ADA糖尿病诊疗标准执行纲要中英文对照.doc

2011年ADA糖尿病诊疗标准执行纲要美国糖尿病协会王新军 于文 译滨州医学院附属滨州市人民医院内分泌科，滨州，256610目前糖尿病的诊断标准l A1C6.5%。试验应该用美国糖化血红蛋白标准化计划组织（National Glycohemoglobin Standardization Program，NGSP）认证的方法进行。并与（Diabetes Control and Complications Trial，DCCT）的检测进行标化l 空腹血糖（FPG）7.0 mmol/L。空腹的定义是至少8小时未摄入热量，或l OGTT 2h血糖11.1 mmol/L。试验应按照世界卫生组织（WHO）的标准进行，用75 g无水葡萄糖溶于水作为糖负荷l 有高血糖的典型症状或高血糖危象，随机血糖11.1 mmol/Ll 如无明确的高血糖症状，结果应重复检测确认。Current criteria for the diagnosis ofdiabetes A1C6.5%. The test should be per-formed in a laboratory using a methodthatisNationalGlycohemoglobinStan-dardization Program (NGSP)-certifiedand standardized to the Diabetes Con-trol and Complications Trial (DCCT)assay fasting plasma glucose (FPG)126mg/dl (7.0 mmol/l). Fasting is definedas no caloric intake for at least 8 h, or 2-h plasma glucose200 mg/dl (11.1mmol/l) during an oral glucose toler-ance test (OGTT). The test should beperformed as described by the WorldHealth Organization, using a glucoseload containing the equivalent of 75 ganhydrous glucose dissolved in water in a patient with classic symptoms ofhyperglycemiaorhyperglycemiccrisis,a random plasma glucose200 mg/dl(11.1 mmol/l) intheabsenceofunequivocalhypergly-cemia, result should be confirmed byrepeat testing.new在无症状患者中进行糖尿病筛查 在无症状的成人，如超重或肥胖（BMI25kg/m2）并有一个以上其他糖尿病危险因素（见“2011年糖尿病诊疗标准”中的表4），应该从任何年龄开始筛查糖尿病并评估将来糖尿病的风险。对没有这些危险因素的人群，应从45岁开始筛查。（B） 如果检查结果正常，至少每3年复查一次。（E） 为筛查糖尿病或评估未来糖尿病的风险，A1C、FPG或2h 75g OGTT均是适用的。（B） 对于那些已经确定未来糖尿病风险增加的人群，应该进一步评估并治疗其他心血管疾病（CVD）危险因素。（B）Testing for diabetes in asymptomaticpatients Testing to detect type 2 diabetes andassess risk for future diabetes in asymptomaticpeople should be considered inadults of any age who are overweight orobese (BMI _25 kg/m2) and who haveone or more additional risk factors fordiabetes (see Table 4 of the “Standardsof Medical Care in Diabetes2011”).In those without these risk factors, testingshould begin at age 45 years. (B) If tests are normal, repeat testing carriedout at least at 3-year intervals isreasonable. (E) To test for diabetes or to assess risk offuture diabetes, A1C, FPG, or 2-h 75-gOGTT are appropriate. (B) In those identified with increased riskfor future diabetes, identify and, if appropriateappropriate,treat other cardiovasculardisease (CVD) risk factors. (B)妊娠期糖尿病的筛查和诊断 在有危险因素的个体中，产前首次就诊时用标准的诊断标准筛查未诊断的2型糖尿病。（B） 在未知是否具有糖尿病的怀孕妇女中，在妊娠2428周用75g 2h OGTT筛查妊娠糖尿病，诊断切点见“2011年糖尿病诊疗标准”表6。（B）Detection and diagnosis ofgestational diabetes mellitus (GDM) Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors, using standard diagnosticcriteria. (B) In pregnant women not known to havediabetes, screen for GDM at 2428weeks of gestation, using a 75-g 2-hOGTT and the diagnostic cut points inTable 6 of the “Standards of MedicalCare in Diabetes2011”. (B) 妊娠糖尿病的妇女在产后612周筛查永久性糖尿病。