糖尿病高危IGT人群的干预培训课件

1、 IDF 主席开幕式演讲YESTERDAY, TODAY AND TOMORROW KGMM Alberti Prevention, Prevention and Prevention IDF 主席开幕式演讲X 综合征 死亡四重奏（Reaven,1988） （Kaplan,1989） 胰岛素抵抗 中心性肥胖糖耐量低减/DM 糖耐量低减/DM高胰岛素血症高TG血症 高TG血症低HDL-c血症高血压 高血压 胰岛素抵抗综合征（DeFronzo, 1991） 代 谢 综 合 征（Zimmet, 1997） X 综合征 死亡四重奏（ReaveInsulin ResistanceHypertension

2、Type 2 DiabetesThe metabolic syndrome of insulin resistance & cardiovascular diseaseReducedFibrinolysisComplexdyslipidemiaTG, sdLDL HDLEndothelialDysfunctionChronic systemicInflammationAthero-sclerosis &CHDVisceralObesityInsulin ResistanceHypertension 2型糖尿病一级预防 糖尿病高危(IGT)人群的干预历史的回顾大庆糖尿病预防研究的由来当前2型糖尿

3、病预防研究的局限 及尚未能解决和正在解决的问题 2型糖一. 历史的回顾一. 历史的回顾Prevention is better than cure糖尿病一级预防研究 对象 干预措施 大庆研究 IGT 生活方式DPP IGT 生活方式+双胍DPS IGT 生活方式STOP-NIDDM IGT 阿卡波糖Prevention is better than cure大庆研究中糖尿病每百人年发病率11.510.811.417.2饮食组运动组饮食+运动对照组BMI=255.16.813.38.3饮食组运动组饮食+运动对照组BMI100例多因素分析胰岛素抵抗对干预疗效分析大庆研究与国外相关研究(1980-1

4、992)比较作者例数随访目的 （大庆）研究是为了在某一特定人群（IGT)，采取某一特定的方法(生活方式干预），证明某种假设（生活方式干预可预防糖尿病的发生）的正确 (合理性和可行性）。然后以这种假设去说服人,让人们采取行动解决问题。 （大庆）研究是为了改变现状（降低中国乃至世界的糖尿病发病率,当时并未提出代谢综合征）。 目的 （大庆）研究是为了在某一特定人群（IGT)，采取某一三.当前2型糖尿病预防研究的局限及尚未能解决和正在解决的问题三.当前2型糖尿病预防研究的局限及尚未能解决和正在解决的问题 生活方式干预预防糖尿病合理性 成本效益? 对预防心脑血管病是否有益?可行性 多少人能长期坚持? 生

5、活方式干预预防糖尿病合理性 成本效益?药物干预预防糖尿病的合理性和可行性最佳剂量？成本效益?耐受性？毒副作用?预防了糖尿病or 提前治疗?药物干预预防糖尿病的合理性和可行性最佳剂量？成本效益?Unanswered Questions How to conduct the screening? One step or two-steps?OGTT or standard meal test? How to do the prevention?Lifestyle or pharmacological?HOW to translate these successful findings in Da-

6、Qing Study DPP and DPS and maintain the lifestyle changes in longer term Targeting insulin resistance or insulin insufficiency?Prevent diabetes or reverse to normal tolerance? Standard protocol or tailored one? How To Increase Effectiveness and Reduce Cost? Unanswered Questions How to cLifestyle or

7、Medication?Lifestyle or Medication?Method of interventionDiet Group: BMI 25 reduce calorie intake to reduce weight 0.5-1.0 kg/monthExercise Group: To increase amount of leisure physical exercise by at least one unit.Diet and Exercise Group: Same as Diet and Exercise groupControls: Only exposed to ge

8、neral information about DM from public health education. No special advice.Method of interventionDiet GroTable 1. Exercise unitsEach category represents one unitTable 1. Exercise unitsEach caLifestyle: How Intensive is Effective? Da-Qing Study : At least decrease 50 gm of Carbohydrate/day at least i

