2014+ADA+糖尿病医学诊疗标准(执行摘要)

Executive Summary: Standards of Medical Care in Diabetesd2014 CURRENT CRITERIA FOR THE DIAGNOSIS OF DIABETES c A1C $6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay. Or c Fasting plasma glucose (FPG) $126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h. Or c Two-hour plasma glucose $200 mg/ dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT). The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. Or c In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose$200 mg/dL (11.1 mmol/L). c In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS c Testing to detect type 2 diabetes and prediabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI $25 kg/m2) and who have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45 years. B c If tests are normal, repeat testing at least at 3-year intervals is reasonable. E c To test for diabetes or prediabetes, the A1C, FPG, or 2-h 75-g OGTT are appropriate. B c In those identified with prediabetes, identify and, if appropriate, treat other cardiovascular disease (CVD) risk factors. B SCREENING FOR TYPE 2 DIABETES IN CHILDREN c Testing to detect type 2 diabetes and prediabetes should be considered in children and adolescents who are overweight and who have two or more additional risk factors for diabetes. E SCREENING FOR TYPE 1 DIABETES c Inform type 1 diabetic patients of the opportunity to have their relatives screened for type 1 diabetes risk in the setting of a clinical research study. E DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS c Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. B c Screen for gestational diabetes mellitus (GDM) at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. A c Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the OGTT and nonpregnancy diagnostic criteria. E c Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. B c Women with a history of GDM found to have prediabetes should receive lifestyle interventions or metformin to prevent diabetes. A c Further research is needed to establish a uniform approach to diagnosing GDM. E PREVENTION/DELAY OF TYPE 2 DIABETES c Patients with impaired glucose tolerance (IGT) A, impaired fasting glucose (IFG) E, or an A1C 5.7–6.4% E should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 min/week of moderate activity such as walking. c Follow-up counseling appears to be important for success. B c Based on the cost-effectiveness of diabetes prevention, such programs should be covered by third-party payers. B c Metformin therapy for prevention of type 2 diabetes may be considered in those with IGTA, IFG E, or an A1C 5.7– 6.4% E, especially for those with BMI .35 kg/m2, aged ,60 years, and women with prior GDM. A c At least annual monitoring for the development of diabetes in those with prediabetes is suggested. E c Screening for and treatment of modifiable risk factors for CVD is suggested. B GLUCOSE MONITORING c Patients on multiple-dose insulin (MDI) or insulin pump therapy should do self-monitoring of blood glucose (SMBG) prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. B c When prescribed as part of a broader educational context, SMBG results may be helpful to guide treatment decisions and/or patient self- management for patients using less DOI: 10.2337/dc14-S005 © 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details. Diabetes Care Volume 37, Supplement 1, January 2014 S5 EX EC U TIV E SU M M A R Y guide.medlive.cn frequent insulin injections or noninsulin therapies. E c When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique and SMBG results, as well as their ability to use SMBG data to adjust therapy. E c When used properly, continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged $25 years) with type 1 diabetes. A c Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. C c CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. E A1C c Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). E c Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. E c Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes. E GLYCEMIC GOALS IN ADULTS c Lowering A1C to below or around 7% has been shown to reduce microvascular complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is ,7%. B c Providers might reasonably suggest more stringent A1C goals (such as ,6.5%) for selected individual patients, if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, long life expectancy, and no significant CVD. C c Less stringent A1C goals (such as ,8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, and extensive comorbid conditions and in those with long-standing diabetes in whom the general goal is difficult to attain despite diabetes self- management education (DSME), appropriate glucose monitoring, and effective doses of multiple glucose- lowering agents including insulin. B PHARMACOLOGICAL AND OVERALL APPROACHES TO TREATMENT Insulin Therapy for Type 1 Diabetes c Most people with type 1 diabetes should be treated with MDI injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII). A c Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. E c Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. A Screening c Consider screening those with type 1 diabetes for other autoimmune diseases (thyroid, vitamin B12 deficiency, celiac) as appropriate. B Pharmacological Therapy for Hyperglycemia in Type 2 Diabetes c Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. A c In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset. E c If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over 3 months, add a second oral agent, a glucagon-like peptide 1 (GLP- 1) receptor agonist, or insulin. A c A patient-centered approach should be used to guide choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia risk, and patient preferences. E c Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes. B MEDICAL NUTRITION THERAPY General Recommendations c Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan. A c Individuals who have prediabetes or diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. A c Because diabetes nutrition therapy can result in cost savings B and improved outcomes such as reduction in A1C A, nutrition therapy should be adequately reimbursed by insurance and other payers. E Energy Balance, Overweight, and Obesity c For overweight or obese adults with type 2 diabetes or at risk for diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss. A c Modest