
美国糖尿病控制与并发症试验
17
糖尿病性神经病变
(Diabetic Neuropathy, DN) • Diabetic Neuropathy
其病变部位以周围神经为最常见，通常为对称性，下肢较上肢 严重，病情进展缓慢
• DPN(Diabetic Peripheral Neuropathies, Distal Symmetric PolyNeuropathy)
对无症状者应隔日复测
9
Criteria for the diagnosis of diabetes
1999年WHO诊断标准
诊断标准
• 糖尿病前期(Pre-Diabetes)
空腹血糖受损(IFG)
FPG=6.1mmol/L~6.9mmol/L OGTT 2hPG<7.8mmol/L and
微量白蛋白尿与心血管疾病
美国第三次国家健康及营养普查（Third National Health and Nutrition Examination Survey，NHANES Ⅲ）结果显示［2］，在22 244名受试者（有或无糖尿病）中，MA的发生率为7.8%，其中糖尿病患者中，MA的发生率为28.8%，高血压患者中MA的发生率为16%；而无糖尿病、CVD且血清肌酐正常的患者中，MA的发生率为5.1%。Groningen市41 000名居民的一项大型健康调查普查中，MA的整体发生率为7%，其中糖尿病、高血压患者MA的发生率分别为16%、11%，而在无任何MA危险因素的居民中，MA的发生率是6.6%［3］。
4 MA临床意义
4.1 MA是心血管疾病发生及死亡的预测因子 1988年Yudkin等［13］研究表明，微量白蛋白尿的出现增加了冠心病的死亡率（研究中微量白蛋白尿定量为标准定量）。Borch等经过10年（1983～1993）对2085例无冠心病、肾脏疾病、尿路感染及糖尿病的患者的前瞻性研究［14］中发现，微量白蛋白尿独立于其他危险因素（包括超体重的男性，升高的血压，血脂的异常，吸烟，年龄等），与急性心肌梗死，无症状性缺血性心脏病的发生相关。Spyridon等［15］对175例急性心肌梗死患者进行3年前瞻性研究，研究终点为心血管原因死亡或再次因急性冠脉综合征住院。研究发现，微量白蛋白尿是3年期间心血管事件发生率的独立的强预测因子。在一项以社区为基础、非高血压、非糖尿病的中年个体样本研究中［16］，受试者共1 568例，是Framingham研究参与者的后代（平均年龄55岁，其中58%是女性），结果显示：低水平的尿白蛋白排泄率（低于当前微量白蛋白尿的阈值）可预测心血管疾病的发生。
5.2.4 胰岛素增敏剂-噻唑烷二酮 有实验显示［27］：胰岛素增敏剂-噻唑烷二酮可降低2型糖尿病患者MA和血压。考虑与其逆转胰岛素抵抗有关。
2015+ADA／AADE／AND联合声明：2型糖尿病的自我管理教育和支持
Diabetes Self-management Education and Support in Type2 Diabetes:A Joint Position Statement of the American Diabetes Association,the American Association of Diabetes Educators,and the Academy of Nutrition and DieteticsDOI:10.2337/dc15-0730Diabetes is a chronic disease that requires a person with diabetes to make a mul-titude of daily self-management decisions and to perform complex care activities. Diabetes self-management education and support(DSME/S)provides the founda-tion to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes(1–7).Diabetes self-management educa-tion(DSME)is the process of facilitating the knowledge,skill,and ability necessary for diabetes self-care.Diabetes self-management support(DSMS)refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis.(See further definitions in Table1.) Although different members of the health care team and community can contribute to this process,it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type2diabetes receive both DSME and DSMS in a consistent manner.The initial DSME is typically provided by a health professional,whereas ongoing support can be provided by personnel within a practice and a variety of community-based resources. DSME/S programs are designed to address the patient’s health beliefs,cultural needs,current knowledge,physical limitations,emotional concerns,family support,financial status,medical history,health literacy,numeracy,and other factors that influence each person’s ability to meet the challenges of self-management.It is the position of the American Diabetes Association(ADA)that all individuals with diabetes receive DSME/S at diagnosis and as needed thereafter(8).This posi-tion statement focuses on the particular needs of individuals with type2diabetes. The needs will be similar to those of people with other types of diabetes(type1 diabetes,prediabetes,and gestational diabetes mellitus);however,the research and examples referred to in this article focus on type2diabetes.The goals of the position statement are ultimately to improve the patient experience of care and education,to improve the health of individuals and populations,and to reduce diabetes-associated per capita health care costs(9).The use of the diabetes edu-cation algorithm presented in this position statement defines when,what,and how DSME/S should be provided for adults with type2diabetes.BENEFITS ASSOCIATED WITH DSME/SDSME/S has been shown to be cost-effective by reducing hospital admissions and readmissions(10–12),as well as estimated lifetime health care costs related to a lower risk for complications(13).Given that the cost of diabetes in the U.S.in2012 was reported to be$245billion(14),DSME/S offers an opportunity to decrease these costs(11,12).It has been projected that one in three individuals willdevelop 1International Diabetes Center at Park Nicollet, Minneapolis,MN2MedStar Health Research Institute and MedStar Nursing,Hyattsville,MD3ABQ Health Partners,Albuquerque,NM4LifeScan,a Johnson&Johnson Diabetes Solu-tions Company,Dubai,United Arab Emirates5University of Michigan Medical School,Ann Arbor,MI6University of Chicago,Chicago,IL7Joslin Diabetes Center,Boston,MA8School of Medicine,University of Pittsburgh, Pittsburgh,PA9University of Wisconsin–Madison,Madison,WI Corresponding author:Margaret A.Powers, margaret.powers@.The position statement was reviewed and approved by the Professional Practice Committee of the American Diabetes Association,the Profes-sional Practice Committee of the American Asso-ciation of Diabetes Educators,and the House Leadership Team,the Academy Positions Commit-tee,and the Evidence-Based Practice Committee of the Academy of Nutrition and Dietetics.This article is being simultaneously published in Diabetes Care,The Diabetes Educator,and the Journal of the Academy of Nutrition and Dietetics.