（E） 有妊娠糖尿病病史的妇女应至少每3年筛查是否发展为糖尿病或糖尿病前期。（E） Screen women with GDM for persistentdiabetes 612 weeks postpartum. (E) Women with a history of GDM shouldHave life long screening for the develop-Ment of diabetes or prediabetes at leastevery 3 years. (E)预防/延缓2型糖尿病 对于糖耐量异常（IGT）（A）、空腹血糖受损（IFG）（E）或A1C 在5.76.4%之间（E）的患者，应该制定长期计划，以减轻体重7%，增加体力活动，每周进行至少150分钟中等强度（如步行）的体力活动。（B） 定期随访咨询对成功非常重要。（B）Prevention/delay of type 2 diabetes Patients with impaired glucose toler-ance (IGT) (A), impaired fasting glu-cose(IFG)(E),oranA1Cof5.76.4%(E) should be referred to an effectiveongoing support program targetingweight loss of 7% of body weight andincreasing physical activity to at least150 min/week of moderate activitysuch as walking. Follow-up counseling appears to be im-portant for success. (B) 基于节约糖尿病预防的潜在医疗费用，这种咨询的费用应由第三方支付。（E） 对于那些可能发展为糖尿病的高危人群，如具有多种危险因素，尤其是尽管进行了生活方式的干预后血糖仍进展（如A1C6%），可以考虑使用二甲双胍治疗以预防2型糖尿病。（B） 糖尿病前期患者应该每年进行检测以观察是否进展为糖尿病。（E） Based on potential cost-savings of dia-betes prevention, such programsshould be covered by third-party pay-ors. (E) Metformin therapy for prevention oftype 2 diabetes may be considered inthose at highest risk for developing di-abetes,such as those with multiple riskfactors, especially if they demonstrateprogression of hyperglycemia(e.g.A1C6%) despite lifestyle interventions.(B) Monitoring for the development of di-Abetes in those with prediabetes shouldbe performed every year. (E)血糖监测 每日多次胰岛素注射或采用胰岛素泵治疗的患者，应该进行自我检测血糖（SMBG）每天3次或以上。（A） 对于胰岛素注射次数少或仅采用口服药物或医学营养治疗（MNT）的患者，SMBG或许有助于治疗成功。（E） 餐后SMBG或许有助于餐后血糖控制达标。（E） SMBG医嘱后，应确保患者获得SMBG的初始指导和定期随访评估，并用SMBG数据指导和调整治疗。（E） 对于年龄25岁以上的1型糖尿病患者进行动态血糖监测（CGM）并联合胰岛素强化治疗，是降低A1C水平的有效方法。（A） 虽然在儿童、青少年和青年患者中降低A1C的证据不强，但是CGM或许有助于该人群的治疗。这种仪器的应用与成功的治疗具有相关性。（C） CGM可以作为SMBG的一种补充，特别适宜无症状低血糖和或频发低血糖的患者。（EGlucose monitoring Self-monitoring of blood glucose(SMBG) should be carried out three ormoretimesdailyforpatientsusingmul-tipleinsulininjectionsorinsulinpumptherapy. (A) Forpatientsusingless-frequentinsulininjections, non-insulin therapies, ormedical nutrition therapy (MNT)alone,SMBGmaybeusefulasaguidetothe success of therapy. (E) To achieve postprandial glucose tar-gets,postprandialSMBGmaybeappro-priate. (E) When prescribing SMBG, ensure thatpatients receive initial instruction in,and routine follow-up evaluation of,SMBGtechniqueandtheirabilitytousedata to adjust therapy. (E) Continuousglucosemonitoring(CGM)in conjunction with intensive insulinregimens can be a useful tool to lowerA1Cinselectedadults(age25years)with type 1 diabetes. (A) Although the evidence for A1C-lowering is less strong in children,teens, and younger adults, CGM maybehelpfulinthesegroups.Successcor-relates with adherence to ongoing useof the device. (C) CGM may be a supplemental tool toSMBG in those with hypoglycemia un-awareness and/or frequent hypoglyce-mic episodes. (E)A1C 对于治疗达标（血糖控制稳定）患者，每年应该至少进行两次A1C检测。