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1、2小时糖耐量试验的临床意义,Finnish Academy Research Fellow 芬兰赫尔辛基大学及 国立公共卫生研究院 北大糖尿病论坛2007年 5 月12日， 北京,乔青 MD, Ph.D,糖尿病诊断试验:历史回顾,糖尿病,症状 尿糖 空腹血糖 糖耐量 (1913年),Jacobsen A. Biochem Z 51:443, 1913,Normal Glucose Homeostasis Daytime Profile (N=12, health; Mean + 95%CI),Owens D ,Zinman B & Bolli G : Lancet 358,739,2001,M
2、eal Times,80,40,0,Insulin (mU/L),08.00,13.00,16.00,19.00 h,Glucose (mmol/L),8,4,2,6,什么是糖耐量异常?,1. 高于均值+2标准差可诊断糖尿病: 根据年轻 (20-30 岁) 健康人群资料, 纯统计！不考虑临床，预后及年龄 (50年代) 2h全血血糖=120mg/dl (100g糖耐量)诊断糖尿病 (血浆血糖比全血高14-16%!) 发病率高 诊断标准混乱 (血样，服糖量，时间) 直到70年代,Mosenthal H.O. and Barry E (Ann Intern Med 33: 1175, 1950),什
3、么是糖耐量异常?,1. 均值+2标准差 2. 血糖双峰分布,小血管病变 (眼病，肾病等): 糖尿病高发人群, 如Pima Indians (1971), Mexican-Americans, Micronesians, Polynesians,Bimodal distribution of glucose and prevalence of retinopathy and proteinuria in Pima Indians,Knowler WC etc. Diabetes Metab Rev 6: 1-27, 1990,Copyright 1994 BMJ Publishing Group
4、 Ltd.,McCane, D R et al. BMJ 1994;308:1323-8,5 year cumulative incidence (top) and prevalence (bottom) of retinopathy in relation to tenths of 2hPG, FPG, and HBa1c,现用诊断标准,NDDG1979: FPG=7.8 mmol/l and 75g OGTT at , 1, 1, 2 hours WHO 1980: adopted the NDDG criteria, 2h glucose=11.1 mmol/l after 75g lo
5、ad as “金标准” WHO 1985: slightly modified the WHO 1980 criteria ADA 1997: FPG 7.8 mmol/l to 7.0 mmol/l，Not use OGTT WHO 1999: adopted the FPG 7.0 mmol/l, retained the 2h OGTT WHO/IDF 2006: no changes except for some terms,什么是糖耐量异常?,1. 均值+2标准差 2. 血糖双峰分布,小血管病变 3.大血管病变: 心脑血管及外周血管病变,Dysglycemia Normoglyce
6、mia in Acute and Stable CV Disease,Consecutive pts: 2107 in-pts; 2854 out-pt elective CV consults in Europe (71% men; mean age 66),OGTT/old DM in 1587 (75%) acute & 1857 (66%) elective pts before discharge or within 2 mo.,Euro Heart Survey Bartnik M et al; Eur Ht J 2004;1880,The DECODE Study (http:/
7、www.ktl.fi/decode/index.html) Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe,2-hour plasma glucose (mmol/l),7.8,7.811.0,11.1,Total,6.1,6.16.9,21,968,2,020,2,562,893,316,206,24,846,3,119,7.0,276,378,489,1,143,Fasting,plasma,glucose,(mmol/l),Total,24,264,3,833,1,011,29,
8、108,Adapted from DECODE Study Group. Br Med J 1998;317:371375,Classification of individuals - the DECODE Study,Discrepancy of FPG and 2hPG criteria in the DECODA study,Diabetologia 2000; 43: 1470-1475,30-39 40-49 50-59 60-69 70-79 80-89,Prevalence (%) of newly diagnosed DM in DECODE populations,The
9、DECODE group, Diabetes Care 2003; 26: 61-69.,30-39 40-49 50-59 60-69 70-79 80-89,Prevalence (%) of IGT but not IFG increases with age in DECODE population,The DECODE group, Diabetes Care 2003; 26: 61-69.,Hazards ratio for all-cause mortality in subjects without prior history of diabetes,Adj. for age
10、, cohorts, sex, chol, BMI, SBP, smoking,2-hour plasma glucose (mmol/l),Adapted from DECODE Study Group, Lancet 1999;354:617621,All-cause mortality has a linear relationship with 2-hour plasma glucose,DECODE, Diabetes Care 2003; 26: 688-696,CVD mortality by 2-hour plasma glucose,Frequency,Hazard rati
11、o,DECODE, Diabetes Care 26: 688-696,CVD mortality by fasting plasma glucose,Frequency,Hazard ratio,DECODE, Diabetes Care 26: 688-696,Hazard ratio for mortality by FPG categories, the DECODA Study,Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smoking Model 2: Additional adjustment for
12、2hPG,DECODA Study Group, Diabetologia 2004; 47: 385-394,Hazard ratio for mortality by 2hPG categories, the DECODA Study,Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smoking Model 2: Additional adjustment for FPG,DECODA Study Group, Diabetologia 2004; 47: 385-394,Incidence density (no
13、./per 1000 person-years),Qiao et al. Diabetes Care 2003; 26:2910-2914,Hazard ratio (95% CI) by glucose status at baseline and at follow-up,Adjusted for age, sex, WHR, SBP, Chol, HDL and smoking,Qiao et al. Diabetes Care 2003; 26:2910-2914,Effect of intensive glycemic control on the risk for any type
14、 of macrovascular events,C Stettler, Am Heart J 2006; 152:27-38,STOP-NIDDM Trial (1),Myocardial infarction Angina Revascularization procedure Cardiovascular death Cerebrovascular event or stroke Peripheral vascular disease Any cardiovascular event,Favours Acarbose,Favours Placebo,Chiasson JL JAMA 20
15、03; 23: 290:486-94,The main changes from baseline to 3 years: Acarbose Placebo,STOP-NIDDM Trial (3),Body Weight (kg) -1.15 0.26 BMI (kg/m2) -0.60 -0.12 Waist (cm) -0.62 0.17 SysBP (mmHg) -0.97 -0.05 DiasBP (mmHg) -2.8 -1.4 2hPG (mmol/L) -0.63 0.04 Triglycerides (mmol/L) -0.18 -0.04,All p0.01 for the difference between the two groups,Summary,Diabetes diagnosed by either FPG or 2h criteria are risk factor for CVD disease, but 2h criteria identify those who are not diabetic by FPG alone IGT is over IFG with regard to the prediction of the CVD More trials are required to show that intensive t
