糖尿病高危(IGT)人群的干预.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,2型糖尿病一级预防,糖尿病高危(,IGT),人群的干预,中日友好医院 李光伟,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 Diabetes,The metabolic syndrome of insulin resistance&cardiovascular disease,Reduced,Fibrinolysis,Complex,dyslipidemia,TG,sdLDL,HDL,EndothelialDysfunction,Chronic,systemicInflammation,Athero,-sclerosis&,CHD,VisceralObesity2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 standard 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 termTargeting insulin resistance or insulin insufficiency?Prevent diabetes or reverse to normal tolerance?,Standard 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 Group: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 increase 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,-,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 modification,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 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 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 lifestyle 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-4.73,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 presented,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 (19972000),77%,88%,0.25,tid,50,mg,tid,Incidence of Diabetes in Pharmacological intervention group of IGT in China,(,Yuexin,Wang,3 years),69%,50mg TID,P,harmacological interventions with,Acarbose,or,Metformin,could,reduce the risk of worsening to diabetes by 6080%,in Chinese,subjects with IGT.,Intervention with,A,carbose,seems,more effective,in Chinese,than that in Westerns,SUMMARY,How To Increase Effectivenessand Reduce Cost?,STRATEGY OF THE INTERVENTION,Incidence/,pys,Reduction of DM in peoples with IGT stratified by INS-SEN and secretion,G 4 G3,G2,G1,药物预防的有效性,DPP,二甲双呱 对年轻肥胖者更有效,25-44 44%,45-59 31%,60 11%,BMI,22-30 3%,30-35 16%,35,53%,药物预防的有效性,DPP,方式干预 与二甲双呱疗效比较,25-44 8%,45-59 41%,60 69%,BMI,22-30 63%,30-35 53%,35,-4%,药物预防的有效性,DPP,二甲双呱 的有效性,PG2H(mg/dl),140-153 41%,154-172 38%,173-199 26%,Targeting Insulin resistance or insulin insufficiency?,Prevent diabetes or reverse to normal glucose tolerance?,How to Screen?One Step or Two Steps?,How can we have IGT clinical trials,Get Out Of the Ivory Tower?,让临床试验走出神殿,任重而道远,THANK YOU,