（E） 对更改治疗方案或血糖控制未达标患者，应每季度进行一次A1C检测。（E） 在需要改变治疗方案时可适时检测A1C。（E）A1C PerformtheA1Ctestatleasttwotimesayearinpatientswhoaremeetingtreat-mentgoals(andwhohavestableglyce-mic control). (E) Perform the A1C test quarterly in pa-tients whose therapy has changed orwhoarenotmeetingglycemicgoals.(E) Useofpoint-of-caretestingforA1Cal-lows for timely decisions on therapychanges, when needed. (E)成人的血糖控制目标 已有证据显示降低A1C到7%左右或以下可减少糖尿病微血管和神经并发症，如果在诊断糖尿病后立即治疗，可以减少远期大血管疾病。所以，在许多非妊娠成人合理的A1C控制目标是7%。（B）Glycemic goals in adults Lowering A1C to below or around 7%hasbeenshowntoreducemicrovascu-lar and neuropathic complications ofdiabetes and,if implemented soon afterthe diagnosis of diabetes, is associatedwith long-term reduction in macrovas-cular disease. Therefore, a reasonableA1Cgoal for many nonpregnant adultsis7%. (B) 因为对多个随机试验进行进一步分析提示，A1C值接近正常在微血管结局方面确实可以获得小的益处，因此在某些患者如果没有明显低血糖或其他副作用，建议更严格的A1C目标或许也是合理的。这些患者或许包括那些糖尿病史较短、预期寿命较长、无明显心血管并发症的病人。（B） Because additional analyses from sev-eral randomized trials suggest a smallbut incremental benefit in microvascu-lar outcomes withA1C value scloser tonormal, providers might reasonablysuggest more stringent A1C goals forselected individual patients, if this canbe achieved without significant hypo-glycemia or other adverse effects oftreatment.Suchpatientsmightincludethose with short duration of diabetes,longlifeexpectancy,andnosignificantcardiovascular disease. (B) 相反，对于有严重低血糖病史、预期寿命有限、有晚期微血管或大血管病发症、同时患伴发其他严重疾病及糖尿病病史多年的患者，尽管实施了糖尿病自我管理教育、合适的血糖检测、应用了包括胰岛素在内的多种有效剂量的降糖药物，而血糖仍难达标者，其A1C目标控制不需太严。（C） Conversely, less stringent A1C goalsmay be appropriate for patients with ahistoryofseverehypoglycemia,limitedlife expectancy, advanced microvascu-larormacrovascularcomplications,ex-tensivecomorbidconditions,andthosewith longstanding diabetes in whomthe general goal is difficult to attain de-spite diabetes self-management educa-tion, appropriate glucose monitoring,and effective doses of multiple glucose-lowering agents including insulin. (C)糖尿病自我管理教育l 糖尿病诊断确定后应该按国家标准接受DSME。（B）l 自我管理和生活治疗的效果是DSME结局的关键，应该作为治疗的一部分进行评估和监测。（C）l DSME必须有心理课，因为情绪会明显影响糖尿病预后。（C）因DSME可以节省花费并能改善预后（B），所以费用应该由第三方支付者负责。（E）Diabetes self-management education(DSME) People with diabetes should receiveDSME according to national standardswhentheirdiabetesisdiagnosedandasneeded thereafter. (B) Effective self-management and qualityof life are the key outcomes of DSMEand should be measured and moni-tored as part of care. (C) DSME should address psychosocial is-sues, since emotional well-being is as-sociated with positive diabetesoutcomes. (C) Because DSME can result in cost-savings and improved outcomes (B),DSME should be adequately reim-bursed by third-party payors. (E)医学营养治疗整体建议 任何糖尿病及糖尿病前期患者都需要依据治疗目标接受个体化的MNT，如果能在熟悉糖尿病知识的注册营养师指导下完成更好。