©2015by the American Diabetes Association, the American Association of Diabetes Educa-tors,and the Academy of Nutrition and Dietet-ics.Readers may use this article as long as the work is properly cited,the use is educational and not for profit,and the work is not altered. Margaret A.Powers,1Joan Bardsley,2 Marjorie Cypress,3Paulina Duker,4 Martha M.Funnell,5Amy Hess Fischl,6 Melinda D.Maryniuk,7Linda Siminerio,8 and Eva Vivian9Diabetes Care1POSITIONtype2diabetes by2050(15).The U.S. health care system will be unable to af-ford the costs of care unless incidence rates and diabetes-related complica-tions are reduced.DSME/S improves hemoglobin A1c (HbA1c)by as much as1%in people with type2diabetes(3,7,16–20).Besides this important reduction,DSME has a positive effect on other clinical,psychoso-cial,and behavioral aspects of diabetes. DSME/S is reported to reduce the onset and/or advancement of diabetes compli-cations(21,22),to improve quality of life (19,23–26)and lifestyle behaviors such as having a more healthful eating pattern and engaging in regular physical activity (27),to enhance self-efficacy and empow-erment(28),to increase healthy coping (29),and to decrease the presence of diabetes-related distress(16,30)and de-pression(31,32).These improvements clearly reaffirm the importance and value-added benefit of DSME.In addition, better outcomes have been shown to be associated with the amount of time spent with a diabetes educator(3,4,7,11).This position statement arms healthcare teams with the information requiredto better understand the educational pro-cess and expectations for DSME andDSMS and their integration into routinecare.The ultimate goal of the process is amore engaged and informed patient(33).It is recommended that all health careproviders and/or systems develop pro-cesses to guarantee that all patients withtype2diabetes receive DSME/S servicesand ensure that adequate resources areavailable in their respective communitiesto support these services.PROVIDING DIABETES EDUCATIONAND SUPPORTHistorically,DSME/S has been providedthrough a formal program where patientsand family members participate in an out-patient service conducted at a hospital/health facility.In keeping with evolvinghealth care delivery systems and in meet-ing the needs of primary care,DSME/S isnow being incorporated into office prac-tices,medical homes,and accountablecare organizations.Receiving DSME/S inalternative and convenient settings,such as community health centers andpharmacies,and through technology-based programs is becoming moreavailable and affords increased access.Regardless of the setting,communi-cating the information and supportingskills that are necessary to promote ef-fective coping and self-managementrequired for day-to-day living with dia-betes necessitate a personalized andcomprehensive approach.Effectivedelivery involves experts in educational,clinical,psychosocial,and behavioraldiabetes care(34,35).Clear communica-tion and effective collaboration amongthe health care team that includes aprovider,an educator,and a personwith diabetes are critical to ensurethat goals are clear,that progress to-ward goals is being made,and that ap-propriate interventions(educational,psychosocial,medical,and/or behav-ioral)are being used.A patient-centeredapproach to DSME/S at diagnosis pro-vides the foundation for current and fu-ture needs.Ongoing DSME/S can help theTable1—Key definitionsDSME(35)c The ongoing process of facilitating the knowledge,skill,and ability necessary for diabetes self-care.c This process incorporates the needs,goals,and life experiences of the person with diabetes or prediabetes and is guided by evidence-basedresearch.c The overall objectives of DSME are to support informed decision making,self-care behaviors,problem solving,and active collaboration withthe health care team and to improve clinical outcomes,health status,and quality of life.Note:CMS uses the term“training”instead of“education”when defining the reimbursable benefit(DSMT);the authors of this position statementuse the term“education”(DSME)as reflected in the National Standards.In the context of this article,the terms have the same meaning.Ongoing DSMS(35)c Activities that assist the person with diabetes in implementing and sustaining the behaviors needed to manage his or her condition on anongoing basis.c The type of support provided can be behavioral,educational,psychosocial,or clinical.Patient-centered care(69)c Providing care that is respectful of and responsive to individual patient preferences,needs,and values and ensuring that patient values guideall clinical