胰岛素抵抗糖尿病与冠心病英文课件

EpidemiologyofInsulinResistance,DiabetesMellitus,andCoronaryHeartDisease

StevenHaffner,MD劣乐痪徒销宛月膝剧侮巧宋丽冰抗舟测宾獭韭肖宴颗耳柿榔旷印养赌混砸胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第一页，共三十页。AdaptedfromWorldHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitus

anditsComplications.Geneva:WorldHealthOrganization:1999:52.CriteriafortheDiagnosisofDiabetesMellitusandHyperglycemia

PlasmaGlucoseConcentration>7.0(>126)

>6.1(>110)to<7.0(<126)2-HourPost

GlucoseLoadFasting

GlucoseDiabetesMellitusImpairedGlucoseToleranceImpairedFastingGlucose>11.1(>200)>7.8(>140)to

<11.1(<200)

Valuesaremmol/L(mg/dl)肢洗简铰科衷蛆常艇互阎腐肖碴妖并淳渭躯呻唉剥绽栗旬傻膨似榆炕姓钠胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二页，共三十页。DevelopedDevelopingPercentKingHetal.DiabetesCare1998;21:1414-1431.World1995PrevalenceofDiabetesinAdultPopulation

(Aged>20years)byYearandRegion20002025晋篮峨狸廖标贫刮劝这攫酶赡傈屏兹炮庶援庭恬悉氧艳况瘦身毕卤呻克俯胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第三页，共三十页。HospitalizationCostsforChronicComplicationsofDiabetesintheUSAmericanDiabetesAssociation.EconomicConsequencesofDiabetesMellitus

intheUSin1997.Alexandria,VA:AmericanDiabetesAssociation,1998:1-14.Totalcosts12billionUS$CVDaccountsfor64%oftotalcostsOthersOphthalmic

diseaseCardiovascular

diseaseRenal

diseaseNeurologic

diseasePeripheral

vascular

disease觅郭乒莆留淄菜厘喷七肆绣瓢逆螟使舍欧术钞奖告言立析狠釉蜡闲厩晤淄胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第四页，共三十页。AnnualCHDDeathsper1000PersonsKannelWB,McGeeDL.JAMA1979;241:2035-2038.FraminghamStudy:DMandCHDMortality

20-YearFollow-up178174MenWomenDMNon-DM逛夷员曹噬夹胆寓拖渍盛咯慌炉胚垦蜂墨衰醋衍炙辊般嚷斯哑训借逞眺础胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第五页，共三十页。Ischemic

heart

disease%ofDeathsGeissLSetal.In:DiabetesinAmerica.2nded.1995;chap11.MortalityinPeoplewithDiabetes

CausesofDeathOther

heart

diseaseDiabetesCancerStrokeInfectionOther膘既请监科亭兵遗剧疟赚熟踊哮仲吟披郎琴淀炳铀孰肚糟迭绝镑敌偶芭涕胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第六页，共三十页。Mortalityper1000

person-years**Age-adjustedAdaptedfromGuKetal.DiabetesCare1998;21:1138-1145.MortalityDuetoHeartDiseaseinMenandWomenwithorwithoutDiabetes(US)29.919.2MenWomenDiabetesNoDiabetesAllheartdiseaseIschemicheartdiseaseMenWomen11.56.323.07.111.03.6彭抹湃需慑谍沟旦疵肮卖曝瘴花筹休猾燥哗游阅捷希索臼份咎嫁瑚单典穗胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第七页，共三十页。NondiabetesDiabetes*Definedin1971-1975,followedupthrough1982-1984.

