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1、2型糖尿病一级预防 糖尿病高危 IGT 人群的干预 IDF 主席开幕式演讲 YESTERDAY TODAY AND TOMORROW KGMM Alberti Prevention Prevention and Prevention 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 Insulin Resistance Hypertension Type
2、 2 Diabetes The metabolic syndrome of insulin resistance cardiovascular disease Reduced Fibrinolysis Complex dyslipidemia TG sdLDL HDL Endothelial Dysfunction Chronic systemic Inflammation Athero sclerosis CHD Visceral Obesity 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型糖尿病预防研究的局限 及尚未能解决和正在解决的问
3、题 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 大庆研究中糖尿病每百人年发病率 11 5 10 8 11 4 17 2 饮食组运动组饮食 运动对照组 BMI 25 5 1 6 8 13 3 8 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 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
4、 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 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 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 Unanswered Questions How to conduct the screening One step or two steps OGTT or sta
5、ndard meal test How to do the prevention Lifestyle or pharmacological HOW to translate these successful findings in Da 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 Standa
6、rd protocol or tailored one How To Increase Effectiveness and Reduce Cost Lifestyle or Medication Method of intervention Diet Group BMI 25 reduce calorie intake to reduce weight 0 5 1 0 kg month Exercise Group To increase amount of leisure physical exercise by at least one unit Diet and Exercise Gro
7、up Same as Diet and Exercise group Controls Only exposed to general information about DM from public health education No special advice Table 1 Exercise units Each category represents one unit Lifestyle How Intensive is Effective Da Qing Study At least decrease 50 gm of Carbohydrate day at least inc
8、rease 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 week Efficacy of lifestyle intervention Comparison of Da Qing Study to DPP and DPS Incidence 100pys CONTROL DIET EXERCISE Da
9、Qing Study BMI 22 4 22 2 13 3 6 8 49 Da Qing Study BMI 27 5 27 0 17 2 11 4 34 DPP BMI 34 2 33 9 11 1 4 8 58 DPS BMI 31 3 31 0 9 6 4 8 58 Q Should The Chinese Need to Use Protocol in DPP or DPS in Their Future Prevention A Yes No Yes or no Weight loss 7 Trail for Prevention DM with lifestyle modifica
10、tion in US Trail for weight loss with medication orlistat in Chinese Lifestyle Olistat Weight Reduction Kg 3 00 6 05 Weight Reduction 3 67 7 45 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 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 intensiv
11、e prevention protocol than DPP may be working if only for preventing DM however reversing them to normal glucose tolerance more intensive prevention protocol is needed Pharmacological Intervention Prevention 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 50 DPP研究 IGT生活方式 双胍 58 31 DPS研究 IGT 生
12、活方式 58 STOP NIDDM IGT 阿卡波糖 33 Lifestyle or Medication Lifestyle intervention studies 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 lifesty
13、le changes in longer term This has lead to consideration pharmacotherapy Simpson RW Shaw JE Zimmet PZ Diabetes Res Clin Pract 2003 59 165 80 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 Incidence pys of DM in IGT subject stratified by Ins sensitivity Sensitive IAI 4 73 Resistant IAI 4 7
14、3 ie FPG FINS 114 Incidence of DM 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 2001 presen
15、ted 58 31 STOP NIDDM 1418 IGT involved follow up 3 years 2001 presented 33 Incidence of Diabetes in Pharmacological intervention group of IGT in China 1997 2000 77 88 0 25 tid 50mg tid Incidence of Diabetes in Pharmacological intervention group of IGT in China Yuexin Wang 3 years 69 50mg TID P Pharm
16、acological interventions with harmacological interventions with AcarboseAcarbose or or MetforminMetformin could could reduce reduce the risk of worsening to diabetes by the risk of worsening to diabetes by 60 80 60 80 in Chinesein Chinese subjects with IGT subjects with IGT Intervention with Acarbosecarbose seems more effective in Chinese than that in Westerns SUMMARY How To Increase Effectiveness and Reduce Cost STRATEGY OF THE INTERVENTION Incidence pys Reduction of DM in peoples with IGT stra