decisions.Shared decision makingc Eliciting patient perspectives and priorities and presenting options and information so patients can participate more actively in care.Shareddecision making is a key component of patient-centered care(43,77)and has been shown to improve clinical,psychosocial,and behavioraloutcomes(78).Diabetes-related distress(29,61)c This refers to the negative emotional responses(overwhelmed,hopeless,and helpless)and perceived burden related to diabetes.CDE(79)c A health professional who has completed a minimum number of hours in clinical diabetes practice,passed the Certification Examination forDiabetes Educators(administered by the National Certification Board for Diabetes Educators[NCBDE]),and has responsibilities that includethe direct provision of diabetes education.BC-ADM(80)c A health care professional who has completed a minimum number of hours in advanced diabetes management,holds a graduate degree,passed the BC-ADM certification exam(administered by the AADE),and has responsibilities of an increased complexity of decision makingrelated to diabetes management and education.2Position Statement Diabetes Careperson to overcome barriers and to cope with the ongoing demands in order to fa-cilitate changes during the course of treatment and life transitions. REIMBURSEMENT,NATIONAL STANDARDS,AND REFERRAL Reimbursement for DSME/S is available from the Centers for Medicare and Med-icaid Services(CMS)and many private payers.Additional discipline-specific counseling,such as medical nutrition therapy(MNT)provided by a registered dietitian nutritionist,medication ther-apy management delivered by phar-macists,and psychosocial counseling offered by mental health professionals, is also reimbursed through CMS and/or third-party payers(35,36).In order to be eligible for DSME/S re-imbursement,DSME/S programs must be recognized or accredited by a CMS-designated national accreditation orga-nization(NAO).Current NAOs are the ADA and the American Association of Diabetes Educators(AADE).Both bodies assess the quality of programs using cri-teria established by the National Standards for DSME/S(Table2)(35). Currently,CMS reimburses for10pro-gram hours of initial diabetes education and2hours in each subsequent year.Re-ferrals for DSME/S must be made by a health care provider and include specified indicators,such as diabetes type,treat-ment plan,and reason for referral.Sam-ple referral forms with information needed for reimbursement are availableon the ADA Web site(http://professional/Recognition.aspx?typ515&cid593574)and the AADE Web site(/export/sites/aade/_resources/pdf/general/Diabetes_Services_Order_Form_v4.pdf).According to the National Standardsfor DSME/S,at least one instructor re-sponsible for designing and planningDSME/S must be a nurse,dietitian,phar-macist,or other trained or credentialedhealth professional(a certified diabeteseducator[CDE]or health care profes-sional with Board Certified-AdvancedDiabetes Management[BC-ADM]certi-fication)(Table1)who meets specificcompetency and continuing educationrequirements(35).This person is con-sidered the primary instructor.Otherscan contribute to DSME and providesupport with appropriate training andsupervision.Trained community healthworkers,practice-based care managers,peers,and other support persons(e.g.,family members,social workers,andmental health counselors)have a rolein helping to sustain the benefits gainedfrom DSME(37–41).Such staff/resourcescan be especially helpful in areas withdiverse populations and serve as culturalnavigators in health care systems and asliaisons to the community.As an alternative to a referral to a for-mal DSME/S program,office-based healthcare teams can explore partnerships witheducators within their community or as-sume responsibility for providing and/orcoordinating some or all of the patient’sdiabetes education and support needs.Al-though this approach requires knowledge,time,and resources to effectively provideeducation,it offers a unique opportunityto reach patients at the point of care.Thisposition statement and the NationalStandards for DSME/S are designed toserve as a resource for the health careteam.Although reimbursement for ed-ucation services is somewhat limited,financial benefits can be realizedwhen an office-based program contrib-utes to improved practice processesand patients’achievement of out-comes that can influence mandatedquality measures.DIABETES EDUCATIONALGORITHMThe diabetes education algorithm providesan evidence-based visual depiction of whento identify and refer individuals withtype2diabetes to DSME/S(Figs.1and2)(figures are also available as a slide set at/dsmeslides).The algorithm defines four critical timepoints for delivery and key informationon the self-management skills that are nec-essary at each of these critical