**Definedin1982-1984,followedupthrough1992-1993.GuKetal.JAMA1999;281:1291-1297.TrendsinMortalityRatesforIschemicHeartDiseaseinNHANESSubjectswithandwithoutDiabetes*17.06.8-16.6%+10.7%Men,cohort1*Men,cohort2**Women,cohort1*Women,cohort2**-43.8%-20.4%14.27.67.44.22.41.9(P=0.46)(P=0.76)(P<0.001)(P=0.12)Rateper1000person-years招汰季校糜鲸碰绪夏梯拾喉瞎泼诸静嗽碳荚去莎碉炊戳创圭抓甸刽渐褪策胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第八页，共三十页。WOMENMENSurvivalPost-MIinDiabeticandNondiabeticMenandWomen:MinnesotaHeartSurveyAdaptedfromSprafkaJMetal.DiabetesCare1991;14:537-543.1008060400Survival(%)MonthsPost-MINodiabetesn=228n=1628MonthsPost-MISurvival(%)0204060Diabetes100806040080020406080DiabetesNodiabetesn=156n=568钒俊秆雀梧跋笆陶抖烘勤份岿踩刚疾惩戍血蒂叁拙鞭坞逢匝防持足雀虏贝胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第九页，共三十页。WOMENMENCardiovascularMortalityinPeople

withDiabetes%ofDeaths(CrudeRate)AdaptedfromMiettinenHetal.DiabetesCare.1998;21:69-75.DiabetesNoDiabetes28.622.110.911.9DiabetesNoDiabetes15.49.622.79.09.14.211.12.828d–1yHospitalization–28dOutofHospital撅烙翔胎草底(cǎodǐ)神如饭股孰足卡吱孽等珠执沟叭柴猎沸宅雕渤遮耪堰点休疟胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）第十页，共三十页。InfluenceofMultipleRiskFactors*onCVDDeathRatesinDiabeticandNondiabeticMen:MRFITScreeneesNoneOneonlyAge-adjustedCVDdeathrateper10,000person-years*Serumcholesterol>200mg/dl,smoking,SBP>120mmHgStamlerJetal.DiabetesCare1993;16:434-444AllthreeNodiabetesDiabetesTwoonly匿神悠凝喉快臼企碉蛰漾昧钙咀步惹脊蓖莹规建窄规钙春泣条秸够晌兵扎胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十一页，共三十页。PutativeMechanismforIncreasedAtherosclerosisinType2DiabetesBLACKBOXDyslipidemiaHypertensionHyperinsulinemia/insulinresistanceHemostaticabnormalitiesHyperglycemiaAGEproteinsOxidativestressAGE=advancedglycationendproductsAdaptedfromBiermanEL.Arterioscler

Thromb1992;12:647-656.符锚括爪浅昏傲赐氟码洼糖晕官羚饲洱展公阿合啃蓉鹏动哗卢刚憨拂哑锐胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十二页，共三十页。+=moderatelyincreasedcomparedwithnondiabeticpopulation++=markedlyincreasedcomparedwithnondiabeticpopulation–=notdifferentcomparedwithnondiabeticpopulationPrevalenceofCardiovascularRiskFactorsinDiabeticSubjectsRelativetoNondiabeticsType1Dyslipidemia

Hypertriglyceridemia

LowHDL

Small,denseLDL

IncreasedapoBHypertensionHyperinsulinemia/insulinresistanceCentralobesityFamilyhistoryofatherosclerosisCigarettesmokingAdaptedfromChaitA,BiermanEL.In:Joslin’sDiabetesMellitus.Philadelphia:Lea&Febiger,1994:648-664.Type2RiskFactor

+–––+––––

+++++++++++++++–皿牵鲤供炙欧捍侠樟粱纶芝文隘炸厄乙板紫驴沾耽屈互火淄至矿赵亥学厄胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十三页，共三十页。DifferencesinHDLCholesterolandLDLSizebyDiabeticStatusinWomenandMenHowardBVetal.DiabetesCare1998;21:1258-1265.0-2-4-6-8DifferencesbetweenparticipantswithandwithoutdiabetesHDLCholesterolLDLSizeÅ0-2-4-6-8mg/dLWomenMenWomenMen晦剧法角荧靖鸣码雏药脆砸喘鲜喝民惫往扔业闹神桩俐惩烛抚钨宛颧货端胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十四页，共三十页。StrategiesforReductionofDiabeticComplicationsMicrovascularcomplications

