美国糖尿病学会2007版糖尿病诊疗标准

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美国糖尿病学会2007版糖尿病诊疗标准

筛查的效果取决于其安排 ,一般在保健机构以外的社区
筛查效果差 ,因为对筛查阳性者的失访率高 ,也很难达到区分高危者和低危者或已诊断者的目的。
根据专家意见自 45 岁起特别是 BMI ≥25 者应由保健机构每 3 年筛查一次 ,理由是遗漏者可在随后失访前得到复查 ,而且即使遗漏 ,3 年内也很少可能发生任何明显的糖尿病合并症 ,对年青超重者及同时伴有一个或更多其他 T2DM 危险因素者应进行多次筛查。
并在以后定期随诊 ,筛查是否发生糖尿病或糖尿病前期 ( E) 在孕妇第一次产前检查时就应进行 GDM 的危险评估 ,
孕妇 GDM 高危因素的临床特征及明显肥胖 ,有过 GDM 病史或生产过大于孕龄的新生儿、尿糖阳性、PCOS 或糖尿病家族史 ,均应尽快测血糖 ,如果 FP G ≥126 mg/ dl 或任意血糖 ≥200 mg/ dl ,需尽快于次日重复检查以确定诊断 ,除非病人已有明显的高血糖症状 ,如果第一次检查排除 GDM 需在孕 24～28 周间按下列两种方案之一进行复查。
·一步法 :作葡萄糖 100 g O GT T ·两步法 :先作 50 g 葡萄糖负荷后 1 h 血糖筛查试验 , 血糖值超过者再作 100 g O GT T 。两步法结果 80 % GDM 血糖 ≥140 mg/ dl ,90 %GDM 血糖 ≥130 mg/ dl 。 100 g O GTT 诊断指标 :空腹 ≥95 mg/ dl ,1 h ≥180 mg/ dl , 2 h ≥155 mg/ dl ,3 h ≥140 mg/ dl 。试验需过夜空腹 8～14 h ,诊断也可用 75 g O GTT 2 h 结果 ,但此结果对发现危险婴儿或母亲不如 100 g O GTT 3 h 结果更可靠。对低危者不需作血糖检查 : ·年龄 < 25 岁 ·妊娠前体重正常 ·为糖尿病患病率低的民族 ·1 级亲属无糖尿病者 ·无糖耐量异常者 ·无产科异常病史因为 GDM 妇女发生糖尿病的危险增加 ,必须产后 6～ 12 周和以后定期进行糖尿病筛查。

美国糖尿病学会2007版糖尿病诊疗标准(二)

・・
・
血脂异常（Ａ）
・
因为可能有药物不良反应和花费，尚无足够的证据支
持药物预防（）Ｅ
许多研究显示对糖尿病高危者（Ｆ或ＩＴ或两者）ＩＧＧ给
予各种干预，明显延迟发病甚至预防发病。用药物二甲双可
严重心血管事件。长期致力于糖尿病预防是否能影响大、小血管并发症尚不清楚，至少可延缓或减少糖尿病微血管并但发症，因后者与高血糖密切相关。总之，因为药物可能的不良反应与花费以及尚无充分证据支持常规加用药物可预防糖尿病，因此专业保健者首先应建议病人保持正常体重和运动。公共卫生信息、生专业人卫员和保健系统都应鼓励人们改变不良行为，取健康的生活采方式。更有效的ＴＤＭ初级预防方案尚有待研究。２
胍、卡波糖、尼可以及罗格列酮也显示可不同程度降低阿赛发病率，必须注意这些药对部分病人可引起不同严重程度但
的不良反应。
・
・
美国糖尿病干预项目（Ｐ）ＤＰ生活方式干预组：低脂（脂
维普资讯
中国பைடு நூலகம் 尿病杂志２０年第１卷第３０７５

2007年 ADA 指南中2型糖尿病高血糖治疗路径解读

2007年ADA 指南中2型糖尿病高血糖治疗路径解读北京大学糖尿病中心纪立农在最新版(2007)美国糖尿病联合会(ADA)的糖尿病临床指南(以下简称为“ADA指南”)中,有关2型糖尿病高血糖治疗路径备受医学界关注。