periods.The diabetes education algorithm canbe used by health care systems,staff,orteams,as well as individuals with diabe-tes,to guide when and how to refer toand deliver/receive diabetes education.Table2—National Standards for DSME/S:10standards1.Internal structure.The organizational structure or system that supports self-management education;necessary for sustainability and ongoingself-management education and support.2.External input.Ensures that providers of DSME will seek input from external stakeholders and experts to promote program quality.3.Access.A system of assuring periodic reassessment of the population or community receiving self-management education to ensure thatidentified barriers to education are addressed.4.Program coordination.The designation of an individual with responsibility for coordinating all aspects of self-management education(even ifthat person is the solo instructor).5.Instructional staff.Identifies who can participate in the delivery of self-management education,recognizing the unique skill set of all potentialproviders of self-management education.6.Curriculum.A set of written guidelines,including topics,methods,and tools to facilitate education for all people with diabetes;exactly what istaught will be based on patient’s needs,preferences,and readiness.7.Individualization.Instructor(s)will assess the patient to determine an individualized education and support plan focused on behavior change.8.Ongoing support.A follow-up plan for ongoing support will be developed by the patient and instructor;communication among the teamregarding goals,outcomes,and ongoing needs is essential.9.Participant progress.Ongoing measurement of patient self-efficacy and success in self-management and achievement of goals;designed tocontinually assess needed support.10.Quality improvement.Incorporation of systems to continuously look for ways to evaluate DSME/S effectiveness and to identify areas forimprovement.Adapted with permission from Haas et al.(35). Powers and Associates3Guiding Principles and Patient-Centered CareThe algorithm relies on five guiding prin-ciples and represents how DSME/S should be provided through patient engagement,information sharing,psychosocial and be-havioral support,integration with other therapies,and coordinated care (Table 3).Associated with each principle are key el-ements that offer speci fic suggestions re-garding interactions with the patient and topics to address at diabetes-related clin-ical and educational encounters (Table 3).Helping people with diabetes to learn and apply knowledge,skills,and behav-ioral,problem-solving,and coping strategies requires a delicate balance of many factors.There is an interplay between the individual and the context in which he or she lives,such as clinical status,culture,values,family,and social and community environment.The be-haviors involved in DSME/S are dynamic and multidimensional (42).In a patient-centered approach,collaboration and effective communication are considered the route to patient engagement (43–45).This approach includes eliciting emotions,perceptions,and knowledge through ac-tive and re flective listening;asking open-ended questions;exploring the desire to learn or change;and supporting self-ef ficacy (44).Through this approach,patients are better able to explore options,choose their own course of action,and feel empowered to make informed self-management deci-sions (45,46).Table 4provides a list of patient-centered assessment questions that can be used at diagnosis and at other encounters to guide the education and ongoing support process.Critical Times to Provide Diabetes Education and SupportThere are four critical times to assess,pro-vide,and adjust DSME/S (47):1)with a new diagnosis of type 2diabetes,2)annu-ally for health maintenance and preven-tion of complications,3)when new complicating factors in fluence self-management,and 4)when transitions in care occur (Figs.1and 2).Although four distinct time-related opportunities are listed,it is important to recognize that type 2diabetes is a chronic condition and situations can arise at any time that requireadditional attention to self-management needs.Whereas patient ’s needs are con-tinuous (Fig.1),these four critical times demand assessment and,if needed,inten-si fied reeducation and self-management planning and support.TheAADE7Self-CareBehaviorsprovidea framework for identifying topics to include at each time:healthy eating,being active,monitoring,taking medication,problem solving,reducing risks,and healthy coping.The educational content listed in each box in Fig.2is not intended to be all-inclusive,as speci fic needs will depend on the pa-tient.However,these topics can guide the educational assessment and plan.Mas-tery of skills and behaviors takes practice and experience.Often a