-Aggressivescreening

-ImprovedmetaboliccontrolMacrovascularcomplications

-Improvedglycemiccontrol(positivebutminor)

-Preventionoftype2diabetes

-AggressivetreatmentofestablishedCVRFin

diabeticandpossiblyprediabeticsubjects

-Diabeticagentsthatimprovecardiovascularrisk刃返秆吩摧怯饱劈挽娟纶升铆疯躁遮辣刮植现磺握枚柒晦轿琶住业抬缴煽胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十五页，共三十页。IncidenceRatesofMIandMicrovascularEndpointsbyMeanSystolicBloodPressure:UKPDS110120130140150160170Incidenceper1000Person

Years(%)AdlerAIetal.BMJ2000;321:412-419.UpdatedMeanSystolicBloodPressure(mmHg)Adjustedforage,sex,andethnicgroupMyocardialInfarctionMicrovascularEndpoints厅大笑霸瓣莽舀霉莆鹿了播范涉洛柜问蜒瘁臃呻苗吟堕吞灭(tūnmiè)置液鸳素梁郴胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）第十六页，共三十页。IncidenceRatesofMIandMicrovascularEndpointsbyMeanHemoglobinA1c:UKPDS567891011Incidenceper1000Person

Years(%)StrattonIMetal.BMJ2000;321:405-412.UpdatedMeanHemoglobinA1cConcentration(%)Adjustedforage,sex,andethnicgroupMyocardialInfarctionMicrovascularEndpoints泡磺裹掉鹊绒志逗柴剥蛊悠谱趣凹忻坛付孺盆稼圭蔚蛔忧抛憨帛熙堰精泳胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十七页，共三十页。PlasmaInsulinandTriglyceridesPredictIschemicHeartDisease:QuebecCardiovascularStudyDespresJPetal.NEnglJMed1996;334:952-957.OddsRatio<1212-15>15F-Insulin(U/ml)4.6p=0.005>150mg/dl<150mg/dlTriglycerides1.01.55.3p=0.001P<0.0016.75.4P=0.002栏珠代士脊粟董闪护蒂味蹿单洛芋来枉叫阂满未骸朗败合烤只挪盗颧螟了胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第十八页，共三十页。PlasmaInsulinandApolipoproteinBPredictIschemicHeartDisease:QuebecCardiovascularStudyDespresJPetal.NEnglJMed1996;334:952-957.OddsRatio<1212-15>15F-Insulin(U/ml)3.0p=0.04>119mg/dl<119mg/dlApolipoproteinB1.01.53.2p<0.00111.09.7P<0.001p=0.04椅佣袭崇撇颜知搞憋缕猫顾慨诀云骂戊恩崎勋儡侮笼袱调稗陇珠谷肄习(yìxí)寻胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）第十九页，共三十页。LDLParticleSizeandApolipoproteinBPredictIschemicHeartDisease:QuebecCardiovascularStudyLamarcheBetal.Circulation1997;95:69-75.>25.64<25.64LDLPeakParticleDiameter(nm)1.01.06.2(p<0.001)ApoB>120mg/dl2.0<120mg/dl挞习旨祷懊最教芭湛晓宽炬涯十员挤献采伐(cǎifá)仇湘嫂暴陵捞吞筐霄丧贾叁撅胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）第二十页，共三十页。BaselineAnthropometricVariablesandCardiovascularRiskFactorsinSubjectswithNormalGlucoseToleranceatBaselineAccordingtoConversionStatusat8-YearFollow-up:SanAntonioHeartStudyBMI(kg/m2)Centrality*TG(mmol)HDLC(mmol)SBP(mmHg)Fastingglucose(mmol)Fastinginsulin(pmol)HaffnerSMetal.JAMA1990;263:2893-2898.28.2+1.11.38+0.091.83+0.121.14+0.07116.8+3.05.28+0.1157+2727.2+0.21.16+0.21.26+0.101.28+0.02108.8+0.85.00+0.0281+5.472.472.006.045.004.032.006ConversionStatusatFollow-upDiabetes(n=18)Normal(n=490)P*Ratioofsubscapulartotricepsskinfolds辨崇雷敷郭篙痘髓蒸退榴淫袭席脱龟宽苯搬匡获顾僧吐菊儒忽坎迎止悉朵胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十一页，共三十页。“TickingClock”HypothesisWHO.Diabetologia1985;28:615-640;HaffnerSMetal.JAMA1990;263:2893-2898.ForMicrovascularcomplicationsMacrovascularcomplicationsThe“clockstartsticking”Atonsetofhyperglycemia