该治疗路径是ADA指南首次在控制高血糖的策略中,推荐具体降糖药使用的前后顺序和路径(图1)。

值得提到的是,该高血糖的控制策略是在2006年发表的ADA /EASD专家共识(以下简称“共识”)基础上制定的。

对于一贯严格遵循循证医学证据的ADA指南而言,该高血糖治疗路径的出现标志着在2型糖尿病药物治疗学上,已经有了大量循证医学数据来支持临床药物治疗路径的制定。

该高血糖治疗路径中,HbA1C≥7%被作为血糖控制不佳而需要采用进一步治疗措施的分界线。

即如果当前的治疗不能使HbA1C控制在7%以内,则需要启动治疗路径中下一步的治疗措施该高血糖治疗路径中,HbA1C≥7%被作为血糖控制不佳而需要采用进一步治疗措施的分界线。

即如果当前的治疗不能使HbA1C控制在7%以内,则需要启动治疗路径中下一步的治疗措施在以磺脲类药物、格列酮类药物为二线治疗的路径上,在使用胰岛素强化治疗(指以基础胰岛素和餐前胰岛素为主的胰岛素治疗)之前,可进行3种口服药物的联合治疗。

而在以基础胰岛素为二线治疗的路径上,则在基础胰岛素和二甲双胍治疗的基础上直接进入到胰岛素强化治疗。

殊途同归,各个治疗路径的终点是强化胰岛素加二甲双胍为主的治疗,加或不加用格列酮类解读1:生活方式干预+二甲双胍作为起始治疗ADA指南突破了传统指南中2型糖尿病治疗的流程,把二甲双胍推荐为与生活方式干预共同开始的一线治疗药物,建议新确诊的糖尿病患者应当在采取生活方式干预的同时应用二甲双胍。

这是因为指南的制定者已经认识到:生活方式干预不能长期有效地控制血糖,绝大多数患者需要药物联合治疗以维持良好的血糖控制。

解读2:二甲双胍作为一线治疗药物并贯穿治疗全程选择降糖药物是基于药物本身特点,包括:降糖效力,安全性、副作用、耐受性、依从性,病人负担、费用,降糖外的作用等,综合平衡多方面因素后才作出最适当的选择。

美国糖尿病学会糖尿病诊疗新标准解析

美国糖尿病学会糖尿病诊疗新标准解析新版标准对糖尿病的定义进行了微调。

根据新的标准，糖尿病是指血糖水平持续高于正常范围的一种代谢性疾病。

具体来说，空腹血糖水平≥126mg/dL（6.9mmol/L），餐后2小时血糖水平≥200mg/dL （11.1mmol/L），或随机血糖水平≥200mg/dL（11.1mmol/L）且伴有典型糖尿病症状，均可诊断为糖尿病。

糖化血红蛋白（HbA1c）水平≥6.5%也被视为糖尿病的诊断标准之一。

在新版标准中，糖尿病的分类也进行了调整。

目前，糖尿病分为1型、2型、其他特殊类型和妊娠期糖尿病。

其中，1型糖尿病是由于胰岛β细胞破坏导致胰岛素绝对缺乏；2型糖尿病则是由于胰岛素抵抗和胰岛β细胞功能缺陷引起；其他特殊类型糖尿病包括遗传性、后天因素导致的糖尿病等。

新版标准强调了早期诊断和治疗糖尿病的重要性。

对于疑似糖尿病患者，建议进行口服葡萄糖耐量试验（OGTT）或糖化血红蛋白检测。

在诊断糖尿病后，医生应根据患者的病情制定个性化的治疗方案，包括生活方式干预、药物治疗和定期监测。

在生活方式干预方面，新版标准推荐糖尿病患者采取低糖、低脂、高纤维的饮食，增加体育锻炼，减轻体重，并戒烟限酒。

对于2型糖尿病患者，药物治疗可根据血糖水平、胰岛β细胞功能和胰岛素抵抗程度选择合适的药物。

目前，常用的降糖药物包括磺脲类、噻唑烷二酮类、α葡萄糖苷酶抑制剂和胰岛素及其类似物。

在糖尿病并发症的预防和管理方面，新版标准提出了更具体的建议。

糖尿病患者应定期进行心血管、肾脏、视网膜和神经系统的检查，以早期发现并干预并发症。

新版标准还强调了糖尿病教育的重要性，医生应向患者提供关于疾病知识、药物治疗、生活方式调整和自我监测等方面的指导。

新版标准对糖尿病的定义进行了微调。

根据新的标准，糖尿病是指血糖水平持续高于正常范围的一种代谢性疾病。

美国糖尿病学会2007糖尿病诊疗标准(三)