（A） 因为可以节省花费并可改善预后的原因（B），MNT应该被相关保险公司及其他支付所覆盖。（E）Medical nutrition therapy (MNT)General recommendations Individualswhohaveprediabetesordi-abetes should receive individualizedMNT as needed to achieve treatmentgoals, preferably provided by a regis-tereddietitianfamiliarwiththecompo-nents of diabetes MNT. (A) BecauseMNTcanresultincost-savingsand improved outcomes (B), MNTshouldbeadequatelycoveredbyinsur-ance and other payors. (E)能量平衡、超重与肥胖 在超重和肥胖的胰岛素抵抗患者，已经证实适度减轻体重能有效减轻胰岛素抵抗。因此，建议所有超重或肥胖的糖尿病患者或有糖尿病危险因素的患者减轻体重。（A） 对于减轻体重，低碳水化合物饮食、低卡路里脂肪限制饮食或地中海饮食在短期内（至少2年）或许有效。（A）Energy balance, overweight, andobesity In overweight and obese insulin-resistant individuals, modest weightloss has been shown to reduce insulinresistance. Thus, weight loss is recom-mended for all overweight or obese in-dividuals who have or are at risk fordiabetes. (A) For weight loss, either low-carbohy-drate, low-fat calorie-restricted, orMediterranean dietsmaybeeffectiveinthe short term (up to 2 years). (A) 对于低碳水化合物饮食的患者，监测其血脂、肾功能和蛋白质摄取（有肾病患者）情况，并及时调整降糖治疗方案。（E） 体力活动和行为矫正是控制体重的重要组成部分，同时最有助于保持减轻的体重（B） Forpatients on low-carbohydrate diets,monitor lipid profiles, renal function,and protein intake (in those with ne-phropathy) and adjust hypoglycemictherapy as needed. (E) Physical activity and behavior modifi-cation are important components ofweight loss programs and are mosthelpful in maintenance of weight loss.(B)糖尿病的一级预防 在2型糖尿病高危人群中，预防措施重点应强调生活方式的改变，包括适度的减轻体重（7%）和规律的体力活动（每周150分钟），饮食控制如减少碳水化合物的摄取、低脂饮食能够减少发生2型糖尿病的风险，因此建议糖尿病高危人群进行生活方式的改变。（A） 对于2型糖尿病高危人群，应该鼓励食用美国农业部推荐的膳食纤维高含量食品及全谷食物。（B）Recommendations for primaryprevention of diabetes Among individuals at high risk for de-veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges that include moderate weightloss (7% of body weight) and regularphysical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietaryfat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A) Individuals at high risk for type 2 dia-betes should be encouraged to achievethe U.S. Department of Agriculture(USDA)recommendationfordietaryfi-ber (14 g fiber/1,000 kcal) and foodscontaining whole grains (one-half ofgrain intake). (B)糖尿病的治疗建议：糖尿病治疗中的营养素 碳水化合物、蛋白质和脂肪最佳比例或许应该调整，以满足糖尿病患者的代谢目标和个人喜好。（E）Recommendations for managementof diabetes: macronutrients indiabetes management The best mix of carbohydrate, protein,and fat may be adjusted to meet themetabolic goals and individual prefer-ences of the person with diabetes. (E) 无论采用计算法、食品交换份法或经验估算来监测碳水化合物的摄入量，也是血糖控制达标的关键策略。（A） Monitoring carbohydrate, whether bycarbohydrate counting, choices, or ex-perience-based estimation, remains akey strategy in achieving glycemic con-trol. (A) 对糖尿病患者，当仅考虑碳水化合物总量时，用血糖指数和血糖负荷，可能更有助于血糖控制。