series of ongoing education and support visits are necessary to provide the time for a patient to practice new skills and behaviors and to form habits that support self-management goals.1.New Diagnosis of DiabetesThe diagnosis of diabetes is often over-whelming (48).The emotional response to the diagnosis can be a signi ficant bar-rier for education andself-management.Figure 1—DSME and DSMS algorithm of care.4Position Statement Diabetes CareEducation at diagnosis should focus on safety concerns (some refer to this as survival-level education)and “what do I need to do once I leave the doctor ’s of fice or hospital.”To begin the process of cop-ing with the diagnosis and incorporating self-management into daily life,a diabe-tes educator or someone on the care team should work closely with the individ-ual and his or her family members to an-swer immediate questions,to address initial concerns,and to provide support and referrals to needed resources.At diagnosis,important messages should be communicated that include acknowl-edgment that all types of diabetes need to be taken seriously,complications are not inevitable,and a range of emotional responses is cators should also emphasize the importance of involving family members and/or signi ficant others and of ongoing education and support.The patient should understand that treat-ment will change over time as type 2diabetes progresses and that changes in therapy do not mean that the patient has failed.Finally,type 2diabetes is largely self-managed and DSME and DSMS involve trial and error.The task of self-management is not easy,yet worth the effort (49).Other diabetes education topics that are typically covered during the visits at the time of diagnosis are treatment targets,psychosocial concerns,behavior change strategies (e.g.,self-directed goal setting),taking medications,purchasing food,plan-ning meals,identifying portion sizes,phys-ical activity,checking blood glucose,and using results for pattern management.At diagnosis of type 2diabetes,educa-tion needs to be tailored to the individual and his or her treatment plan.At a mini-mum,plans for nutrition therapy and physical activity need to be addressed.Based on the patient ’s medication and monitoring recommendations,themes such as hypoglycemia identi fication and treatment,interpreting glucose results,risk reduction,etc.may need to be consid-ered.Patients are supported when person-alized education and self-management plans are developed in collaboration with the patients and their primary care pro-vider.Depending on the quali fications of the diabetes educator or staff member fa-cilitating these steps,additional referrals to a registered dietitian nutritionist for MNT,mental health provider,or other specialist may be needed.Individuals requiring insulin should re-ceive additional education so that the in-sulin regimen can be coordinated with the patient ’s eating pattern and physical activity habits (50,51).Patients present-ing at the time of diagnosis with diabetes-related complications or other health issues may need additional or repriori-tized education to meet speci fic needs.2.Annual Assessment of Education,Nutrition,and Emotional NeedsThe health care team and others can help to promote the adoptionandFigure 2—Content for DSME and DSMS at four critical time points. Powers and Associates 5maintenance of new diabetes manage-ment tasks(52),yet sustaining these be-haviors is frequently difficult.Thus,annual assessments of knowledge,skills,and be-haviors are necessary for those who do meet the goals as well as for those who do not.Annual visits for diabetes educationare recommended to assess all areas ofself-management,to review behaviorchange and coping strategies and problem-solving skills,to identify strengths andchallenges of living with diabetes,and to make adjustments in therapy(35,52).The primary care provider or clin-ical team can conduct this review and referto a DSME/S program as indicated.Morefrequent DSME/S visits may be neededwhen the patient is starting a new diabe-tes medication or experiencing unex-plained hypoglycemia or hyperglycemia,Table3—Guiding principles and key elements of initial and ongoing DSME/S(45,58,81)Engagement.Provide DSME/S and care that reflects person’s life,preferences,priorities,culture,experiences,and capacity.c Solicit and respond to questionsc Focus on decisions,reasons for the decisions,and resultsc Ask about strengths and challengesc Use shared decision making and principles of patient-centered care to guide each visitc Engage the patient in a dialogue about current self-management successes,concerns,and strugglesc Engage the patient in a dialogue about therapy and changes in treatmentc Remain“solution neutral”and support patient identifying solution(s)c Provide support and education to patient’s