9、ncrease 50 min physical exercise/day 5 days/week Diabetes Prevention Program: Weight loss 7% and exercise 150min/week Diabetes Prevention Study: Weight loss 5% and exercise 4 hours/weekLifestyle: How Intensive is EfEfficacy of lifestyle intervention Comparison of Da-Qing Study to DPP and DPS Inciden

10、ce/100pys CONTROL DIET+EXERCISE Da-Qing StudyBMI 22.4 22.2 13.3 6.8 49% Da-Qing StudyBMI 27.5 27.0 17.2 11.4 34% DPPBMI 34.2 33.9 11.1 4.8 58% DPSBMI 31.3 31.0 9.6 4.8 58%Efficacy of lifestyle intervenQ: Should The Chinese Need to Use Protocol in DPP or DPS in Their Future Prevention?A: Yes ? No! Ye

11、s or no!Weight loss 7% Trail for Prevention DM with lifestyle modification in US Trail for weight loss with medication (orlistat) in Chinese Lifestyle OlistatWeight Reduction (Kg) 3.00 6.05 Weight Reduction (%) 3.67 7.45 Q: Should The Chinese Need t 过强的生活方式干预会大大增加退出干预的人数，中等强度的干预才能既有效又能为广大人群接受并常年坚持。

12、过强的生活方式干预会大大增加退出干预的人数，中等强度的 DA-QING STUDY 未采用过于激烈的强度大的干预，失访率仅8%. DPP，DPS 体重减轻第一年达标率27?)No, For most non-obese Chinese IGT, less intensive prevention protocol than DPP may be working if only for preventing DM, however reversing them to normal glucose tolerance more intensive prevention protocol is ne

13、eded. Should The Chinese Need to UsePharmacological InterventionPharmacological InterventionPrevention is better than cure糖尿病一级预防研究 对象 干预措施 结果大庆研究 IGT 生活方式 50DPP研究 IGT生活方式+双胍 58 - 31%DPS研究 IGT 生活方式 58STOP-NIDDM IGT 阿卡波糖 33Prevention is better than cureLifestyle or Medication?Lifestyle intervention s

14、tudies have consistently shown that quite modest changes can reduce the progression from IGT to diabetes by 50-60%.It may, however, be impossible to translate these successful findings in larger cohots or maintain the lifestyle changes in longer term.This has lead to consideration pharmacotherapy. S

15、impson RW,Shaw JE,Zimmet PZ: Diabetes Res Clin Pract 2003 59:165-80Lifestyle or Medication?Lifest改变生活方式的艰难 说了,但未听见听见了,但未理解理解了,但未接受接受了,但未付诸行动行动了,但能坚持多久?改变生活方式的艰难 说了,但未听见听见了,但未理解Incidence/pys of DM in IGT subject stratified by Ins-sensitivitySensitive IAI-4.73 Resistant IAI -4.73 ie FPG FINS 114Incide

16、nce of DMIncidence/pys of DM in IGT su. In IGT subjects with higher degrees of insulin resistance the life-style change alone is less effective in preventing DM and some additional intervention such as metformin may be needed. .Diabetes Prevention Program (USA) 3000IGT involved ,follow-up 3.3 years,

17、2001 presented5831% Diabetes Prevention Program (U STOP NIDDM 1418 IGT involved, follow-up 3 years,2001 presented33% STOP NIDDM 1418 IGT involIncidence of Diabetes in Pharmacological intervention group of IGT in China (19972000)77% 88% 0.25 tid50mg tidIncidence of Diabetes in PharIncidence of Diabet

18、es in Pharmacological intervention group of IGT in China (Yuexin Wang ,3 years)69% 50mg TIDIncidence of Diabetes in Phar Pharmacological interventions with Acarbose or Metformin could reduce the risk of worsening to diabetes by 6080% in Chinese subjects with IGT. Intervention with Acarbose seems more effective in Chinese than that in Westerns SUMMARY Pharmacological intervent How To Increase Effectivenessand Reduce Cost? STRATEGY OF THE INTERVENTION How To Increase EffectiveneIncidence/pys Reduction of DM in peoples with IGT stratified by INS-SEN and secretionG 4 G3 G2 G1Incidence/pys Red