・
糖尿病患者每次就诊均应该测量血压。收缩压≥１０３
ｍｍＨｇ或者舒张压 ≥ ８０ｍｍＨｇ的患者，该在另一天确认应
血压是否升高。（）Ｃ
ｂ目标血压．
・
压。（Ｅ）
高血压是糖尿病常见的合并病，响到大多数糖尿病患影者；尿病是否合并高血压取决于糖尿病类型、龄、胖、糖年肥种族。高血压也是心血管病和微血管并发症（比如视网膜病和肾病）的主要危险因素。ＴＤ的高血压常常是合并肾病１Ｍ
而且剂量应该适当）能达到血压控制目标。（）才Ｂ
・
的患者应该接受生活方式和行为治疗；果疗程达到３个况下，因在目标血压＜
１ｏ８３／ｏｍｍＨｇ是合理的。
・
老年高血压患者，该逐渐降低血压，应以便避免并发尽管多种药物联合应用，压仍然不能达标的患者，血
糖尿病患者如果有高血压指征，该测定直立位血应
症的出现。（Ｅ）
・
应该转诊给有经验的医师。（）Ｅ
应该是减少糖尿病患者心血管事件的药物，括：管紧张包血
素转化酶抑制剂（ＣＩ、管紧张素受体阻滞剂（Ｂ）８ＡＥ）血ＡＲｓ、－
・
妊娠糖尿病患者（ＤＭ）现慢性高血压时，了母Ｇ出为

2007美国糖尿病治疗指南(英文)