family and caregiverInformation sharing.Determine what the patient needs to make decisions about daily self-management.c Discuss that DSME/S is an important and essential part of diabetes managementc Describe that DSME/S is needed throughout the life cycle and is on a continuum from prediabetes,newly diagnosed diabetes,healthmaintenance/follow-up,early to late diabetes complications,and transitions in care related to changes in health status and developmental orlife changesc Avoid being didacticc Provide“need-to-know”information and avoid providing the encyclopedia on diabetesc Review that diabetes treatment will change over timec Provide information to the patient using the above engagement key elementsc Take advantage of“teachable moments”to provide information specific to the patient’s care and treatmentc Assess DSME/S patient/family needs for the behavioral and psychosocial aspects of informed decision makingPsychosocial and behavioral support.Address the psychosocial and behavioral aspects of diabetes.c Assess and address emotional and psychosocial concerns,such as diabetes-related distress and depressionc Present that diabetes-related distress and a range of emotions are common and that stress can raise blood glucose and blood pressure levelsc Discuss that diabetes self-management is challenging but worth the effortc Support self-efficacy and self-confidence in self-management decisions and abilitiesc Support action by the patient to identify self-management problems and develop strategies to solve those problems,including self-selectedbehavioral goal settingc Note that it takes about2–8months to change a habit/learn/apply behaviorc Address the whole personc Include family members and/or support system in the educational and ongoing support processc Refer to community,online,and other resourcesIntegration with other therapies.Ensure integration and referrals with and for other therapies.c Ensure access to ongoing MNTc Recommend additional referrals as needed for behavioral therapy,medication management,physical therapy,etc.c Address factors that limit the application of diabetes self-management activitiesc Advocate for easy access to social services programs that address basic life needs andfinancial resourcesc Identify resources and services that support the implementation of therapies in health care and community settingsCoordination of care across specialty care,facility-based care,and community organizations.Ensure collaborative care and coordination withtreatment goals.c Understand primary care provider and specialist’s treatment targetsc Provide overview of DSME/S to referring providersc Follow medication adjustment protocols or make necessary recommendation to primary care providerc Correspond with referring provider about education plan,progress toward treatment goals,and needs to coordinate education and supportfrom entire clinical team;ensure documentation in the health recordc Ensure provision of culturally appropriate carec Use evidence-based decision supportc Use performance data to identify opportunities for improvement6Position Statement Diabetes Caregoals and targets are not being met,clin-ical indicators are worsening,and there is a need to provide preconception plan-ning.Importantly,the educator is charged with communicating the revised plan to the referring provider.Family members are an underutilized resource for ongoing support and often struggle with how to best provide this help(53,54).Including family members in the DSME/S process on at least an annual basis can help to facilitate their positive involvement(55–57).Since the patient has now experienced living with diabetes,it is important to be-gin each maintenance visit by asking the patient about successes he or she has had and any concerns,struggles,and ques-tions.The focus of each session should be on patient decisions and issues d what choices has the patient made,why has the patient made those choices,and if those decisions are helping the patient to attain his or her goals d not on perceived adher-ence to recommendations.Instead,it is important for the patient/family mem-bers to determine their clinical,psychoso-cial,and behavioral goals and to create realistic action plans to achieve those goals.Through shared decision making, the plan is adjusted as needed in collabo-ration with the patient.To help to rein-force plans made at the visit and support ongoing self-management,the patient should be asked at the close of a visit to “teach-back”what was discussed during the session and to identify one specific behavior to target or prioritize(58).3.Diabetes-Related Complications and Other Factors Influencing Self-management The identification of diabetes complica-tions or other patient factors that may influence self-management should be considered a critical