糖尿病高危IGT人群的干預(yù)培訓(xùn)課件

1、 IDF 主席開(kāi)幕式演講YESTERDAY, TODAY AND TOMORROW KGMM Alberti Prevention, Prevention and Prevention IDF 主席開(kāi)幕式演講X 綜合征 死亡四重奏（Reaven,1988） （Kaplan,1989） 胰島素抵抗 中心性肥胖糖耐量低減/DM 糖耐量低減/DM高胰島素血癥高TG血癥 高TG血癥低HDL-c血癥高血壓 高血壓 胰島素抵抗綜合征（DeFronzo, 1991） 代 謝 綜 合 征（Zimmet, 1997） X 綜合征 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型糖尿病一級(jí)預(yù)防 糖尿病高危(IGT)人群的干預(yù)歷史的回顧大慶糖尿病預(yù)防研究的由來(lái)當(dāng)前2型糖尿

3、病預(yù)防研究的局限 及尚未能解決和正在解決的問(wèn)題 2型糖一. 歷史的回顧一. 歷史的回顧Prevention is better than cure糖尿病一級(jí)預(yù)防研究 對(duì)象 干預(yù)措施 大慶研究 IGT 生活方式DPP IGT 生活方式+雙胍DPS IGT 生活方式STOP-NIDDM IGT 阿卡波糖Prevention is better than cure大慶研究中糖尿病每百人年發(fā)病率11.510.811.417.2飲食組運(yùn)動(dòng)組飲食+運(yùn)動(dòng)對(duì)照組BMI=255.16.813.38.3飲食組運(yùn)動(dòng)組飲食+運(yùn)動(dòng)對(duì)照組BMI100例多因素分析胰島素抵抗對(duì)干預(yù)療效分析大慶研究與國(guó)外相關(guān)研究(1980-1

4、992)比較作者例數(shù)隨訪目的 （大慶）研究是為了在某一特定人群（IGT)，采取某一特定的方法(生活方式干預(yù)），證明某種假設(shè)（生活方式干預(yù)可預(yù)防糖尿病的發(fā)生）的正確 (合理性和可行性）。然后以這種假設(shè)去說(shuō)服人,讓人們采取行動(dòng)解決問(wèn)題。 （大慶）研究是為了改變現(xiàn)狀（降低中國(guó)乃至世界的糖尿病發(fā)病率,當(dāng)時(shí)并未提出代謝綜合征）。 目的 （大慶）研究是為了在某一特定人群（IGT)，采取某一三.當(dāng)前2型糖尿病預(yù)防研究的局限及尚未能解決和正在解決的問(wèn)題三.當(dāng)前2型糖尿病預(yù)防研究的局限及尚未能解決和正在解決的問(wèn)題 生活方式干預(yù)預(yù)防糖尿病合理性 成本效益? 對(duì)預(yù)防心腦血管病是否有益?可行性 多少人能長(zhǎng)期堅(jiān)持? 生

5、活方式干預(yù)預(yù)防糖尿病合理性 成本效益?藥物干預(yù)預(yù)防糖尿病的合理性和可行性最佳劑量？成本效益?耐受性？毒副作用?預(yù)防了糖尿病or 提前治療?藥物干預(yù)預(yù)防糖尿病的合理性和可行性最佳劑量？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 過(guò)強(qiáng)的生活方式干預(yù)會(huì)大大增加退出干預(yù)的人數(shù)，中等強(qiáng)度的干預(yù)才能既有效又能為廣大人群接受并常年堅(jiān)持。

12、過(guò)強(qiáng)的生活方式干預(yù)會(huì)大大增加退出干預(yù)的人數(shù)，中等強(qiáng)度的 DA-QING STUDY 未采用過(guò)于激烈的強(qiáng)度大的干預(yù)，失訪率僅8%. DPP，DPS 體重減輕第一年達(dá)標(biāo)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糖尿病一級(jí)預(yù)防研究 對(duì)象 干預(yù)措施 結(jié)果大慶研究 IGT 生活方式 50DPP研究 IGT生活方式+雙胍 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改變生活方式的艱難 說(shuō)了,但未聽(tīng)見(jiàn)聽(tīng)見(jiàn)了,但未理解理解了,但未接受接受了,但未付諸行動(dòng)行動(dòng)了,但能堅(jiān)持多久?改變生活方式的艱難 說(shuō)了,但未聽(tīng)見(jiàn)聽(tīng)見(jiàn)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