3夏文芳成人糖尿病患者管理的营养治疗建议.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,成人糖尿病患者管理的营养治疗建议,华中科技大学附属协和医院内分泌科 夏文芳,2002,年美国糖尿病学会,(ADA),首次提出“基于循证的糖尿病营养供给量标准”，并制定出证据分级标准,2006,年,ADA,强调，糖尿病患者应接受注册营养（医）师指导下的个性化营养治疗，以达到理想的治疗目标,2010,年,ADA,强调由于,MNT,可节约医疗花费并改善糖尿病临床结局，相关保险公司或其他医疗保障应该支付,MNT,的费用,2013,年,ADA,的营养治疗推荐中提出没有一种固定的饮食模式适合所有糖尿病患者，强调在循证基础上制定个体化营养治疗方案,2010,年，由国内糖尿病和临床营养领域的专家根据糖尿病,MNT,的循证医学证据以及科学研究进展，结合中国糖尿病的流行病学特点和营养现状，共同起草了我国首个糖尿病,MNT,指南,中国糖尿病医学营养治疗指南（,2010,版）,推荐意见,推荐,级别,证据,1,对于所有患有糖尿病或有罹患糖尿病风险的超重个体，应建议,减轻体重,A,RCT,研究、,指南推荐,2,在超重和肥胖的胰岛素抵抗的个体中，适当地减轻体重可以改善胰岛素抵抗,A,RCT,研究、,Meta-,分析,3,低碳水化合物或低脂肪的限制能量的饮食,在短期内（,1,年内）可有效减轻体重,B,RCT,4,就减重效果而言，限制能量摄入较营养素比例更关键,B,RCT,、,Meta-,分析,5,低碳水化合物饮食患者，应当监测血糖、血脂、肾功能、蛋白质摄入情况（对于伴有肾病的个体），必要时调整降糖措施,D,专家意见,6,个体化的饮食计划应该包括食物选择的优化，符合中国居民膳食推荐摄入量，以获得各种营养素合理摄入,D,专家意见,7,不推荐,2,型糖尿病患者长期接受极低能量（,800kcal/d,）治疗,D,指南推荐、,专家意见,25,克 小米,37.5,克 咸面包,35,克 淡馒头,25,克 大米,35,克 窝头,25,克 赤豆,25,克 卷面,供蛋白质,2,克，脂肪,0.5,克，碳水化合物,20,克，热量,90,千卡,主食类,Effectiveness of nutrition therapy,Recommendation,Evidence rating,Nutrition therapy is recommended for all people,with type 1 and type 2 diabetes as an effective,component of the overall treatment plan.,A,营养疗法是推荐给所有的,1,型和,2,型糖尿病患者，作为整体治疗计划的一种有效组成部分。,Effectiveness of nutrition therapy,Recommendation,Evidence rating,Individuals who have diabetes should receive,individualized MNT as needed to achieve,treatment goals,preferably provided by an,registered dietitian,（,RD,）,familiar with the,components of diabetes,medical nutrition,therapy,（,MNT,）,.,A,患有糖尿病的人应该接受个体化的医学营养治疗（,MNT,）以实现治疗的目标，最好通过熟悉糖尿病医学营养治疗的注册营养师（,RD,）的指导下完成,Effectiveness of nutrition therapy,Recommendation,Evidence rating,For individuals with type 1 diabetes,participation,in an intensive flexible insulin therapy education,program using the carbohydrate counting meal,planning approach can result in improved,glycemic control.,A,对于,1,型糖尿病患者，推荐用碳水化合物计量的饮食计划并参加集中而多样的胰岛素治疗教育项目，可以获得良好的血糖控制,Effectiveness of nutrition therapy,Recommendation,Evidence rating,For individuals using fixed daily insulin doses,consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia.,B,对于每位糖尿病患者，每日固定的胰岛素剂量、时间和数量固定的碳水化合物的摄入量，能明显改善患者的血糖控制和减少低血糖的风险。,Effectiveness of nutrition therapy,Recommendation,Evidence rating,A simple diabetes meal planning approach such,as portion control or healthful food choices may,be better suited to individuals with type 2,diabetes identified with health and numeracy,literacy concerns.This may also be an effective,meal planning strategy for older adults.,C,一个简单的糖尿病膳食计划的方法如选择营养成分或健康食品，可以更适合于健康和计算能力的有困难的,2,型的人糖尿病患者。这也可能是一种有效的老年人的膳食计划策略。,代餐治疗是,MNT,的重要组成部分,代餐治疗,：,MNT,的重要组成部分，满足了,专业性,和,便捷性,的双重需求,首先，代餐治疗是由专业营养师配制的，针对高血糖人士代谢特点的，营养素配比合理的食品。有效避免长期饮食限制有可能发生的营养不良,其次，通过代餐治疗能精确控制患者能量摄入，避免,MNT,可操作性不强的弱点。,第三，代餐治疗的形式多种多样，可通过调整风味和口感来增强患者接受度，且使用方法灵活多变。