indicator for diabe-tes education that requires immediate attention and adequate resources.Dur-ing routine medical care,the provider may identify factors that influence treatment and the associated self-management plan.These factors may include the patient’s ability to manageand cope with diabetes complications,other health conditions,medications,physical limitations,emotional needs,and basic living needs.These factors maybe identified at the initial diabetes encoun-ter or may arise at any time.Such patientfactors influence the clinical,psychosocial,and behavioral aspects of diabetes care.The diagnosis of additional healthconditions and the potential need for ad-ditional medications can complicate self-management for the patient.Diabeteseducation can address the integration ofmultiple medical conditions into overallcare with a focus on maintaining or ap-propriately adjusting medication,eatingplan,and physical activity levels to maxi-mize outcomes and quality of life.In ad-dition to the introduction of new self-careskills,effective coping,defined as a posi-tive attitude toward diabetes and self-management,positive relationships withothers,and quality of life,can be ad-dressed in DSME/S(29).Additional andfocused emotional support may beneeded for anxiety,stress,and diabetes-related distress and/or depression.Diabetes-related health conditions cancause physical limitations,such as visualimpairment,dexterity issues,and physicalactivity restrictions.Diabetes educatorscan help patients to manage limitationsthrough education and various supportresources.For example,educators canhelp patients to access large-print or talk-ing glucose meters that benefit thosewith visual impairments and specializedaids for insulin users that can help thosewith visual and/or dexterity limitations.Psychosocial and emotional factorshave many contributors and includediabetes-related distress,life stresses,anxiety,and depression.In fact,these fac-tors are often considered complicationsof diabetes and result in poorer diabetesoutcomes(59,60).Diabetes-relateddistress(see definition in Table1)isparticularly common,with prevalencerates of18%to35%and an18-monthincidence of38%to48%(61).It has agreater impact on behavioral and meta-bolic outcomes than does depression(61).Diabetes-related distress is responsive tointervention,including DSME/S and fo-cused attention(30).Although theNational Standards for DSME/S includethe development of strategies to ad-dress psychosocial issues and concerns(35),additional mental health resourcesare generally required to address severediabetes-related distress,clinical de-pression,and anxiety.Social factors,including difficulty pay-ing for food,medications,monitoringand other supplies,medical care,hous-ing,or utilities,negatively affect meta-bolic control and increase resource use(62).When basic living needs are notmet,diabetes self-management be-comes increasingly difficult.Basic livingneeds include food security,adequatehousing,safe environment,and accessto medications and health ca-tion staff can address such issues,provide information about availableresources,and collaborate with the pa-tient to create a self-management planthat reflects these challenges.If complicating factors are present dur-ing initial education or a maintenancesession,the DSME/S educators can eitherdirectly address these factors or ar-range for additional resources.How-ever,complicating factors may arise atany time;providers should be preparedto promptly refer patients who developcomplications or other issues for diabe-tes education and ongoing support.4.Transitional Care and Changes in HealthStatusThroughout the life span,changes inage,health status,living situation,orhealth insurance coverage may require areevaluation of the diabetes care goalsand self-management needs.Criticaltransition periods include transitioninginto adulthood,hospitalization,andmoving into an assisted living facility,skilled nursing facility,correctionalfacility,or rehabilitation center.Table4—Sample questions to guide a patient-centered assessment(82)c How is diabetes affecting your daily life and that of your family?c What questions do you have?c What is the hardest part right now about your diabetes,causing you the most concern or most worrisome to you about your diabetes?c How can we best help you?c What is one thing you are doing or can do to better manage your diabetes? Powers and Associates7。
实时荧光定量聚合酶链式反应检测百日咳鲍特菌的效能研究
·2815· E-mail:zgqkyx@ ·论著·实时荧光定量聚合酶链式反应检测百日咳鲍特菌的效能研究王青，刘莹，袁林，孟庆红，姚开虎*【摘要】 背景 百白破疫苗效价不足事件引发公众对百日咳的关注，但目前各种百日咳实验室检测方法均具有一定的局限性，无法满足快速进行病原学诊断的临床需求。
目的 评价一种商品化的实时荧光定量聚合酶链式反应（Q-PCR）试剂盒对百日咳鲍特菌（BP）感染的临床检测效果。
方法 2016年11月—2017年4月在首都医科大学附属北京儿童医院采集无热咳嗽患儿鼻咽拭子302例，以及临床诊断为百日咳患儿鼻咽拭子50例。
采用Q-PCR 与细菌培养方法筛查302例无热咳嗽患儿是否存在BP 感染，并比较两种方法检测50例临床诊断百日咳病例的阳性率，综合评估Q-PCR 的临床应用价值。