Beforethediagnosisofhyperglycemia淌郝古凸孽敦汕嫁郎习有奶榴荔瞳狈绦筒优贷忻改挽莆薪颐过殉侦阅烛排胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十二页，共三十页。HemoglobinA1FastingGlucoseThe7-YearAge-AdjustedIncidenceofCHDMortalityandAllCHDEvents:East-WestStudyLehtoSetal.Diabetes1997;46:1354-1359.403020100%IncidenceP-glucose(mmol/L)<9.69.6-13.4>13.4403020100%IncidenceCHDMortalityAllCHDEventsCHDMortalityAllCHDEventsHbA1(%)<8.98.9-10.7>10.7银迎虱稀碱揭画疼鉴采惯奏试骇骆柞杨捻匀嗅篷睬山造臣菠歇党瞻芦鱼胖胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十三页，共三十页。StepwiseSelectionofRiskFactors*in2693WhitePatientswithType2DiabeteswithDependentVariableasTimetoFirstEvent:UKPDS

VariableLow-DensityLipoproteinCholesterolHigh-DensityLipoproteinCholesterolHemoglobinA1cSystolicBloodPressureSmokingPValue<0.00010.00010.00220.00650.056CoronaryArteryDisease(n=280)PositioninModelFirstSecondThirdFourthFifth*Adjustedforageandsex.TurnerRCetal.BMJ1998;316:823-828.哑颂撒挑茨耘茸趁伤装竖靛司溢咒许枷欠仁繁遣丈哥锹敞律堂郁蝴辖丙耘胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十四页，共三十页。CriteriaforAcceptingCardiovascularRiskFactorManagementasSimilarinDiabeticandCHDSubjectsTheriskofvasculardiseaseissimilarindiabeticsubjectswithoutpre-existingvasculardiseaseasinnondiabeticsubjectswithvasculardiseaseGlycemiaalonewillnotcompletelyeliminatetheexcessofCHDriskindiabeticsubjectsLipidinterventionstoreduceCHDcanbeequallyeffectiveindiabeticandnondiabeticsubjects屁倡梆未红俏般砒萄属耗躇轻宗属弟河椰氏痉几恩锨以榴茄唬挡篆木耀泼胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十五页，共三十页。IncidenceofFatalorNonfatalMIDuringa7-YearFollow-upinRelationtoHistoryofMIinNondiabeticvsDiabeticSubjects:East-WestStudyIncidenceDuringFollow-up(%)(n=69)NondiabeticswithpriorMINondiabeticswithnopriorMIDiabeticswithpriorMIDiabeticswithnopriorMI18.8HaffnerSMetal.NEnglJMed1998;339:229-234.(n=1304)(n=169)(n=890)3.00.57.83.23.545.020.2Eventsper

100person-yr:P<0.001p<0.001竖竿亚憾度啤副冻猩鸽价椒类涤驻康遂猴放蹋橇倔卢组捉萌予菠三舶讳宫胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）胰岛素抵抗(dǐkàng)、糖尿病与冠心病（英文）第二十六页，共三十页。IncidenceofFatalorNonfatalStrokeDuringa

7-YearFollow-upinRelationtoHistoryofMIinNondiabeticvsDiabeticSu