,高血糖人士专用代餐食品,营养全面均衡完整的原装进口营养品,符合多个医学学会营养指南,Man JI et al.,Nutr Metab Cardiovasc,Dis 2004;12:373-394.American Diabetes AssociationDiabetes Care,2007;30:S48-S65.,EASD:European Association for the Study of Diabetes,ADA:American Diabetes Association,SFA:saturated fatty acids,MUFA:monounsaturated fatty acids,EASD,（,%,，能量）,ADA,（,%,，能量）,益力佳配方,蛋白质,10-20,15-20,20,脂肪,35,-,33,饱和脂肪酸,饱和脂肪酸,+,反式脂肪酸,10,视个体而定,单不饱和脂肪酸,7,限制反式脂肪酸,胆固醇,200,毫克,/天,视个体而定,单不饱和脂肪酸,3,碳水化合物,45-60,至少,130,克,/,天,47,Effectiveness of nutrition therapy,Recommendation,Evidence rating,People with diabetes should receive DSME according,to national standards and diabetes self-management,support,（,DSME,）,when their diabetes is diagnosed,and as needed thereafter.,B,，,A,，,E糖尿病患者在诊断之后应该接受国家标准的糖尿病自我管理支持（,DSME,）方案,Energy balance,Recommendation,Evidence rating,For overweight or obese adults with type 2 diabetes,reducing energy intake while maintaining a healthful eating,pattern is recommended to promote weight loss.,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,超重或肥胖的成年人,2,型糖尿病患者，减少能量摄入的同时保持健康的饮食模式来减轻体重。在一些糖尿病患者特别是早期的糖尿病患者适度减重可提供临床益处（改进血糖，血压，和,/,或血脂）。为了达到适度的体重下降，需要进行持续的强化生活方式干预（营养治疗，运动和行为的改变）。,ADA,发布最新营养指南,在,LOOK AHEAD,等研究究分别采用了营养代餐、低脂肪或高蛋白或低脂肪高碳水化合物的饮食模式,减重干预显著升高高密度脂蛋白，降低甘油三酯、血压等心血管疾病危险因素,Optimal mix of macronutrients,Recommendation,Evidence rating,Evidence suggests that there is not an ideal percentage of,calories from carbohydrate,protein,and fat for all people,with diabetes;,therefore,macronutrient distribution should be based on,individualized assessment of current eating patterns,preferences,and metabolic goals.,B,，,E,有证据表明没有一个来自碳水化合物，蛋白质，脂肪理想的能量比例适用于所有的糖尿病患者。因此，应该是基于当前饮食模式、嗜好和代谢的目标的评估制定个性化的营养素的比例。,Eating patterns,Recommendation,Evidence rating,A variety of eating patterns(combinations of different foods,or food groups)are acceptable for the management of,diabetes.Personal preferences(e.g.,tradition,culture,religion,health beliefs and goals,economics)and metabolic,goals should be considered when recommending one eating,pattern over another.,E,各种饮食模式（组合不同的食物或食物组）都可以用来治疗糖尿病。在向糖尿病患者推荐一种饮食模式时要考虑患者的个人喜好（例如，传统，文化，宗教，健康的信念和目标，经济学）和代谢目标。,蛋白质占,16%-18%,碳水化合物占,45,维生素、无机盐要充足,脂肪占,36%-40%,控制总热能,饮食均衡 合理搭配,三大宏量营养素配比,地中海饮食,高血压膳食（,DASH,）,植物性饮食（素食）,低脂饮食,低碳水化合物饮食,多种饮食模式已被证明对糖尿病管理有益,食用适量的乳制品（主要是奶酪和酸奶）,每周食用,4,个蛋,较少食用红肉（频率低，量少）,随餐饮用少量或适量的葡萄酒,地中海饮食,含有丰富的植物性食物（如水果、蔬菜、面包，其他形式的谷物、豆类、坚果和籽实）,粗加工，当地种植，当季新鲜食物,新鲜水果作为每日的甜点，特殊情况下才使用浓缩糖浆或蜂蜜,使用橄榄油作为膳食脂肪的主要来源,包含全素饮食（不食用肉类和动物性产品）和蛋奶素饮食,不食用肉类食物但食用蛋类和（或）乳制品,素食饮食模式摄人较少饱和脂肪和胆固醇，摄入较多水果、蔬菜、谷类、坚果、大豆产品、膳食纤维和植物化学物质，有助降低慢性病发病风险,植物性饮食（素食）,低脂饮食,强调多摄食蔬菜、水果、淀粉类（例如面包、饼干、面食、全谷类、含淀粉的蔬菜）瘦肉和低脂乳制品,每日总脂肪摄人量占总能量的,30,以下，饱和脂肪的摄人量,总能量,12,）时，游离果糖不会对血清甘油三酯产生不利影响,Fructose,Recommendation,Evidence rating,People with diabetes should limit or avoid intake of SSBs,(from any caloric sweetener