结果 302例无热咳嗽患儿中，以细菌培养为金标准时，Q-PCR 检测的灵敏度为78.6%（11/14），特异度为95.8%（276/288），阳性预测值为47.8%（11/23），阴性预测值为98.9%（276/279）。
在50例临床诊断百日咳病例的鼻咽拭子标本中，Q-PCR 检测的阳性率为34.0%（17/50），细菌培养的阳性率为22.0%（11/50），两者比较，差异无统计学意义（χ2=3.125，P =0.077）。
结论 以细菌培养结果为金标准，Q-PCR 筛查百日咳的灵敏度及特异度较高；在为临床诊断百日咳患儿提供病原学证据中，Q-PCR 与细菌培养方法检测阳性率相当。
【关键词】 百日咳；百日咳鲍特菌；实时聚合酶链反应；细菌学技术；灵敏度；特异度【中图分类号】 R 516.6 【文献标识码】 A DOI：10.12114/j.issn.1007-9572.2018.00.443王青，刘莹，袁林，等．实时荧光定量聚合酶链式反应检测百日咳鲍特菌的效能研究［J］．中国全科医学，2019，22（23）：2815-2819．［］WANG Q，LIU Y，YUAN L，et al．Real-time polymerase chain reaction on diagnosis of bordetella pertussis ［J］．Chinese General Practice，2019，22（23）：2815-2819．基金项目：国家自然科学基金资助项目（81371853）；国家科学技术部项目（2013BA109B11）100045北京市，国家儿童医学中心 首都医科大学附属北京儿童医院 北京市儿科研究所 国家呼吸系统疾病临床医学研究中心 教育部儿科重大疾病研究重点实验室 儿童呼吸道感染性疾病研究北京市重点实验室*通信作者：姚开虎，研究员，副教授；E-mail：yaokaihu@［4］张秀梅，陆卫平．2型糖尿病合并非酒精性脂肪肝病患者IGF-1与胰岛素抵抗关系研究［J］．现代生物医学进展，2012，12（10）：1998-2000．DOI：10.13241/ki.pmb.2012.10.027.ZHANG X M，LU W P.Relationship between insulin-like growth factor-1 and insulin resistance in type 2 diabetic patients with nonalcoholic fatty liver disease［J］．Progress in Modern Biomedicine，2012，12（10）：1998-2000．DOI：10.13241/ki.pmb.2012.10.027.［5］World Health Organization.Definition，diagnosis and classification ofdiabetes mellitus.Report of a WHO consulation［R］Geneva：World Health Organization，1999.［6］李丽芳，刘静芹，贾振祥.1194例糖尿病住院患者甲状腺疾病及甲状腺自身抗体患病率分析［J］．中国卫生检验杂志，2012，22（10）：2401-2402.LI L F，LIU J Q，JIA Z X.The prevalence study on thyroid disease and thyroid autoantibody in 1194 diabetes inpatients［J］．Chinese Journal of Health Laboratory Technology，2012，22（10）：2401-2402.［7］American Diabetes Association.Standards of medical care indiabetes—2016 abridged for primary care providers［J］．ClinDiabetes，2016，34（1）：3-21．DOI：10.2337/diaclin.34.1.3.［8］C H A K E R L ，L I G T H A R T S ，K O R E V A A R T I ，e t a l ．Thyroid function and risk of type 2 diabetes：a population-based prospectivecohort study［J］．BMC Med，2016，14（1）：150．DOI：10.1186/s12916-016-0693-4.［9］BARMPARI M E，KOKKOROU M，MICHELI A，et al．Thyroiddysfunction among greek patients with type 1 and type 2 diabetes mellitus as a disregarded comorbidity［J］．J Diabetes Res，2017，2017：6505814．DOI：10.1155/2017-6505814.［10］CHO J H，KIM H J，LEE J H，et al．Poor glycemic control isassociated with the risk of subclinical hypothyroidism in patients with type 2 diabetes mellitus ［J］．Korean J Intern Med，2016，31（4）：703-711．DOI：10.3904/kjim.2015.198.［11］裴薇，刘赫.2型糖尿病与甲状腺疾病［J］．实用糖尿病杂志，2016，12（6）：6-7.PEI W，LIU H.Type 2 diabetes mellitus and thyroid disease［J］．Journal of Practical Diabetology，2016，12（6）：6-7.（收稿日期：2018-08-23；修回日期：2018-12-24）（本文编辑：张晓晓）·2816· E-mail:zgqkyx@百日咳是由百日咳鲍特菌（bordetella pertussis，BP）引起的急性呼吸道感染性疾病，该病具有较强的传染性。
american association of liver study
american association of liver study
美国肝病研究协会（American Association for the Study of Liver Diseases，简称AASLD）成立于1950年，是一个致力于肝病研究和学术交流的国际性学术组织。
该协会由一流的肝病专家创立，目的是将那些愿意在肝病领域做出贡献的科学家联合起来，共同推动肝病的研究和防治工作。
经过几十年的发展，美国肝病研究协会已经成长为有关肝病各个方面研究的国际性的组织。
美国肝病研究协会的主要工作包括：
组织学术会议：该协会每年都会举办各种形式的学术会议，包括年会、研讨会和讲座等，为肝病领域的专家学者提供交流和学习的平台。
发布研究成果：该协会会发布最新的研究成果，包括临床研究、基础研究、流行病学研究等，为肝病的治疗和预防提供科学依据。
推动肝病研究：该协会通过资助和合作等方式，推动肝病领域的研究工作，包括药物研发、临床试验、基础研究等。
提供教育资源：该协会还提供丰富的教育资源，包括教材、培训课程、在线学习等，为专业人士提供学习和进修的机会。
促进国际合作：该协会与世界各地的学术组织、研究机构和政府部门保持密切联系，促进国际间的合作与交流，共同推进全球肝病防治事业的发展。
总之，美国肝病研究协会在肝病领域的研究和防治工作中发挥了重要作用，为全球的肝病防治事业做出了重要贡献。
糖尿病教育计划及方法
糖尿病教育计划及方法Diabetes is a chronic disease that affects millions of people around the world. 糖尿病是一种慢性疾病，影响着全世界数百万人的生活。
It is essential to have proper education and management methods for diabetes to improve the quality of life for those affected. 对于糖尿病患者来说，获得正确的教育和管理方法是至关重要的，可以改善生活质量。
One important aspect of a diabetes education program is to provide information about the disease and its management. 一个糖尿病教育计划的重要方面是提供关于疾病及其管理的信息。
This includes educating individuals about the different types of diabetes, the importance of monitoring blood sugar levels, and the role of a healthy diet and exercise in managing the condition. 这包括教育个人有关不同类型的糖尿病、监测血糖水平的重要性以及健康饮食和锻炼在管理糖尿病中的作用。
Furthermore, a diabetes education program should address the emotional and psychological impact of living with the disease. 此外，糖尿病教育计划应该关注生活在疾病中对情绪和心理的影响。
中国糖尿病医学营养治疗指南2013
热能的分布（%） 碳水化合物 蛋白质 饥饿食疗 20 10 40 20 45 20 <60 12-20
55-60，根据营养 评价和治疗目标 确定 循证医学的引入
脂肪 70 40 35 <30
10-20 10-20
<30， 饱和脂肪酸产热 低于 10% 调整单不饱和脂肪酸 的比例
4
NO！？
代谢调整 营养康复
推荐量
占能比<10% 占能比<7% <300mg/天 占能比<10%
推荐意见
A A
C
D B C
*根据欧洲EASD 2004糖尿病营养管理指南
21
碳水化合物的考虑&血糖指数
• 碳水化合物 的摄入量 • 食物种类 • 淀粉类型 • 烹调方式和 （直链淀粉 时间 和支链淀粉） • 加工程度
量
质
GI =
质
碳水化合物的质和量
控制碳水化合物的摄入量是实现血糖控制的关键，可以通过计算确定或根据
经验估计碳水化合物摄入量。（B）
对健康人群，推荐优先选择蔬菜、水果、全谷类、豆类、乳制品中作为碳水
化合物主要来源，避免摄入添加了脂肪、糖或钠盐食品。（B）
用低GI食物来代替高GI食物，可轻度改善血糖控制（C） 糖尿病患者应该摄入至少和一般人群推荐值等量的纤维素和全谷物。（C） 尽管含蔗糖食物对血糖的影响类似于等热量的其他碳水化合物，但以蔗糖替
代其他碳水化合物可能导致其他营养素摄入不足，因此不推荐这样做。（A）
糖尿病患者和糖尿病高危人群应限制或避免摄入含糖饮料，避免体重增加及
增加心血管疾病风险。（B）
ቤተ መጻሕፍቲ ባይዱ25
与早年相比，中国人群高GI食物摄入量逐年升高