（B） For individuals with diabetes, the use ofthe glycemic index and glycemic loadmay provide a modest additional bene-fit for glycemic control over that ob-served when total carbohydrate isconsidered alone. (B) 饱和脂肪摄入量不应该超过总摄入能量的7%。（A） Saturated fat intake should be7% oftotal calories. (A) 减少反式脂肪摄入量能降低LDL胆固醇，增加HDL胆固醇；所以应减少反式脂肪的摄入量。（B） Reducing intake of trans fat lowersLDLcholesterol and increases HDL choles-terol (A); therefore, intake of trans fatshould be minimized. (E)其他营养建议l 成年糖尿病患者如果想饮酒，每日摄入量应限少量（成年女性每天1杯，成年男性2杯）。（E）l 不建议常规补充抗氧化剂如维生素E、C和胡萝卜素，因为缺乏有效性和长期安全性的证据。（A）l 个体化的饮食计划应包括优化食物选择，以满足所有微量元素的每日建议容许量（RDAs）/饮食参考摄入量（DRI）。（E）Other nutrition recommendations If adults with diabetes choose to usealcohol, daily intake should be limitedto a moderate amount (one drink perday or less for adult women and twodrinks per day or less for adult men).(E) Routine supplementation with antioxi-dants, such as vitamins E and C andcarotene,is not advised because of lackof evidence of efficacy and concern re-lated to long-term safety. (A) Individualized meal planning shouldInclude optimization of food choices tomeet recommended daily allowance(RDA)/dietary reference intake (DRI)for all micronutrients. (E)体力活动l 糖尿病患者应该每周至少进行中等强度有氧体力活动（5070最大心率）150 分钟。（A）l 对无禁忌证的2型糖尿病患者鼓励每周进行3次耐力运动。（A）Physical activity Peoplewithdiabetesshouldbeadvisedto perform at least 150 min/week ofmoderate-intensityaerobicphysicalac-tivity (5070% of maximum heartrate). (A) In the absence of contraindications,people with type 2 diabetes should beencouragedtoperformresistancetrain-ing three times per week. (A)心理评估与治疗l 糖尿病治疗应包括心理学和社会状态的评估。（E）l 心理筛查应该包括但不限于：对疾病的态度、对治疗和预后的期望值、情感/情绪状态、一般的及与糖尿病相关的生活质量、生活来源（经济上、社会和情感方面）以及精神病史。（E）l 当自我管理较差时，应筛查如抑郁和糖尿病相关的压抑、焦虑、饮食障碍以及认知障碍等心理问题。（C）Psychosocial assessment and care Assessment of psychological and socialsituation should be included as an on-going part of the medical managementof diabetes. (E) Psychosocial screening and follow-upshould include, but is not limited to,attitudesabouttheillness,expectationsfor medical management and out-comes, affect/mood,general and diabe-tes-related quality of life, resources(financial, social, and emotional), andpsychiatric history. (E) Screen for psychosocial problems suchas depression and diabetes-related dis-tress, anxiety, eating disorders, andcognitive impairment when self-management is poor. (C)证据级别提升低血糖l 治疗症状性低血糖首选葡萄糖（1520g），也可选用任何含有葡萄糖的碳水化合物。如果治疗15分钟后SMBG依然为低血糖，应该再次给药。一旦SMBG血糖正常后，患者应该继续追加一次正常饮食或点心，以预防低血糖复发。（E）l 所有严重低血糖高危的患者、照护者或家人均应给予胰高血糖素，并教会如何用药。胰高血糖素不要求必须由专业人员给予。（E）l 对于无症状低血糖或出现过一次或多次严重低血糖的糖尿病患者，应该降低血糖控制目标，以严格避免至少在近几周内再次发生低血糖，还可以部分逆转无症状性低血糖并减少将来发生低血糖的风险。