including high fructose corn,syrup and sucrose)to reduce risk for weight gain and,worsening of cardiometabolic risk profile.,B,强调糖尿病患者应限制或避免摄入含糖饮料（即含有能量型甜味剂，包括高果葡糖浆和蔗糖），以降低体重增加的风险和心血管代谢的负担,NNSs and hypocaloric sweeteners,Recommendation,Evidence rating,Use of NNSs has the potential to reduce overall calorie and,carbohydrate intake if substituted for caloric sweeteners,without compensation by intake of additional calories from,other food sources.,B,在不从其他食物中摄取额外能量的情况下，使用非能量型甜味剂,来替代能量型甜味剂，则有助于减少总能量和碳水化合物的摄人。,对于肾功能正常的糖尿病患者，基于目前的研究证据，有利于血糖控,制或降低心血管风险的理想蛋白质摄人量尚无定论，因此需结合个体,情况制定蛋白质摄入目标。,Recommendation,Evidence rating,For people with diabetes and no evidence of diabetic kidney,disease,evidence is inconclusive to recommend an ideal,amount of protein intake for optimizing glycemic control or,improving one or more CVD risk measures;therefore,goals,should be individualized.,C,蛋白质,对于糖尿病肾病患者（包括微量和大量蛋白尿），均不建议将蛋白质摄入量减少至正常水平以下（,0.8 g/kgd,），因为目前证据未能证明单纯低蛋白饮食可改善血糖、降低心血管疾病风险及改善肾小球滤过率（,GFR,）,Recommendation,Evidence rating,For people with diabetes and diabetic kidney disease(either,micro-or macroalbuminuria),reducing the amount of dietary,protein below usual intake is not recommended because it,does not alter glycemic measures,cardiovascular risk,measures,or the course of GFR decline.,A,蛋白质,2,型糖尿病患者摄入优质蛋白质可能有助提高胰岛素应答，却不升高血,糖水平。因此，蛋白含量高的碳水化合物不能用于治疗或预防低血糖,Recommendation,Evidence rating,In individuals with type 2 diabetes,ingested protein appears to,increase insulin response without increasing plasma glucose,concentrations.Therefore,carbohydrate sources high in,protein should not be used to treat or prevent hypoglycemia.,B,蛋白质,糖尿病患者适合的每日总脂肪推荐摄人比例仍无定论。美国医学研究所,（,IOM,）,提出正常成年人膳食脂肪摄人在20-35时，冠心病及肥胖的发病风险最低,。然而，这一建议并非针对糖尿病患者，由于目前研究证据有限，仍需,结合个体情况制定摄人目标。从已有的研究来看，脂肪的质要比量重要,。,Recommendation,Evidence rating,Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes;therefore,goals should be individualized.,Fat quality appears to be far more important than quantity,C,，,B,Total fat,高单不饱和脂肪酸（,MUFA,）饮食，一种地中海饮食模式，可改善血糖控制并,降低心血管疾病风险。,MUFA,饮食可作为低脂肪，高碳水化合物饮食模式的一,种有效的替代方法,Recommendation,Evidence rating,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,MUFAs/PUFAs,对于糖尿病患者，尚无明确证据支持,-,3,（,EPA,与,DHA,）补充剂对预防或者治疗心血管事件有益。,Recommendation,Evidence rating,Evidence does not support recommending omega-3(EPA and,DHA)supplements for people with diabetes for the prevention,or treatment of cardiovascular events.,A,Omega-3 fatty acids,与针对普通人群的建议一致，推荐糖尿病患者多摄入含有长链,-,3,脂肪酸,（含脂肪多的鱼中,EPA,及,DHA,）和,-,3,亚麻酸（,ALA,）的食物。观察性研究显,示它们对脂蛋白和预防心脏病有益,Recommendation,Evidence rating,As recommended for the general public,an increase in foods,containing long-chain omega-3 fatty acids(EPA and DHA),(from fatty fish)and omega-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.,A,Omega-3 fatty acids,同普通人群一样，推荐糖尿病患者每周至少吃两次（两份）鱼（尤其,是含脂肪多的鱼，如三文鱼等）。