weight loss may provide clinical benefits (improved glycemia, blood pressure, and/or lipids) in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions (counseling about nutrition therapy, physical activity, and behavior change) with ongoing support are recommended. A Eating Patterns and Macronutrient Distribution c Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes B; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. E c A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal S6 Executive Summary Diabetes Care Volume 37, Supplement 1, January 2014 guide.medlive.cn preference (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another. E Carbohydrate Amount and Quality c Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control. B c For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium. B c Substituting low-glycemic load foods for higher-glycemic load foods may modestly improve glycemic control. C c People with diabetes should consume at least the amount of fiber andwhole grains recommended for the general public. C c While substituting sucrose- containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices. A c People with diabetes and those at risk for diabetes should limit or avoid intake of sugar-sweetened beverages (from any caloric sweetener including high-fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk profile. B Dietary Fat Quantity and Quality c Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized. C Fat quality appears to be far more important than quantity. B c In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher- carbohydrate eating pattern. B c As recommended for the general public, an increase in foods containing long-chain n-3 fatty acids (EPA and DHA) (from fatty fish) and n-3 linolenic acid (ALA) is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies. B c The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population. C Supplements for Diabetes Management c There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. C c Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. A c Evidence does not support recommending n-3 (EPA and DHA) supplements for people with diabetes for the prevention or treatment of cardiovascular events. A c There is insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes. C c There is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes. C c It is reasonable for individualized meal planning to include optimization of food choices to meet recommended daily allowance/dietary reference intake for all micronutrients. E Alcohol c If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). E c Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia is warranted. C Sodium c The recommendation for the general population to reduce sodium to ,2,300 mg/day is also appropriate for people with diabetes. B c For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. B Primary Prevention of Type 2 Diabetes c Among individuals at high risk for developing type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% of body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended. A c Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). B DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT c People with diabetes should receive DSME and diabetes self-management support (DSMS) according to National Standards for Diabetes Self- Management Education and Support when their diabetes is diagnosed and as needed thereafter. B c Effective self-management and quality of life are the key outcomes of DSME and DSMS and should be measured and monitored as part of care. C c DSME and DSMS should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes. C c DSME and DSMS programs are appropriate venues for people with prediabetes to receive education and support to develop and maintain behaviors that can prevent or delay the onset of diabetes. C care.diabetesjournals.org Executive Summary S7 guide.medlive.cn c Because DSME and DSMS can result in cost-savings and improved outcomes B, DSME and DSMS should be adequately reimbursed by third- party payers. E PHYSICAL ACTIVITY c As is the case for all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 min of physical activity each day. B c Adults with diabetes should be advised to perform at least 150 min/ week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. A c In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. A PSYCHOSOCIAL ASSESSMENT AND CARE c It is reasonable to include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes. B c Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/ mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. E c Routinely screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment. B HYPOGLYCEMIA c Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. C c Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. After 15 min of treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. E c Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed on its administration. Glucagon administration is not limited to health care professionals. E c Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen. E c Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks, to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A c Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition and/or declining cognition is found. B BARIATRIC SURGERY c Bariatric surgery may be considered for adults with BMI .35 kg/m2 and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. B c Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring. B c Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI,35 kg/m2 outside of a research protocol. E c The long-term benefits, cost- effectiveness, and risks of bariatric surgery in individuals with type 2 diabetes should be studied in well- designed controlled trials with optimal medical and lifestyle therapy as the comparator. E IMMUNIZATION c Annually provide an influenza vaccine to all diabetic patients $6 months of age. C c Administer pneumococcal polysaccharide vaccine to all diabetic patients $2 years of age. A one-time revaccination is recommended for individuals .65 years of age who have been immunized .5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. C c Administer hepatitis B vaccination to unvaccinated adults with diabetes who are aged 19–59 years. C c Consider administering hepatitis B vaccination to unvaccinated adults with diabetes who are aged $60 years. C HYPERTENSION/BLOOD