（B）Hypoglycemia Glucose (1520 g) is the preferredtreatment for the conscious individualwithhypoglycemia,althoughanyformof carbohydrate that contains glucosemay be used. If SMBG 15 min aftertreatmentshowscontinuedhypoglyce-mia, the treatment should be repeated.OnceSMBGglucosereturnstonormal,the individual should consume a mealorsnacktopreventrecurrenceofhypo-glycemia. (E) Glucagon should be prescribed for allindividuals at significant risk of severehypoglycemia,andcaregiversorfamilymembersoftheseindividualsshouldbeinstructedinitsadministration.Gluca-gon administration is not limited tohealth care professionals. (E) Individuals with hypoglycemia un-awareness or one or more episodes ofseverehypoglycemiashouldbeadvisedtoraisetheirglycemictargetstostrictlyavoid further hypoglycemia for at leastseveralweeks,topartiallyreversehypo-glycemia unawareness and reduce therisk of future episodes. (B)减肥手术l BMI35 kg/m2的2型糖尿病患者，特别是糖尿病或相关并发症通过生活方式和药物治疗仍难以控制者，可以考虑进行减肥手术治疗。（B）Bariatric surgery Bariatric surgery may be considered for2 adults with BMI35kg/m and type2diabetes, especially if the diabetes or as-sociated comorbidities are difficult tocontrol with lifestyle and pharmaco-logic therapy. (B)l 接受了减肥手术的2型糖尿病患者应接受长期生活方式咨询与医学监测。（E）l 尽管小型研究表明BMI在30-35kg/m2之间的2型糖尿病患者接受减肥手术也可更好控制血糖，但目前没有充足的循证医学证据建议，除研究之外对BMI35 kg/m2 的2型糖尿病患者进行减肥手术。（E） Patientswithtype2diabeteswhohaveundergone bariatric surgery need life-long lifestyle support and medicalmonitoring. (E) Although small trials have shown gly-cemicbenefitofbariatricsurgeryinpa-tients with type 2 diabetes and BMI of23035 kg/m , there is currently insuf-ficient evidence to generally recom-mendsurgeryinpatientswithBMI352kg/m outside of a research protocol.(E)l 2型糖尿病患者减肥手术的长期获益、花费效益比及风险，应该通过设计良好的随机对照试验与合适的药物及生活方式治疗加以比较研究。（E） The long-term benefits, cost-effectiveness,andrisksofbariatricsur-geryinindividualswithtype2diabetesshould be studied in well-designedcontrolled trials with optimal medicaland lifestyle therapy as the comparator.(E)免疫接种l 年龄6个月的糖尿病患者每年都要接种流感疫苗。（C）l 所有2岁以上的糖尿病患者须接种肺炎球菌疫苗。年龄64岁者，如5年前接种过疫苗需再接种一次。再接种指征还包括肾病综合征、慢性肾病及其他免疫损害者如器官移植后。（C）Immunization Annually provide an influenza vaccineto all diabetic patients6 months ofage. (C) Administer pneumococcal polysaccha-ride vaccine to all diabetic patients2yearsofage.Aone-timerevaccinationisrecommended for individuals64years of age previously immunizedwhentheywere65yearsofageifthevaccine was administered5 yearsago.Otherindicationsforrepeatvacci-nation include nephrotic syndrome,chronicrenaldisease,andotherimmu-nocompromised states, such as aftertransplantation. (C)高血压血压控制筛查和诊断糖尿病患者每次随访时均应测量血压。收缩压130mmHg或舒张压80mmHg的患者，应该改天重复测量。再次测量仍收缩压130mmHg或舒张压80mmHg，可确诊为高血压。（C）Hypertension/blood pressure controlScreening and diagnosis Blood pressure should be measured atevery routine diabetes visit. Patientsfound to have systolic blood pressure130 mmHg or diastolic blood pres-sure80 mmHg should have bloodpressure confirmed on a separate day.Repeat systolic blood pressure130mmHg or diastolic blood press