,Recommendation,Evidence rating,The recommendation for the general public to eat fish,(particularly fatty fish)at least two times(two servings)per,week is also appropriate for people with diabetes.,B,Omega-3 fatty acids,少数随机对照研究显示每日摄入,1.6,3.0g,膳食来源的植物甾烷醇或植,物固醇对糖尿病和血脂异常患者降低总胆固醇和低密度脂蛋白可能有益,Recommendation,Evidence rating,Individuals with diabetes and dyslipidemia may be able to modestly reduce total and LDL cholesterol by consuming 1.6,3 g/day of plant stanols or sterols typically found in enriched foods.,C,Plant stanols and sterols,脂肪成分中的饱和脂肪酸，膳食胆固醇和反式脂肪酸与普通人群预防,心血管疾病的推荐相同。,Recommendation,Evidence rating,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,Saturated fat,dietary cholesterol,and,trans fat,于维生素或矿物质补充剂，无明确证据表明对不存在缺乏的糖尿病患者有益。,出于长期安全性因素考虑，不推荐常规补充抗氧化剂，如维生素,E,、维生素,C,及胡萝卜素。,Recommendation,Evidence rating,There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.,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.,C,A,Micronutrients and herbal supplements,无足够证据支持糖尿病患者应常规性服用微量营养素，如铬、镁及维,生素,D,，以改善血糖控制,关于中草药制剂，尚无明确证据支持肉桂及其他植物类补充剂对糖尿,病患者有益,Recommendation,Evidence rating,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.,There is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes.,C,C,Micronutrients and herbal supplements,仍推荐个体化的饮食计划包括将食物进行优化组合，满足所有微量营,养素推荐摄入标准,Recommendation,Evidence rating,It is recommended that individualized meal planning include,optimization of food choices to meet recommended dietary,allowance/dietary reference intake for all micronutrients.,E,Micronutrients and herbal supplements,若糖尿病患者选择饮酒，他们应建议适量（成年女性每天只喝一杯酒或,更少，和成年男子每天两杯酒或更少的）,饮酒会增加延迟糖尿病低血糖风险，特别是如果注射胰岛素或服用胰岛素,促泌剂。教育和宣传有关延迟低血糖的识别和管理是必要的,Recommendation,Evidence rating,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,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,Alcohol,建议糖尿病患者减少钠摄取，一般小于,2.3,克,/,天。,对糖尿病合并高血压的患者，是否进一步减少钠摄入量应个体化。,Recommendation,Evidence rating,The recommendation for the general population to reduce sodium to less than 2,300 mg/day is also appropriate for people with diabetes.,For individuals with both diabetes and hypertension,further reduction in sodium intake should be individualized.,B,B,Sodium,美国糖尿病协会（,ADA,）发布最新营养指南,提出糖尿病患者的日常膳食计划不应仅注重个别营养素或某单一食物,而应注意搭配与个体化饮食模式,美国糖尿病协会（,ADA,）发布最新营养指南,重点关注整体饮食模式及患者的喜好，而非特定的膳食处方,指南文件中提到的都是“饮食计划,(eating plans)”,或“饮食模式,(eating patterns)”,，而非饮食,(diet),美国糖尿病协会（,ADA,）发布最新营养指南,新指南回顾了地中海饮食、素食、低脂肪饮食、低碳水化合物饮食、预防高血压膳食疗法（,DASH,）等几种常见饮食计划的循证证据，但并未特别推荐其中一种,新指南建议，应根据患者的个人喜好（包括习俗、文化、宗教、健康理念和目标、经济状况）及其要达到的代谢目标来选择适合自己的饮食计划,重要的是，医生在确诊患者患有糖尿病后应尽快将其转诊至营养科进行营养治疗,美国糖尿病协会（,ADA,）发布最新营养指南,在碳水化合物方面，新指南推荐可选用营养价值高、富含纤维的食物，并呼吁不要饮用含糖饮料,新指南推荐，应根据患者个人目前的饮食模式、偏好及目标据顶其营养素的分配比例,新指南推荐用含不饱和脂肪酸的食物替代饱和脂肪酸含量较高的食物，并推荐个体化的钠盐摄入推荐值，建议糖尿病患者不要应用特定的维生素或矿物质补充剂、,-3,脂肪酸及中草药,谢 谢！,