Standards of Medical Care in Diabetes—2007 A MERICAN D IABETES A SSOCIATIONCONTENTSI.CLASSIFICATION AND DIAGNOSIS,p.S4A.ClassiﬁcationB.DiagnosisII.SCREENING FOR DIABETES,p.S5 III.DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS,p.S7IV.PREVENTION/DELAY OF TYPE2 DIABETES,p.S7V.DIABETES CARE,p.S8A.Initial evaluationB.ManagementC.Glycemic control1.Assessment of glycemic controla.Self-monitoring of bloodglucoseb.A1C2.Glycemic goals3.Approach to treatmentD.Medical nutrition therapyE.Diabetes self-management educationF.Physical activityG.Psychosocial assessment and careH.Referral for diabetes managementI.Intercurrent illnessJ.HypoglycemiaK.ImmunizationVI.PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS,p.S15A.Cardiovascular disease1.Hypertension/blood pressurecontrol2.Dyslipidemia/lipid manage-ment3.Antiplatelet agents4.Smoking cessation5.Coronary heart diseasescreening and treatmentB.Nephropathy screening andtreatmentC.Retinopathy screening andtreatmentD.NeuropathyE.Foot careVII.DIABETES CARE IN SPECIFIC POPU-LATIONS,p.S24A.Children and adolescentsB.Preconception careC.Older individualsVIII.DIABETES CARE IN SPECIFICSETTINGS,p.S27A.Diabetes care in the hospitalB.Diabetes care in the school and daycare settingC.Diabetes care at diabetes campsD.Diabetes care at correctionalinstitutionsE.Emergency and disaster prepared-nessIX.HYPOGLYCEMIA AND EMPLOY-MENT/LICENSURE,p.S33X.THIRD-PARTY REIMBURSEMENTFOR DIABETES CARE,SELF-MANAGEMENT EDUCATION,ANDSUPPLIES,p.S33XI.STRATEGIES FOR IMPROVING DIA-BETES CARE,p.S33D iabetes is a chronic illness that re-quires continuing medical care andpatient self-management educationto prevent acute complications and to re-duce the risk of long-term complications.Diabetes care is complex and requires thatmany issues,beyond glycemic control,beaddressed.A large body of evidence existsthat supports a range of interventions toimprove diabetes outcomes.These standards of care are intendedto provide clinicians,patients,research-ers,payors,and other interested individ-uals with the components of diabetescare,treatment goals,and tools to evalu-ate the quality of care.While individualpreferences,comorbidities,and other pa-tient factors may require modiﬁcation ofgoals,targets that are desirable for mostpatients with diabetes are provided.These standards are not intended to pre-clude more extensive evaluation andmanagement of the patient by other spe-cialists as needed.For more detailed in-formation,refer to refs.1–3.The recommendations included arediagnostic and therapeutic actions thatare known or believed to favorably affecthealth outcomes of patients with diabetes.A grading system(Table1),developed bythe American Diabetes Association(ADA)and modeled after existing methods,wasutilized to clarify and codify the evidencethat forms the basis for the recommenda-tions.The level of evidence that supportseach recommendation is listed after eachrecommendation using the letters A,B,C,or E.I.CLASSIFICATION ANDDIAGNOSISA.ClassiﬁcationIn1997,ADA issued new diagnostic andclassiﬁcation criteria(4);in2003,modi-ﬁcations were made regarding the diagno-sis of impaired fasting glucose(IFG)(5).The classiﬁcation of diabetes includesfour clinical classes:●Type1diabetes(results from␤-cell de-struction,usually leading to absoluteinsulin deﬁciency)●Type2diabetes(results from a progres-sive insulin secretory defect on thebackground of insulin resistance)●Other speciﬁc types of diabetes due toother causes,e.g.,genetic defects in●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●The recommendations in this article are based on the evidence reviewed in the following publication: Standards of care for diabetes(Technical Review).Diabetes Care17:1514–1522,1994.Originally approved1988.Most recent review/revision,October2006.Abbreviations:ABI,ankle-brachial index;AMI,acute myocardial infarction;ARB,angiotensin receptor blocker;CAD,coronary artery disease;CBG,capillary blood glucose;CHD,coronary heart disease;CHF, congestive heart failure;CKD,chronic kidney disease;CMS,Centers for Medicare and Medicaid Services; CSII,continuous subcutaneous insulin infusion;CVD,cardiovascular disease;DCCB,dihydropyridine calcium channel blocker;DCCT,Diabetes Control and Complications Trial;DKA,diabetic ketoacidosis; DMMP,diabetes medical management plan;DPN,distal symmetric polyneuropathy;DPP,Diabetes Preven-tion Program;DRI,dietary reference intake;DRS,Diabetic Retinopathy Study;DSME,diabetes self-management education;DSMT,diabetes self-management training;ECG,electrocardiogram;ESRD,end-stage renal disease;ETDRS,Early Treatment Diabetic Retinopathy Study;FDA,Food and Drug Administration;FPG,fasting plasma glucose;GDM,gestational diabetes mellitus;GFR,glomerularﬁltration rate;HRC,high-risk characteristic;ICU,intensive care unit;IFG,impaired fasting glucose;IGT,impaired glucose tolerance;MNT,medical nutrition therapy;NDEP,National Diabetes Education Program;NPDR, nonproliferative diabetic retinopathy;OGTT,oral glucose tolerance test;PAD,peripheral arterial disease; PDR,proliferative diabetic retinopathy;PPG,postprandial plasma glucose;RDA,recommended dietary allowance;SMBG,self-monitoring of blood glucose;TZD,thiazolidinedione;UKPDS,U.K.Prospective Diabetes Study.DOI:10.2337/dc07-S004©2007by the American Diabetes Association.P o s i t i o n S t a t e m e n t␤-cell function,genetic defects in insu-lin action,diseases of the exocrine pan-creas(such as cysticﬁbrosis),and drug or chemical induced(such as in the treatment of AIDS or after organ trans-plantation)●Gestational diabetes mellitus(GDM) (diagnosed during pregnancy)Some patients cannot be clearly classiﬁed as type1or type2diabetes.Clinical pre-sentation and disease progression vary considerably in both types of diabetes. Occasionally,patients who otherwise have type2diabetes may present with ke-toacidosis.Similarly,patients with type1 may have a late onset and slow(but re-lentless)progression of disease despite having features of autoimmune disease. Such difﬁculties in diagnosis may occur in children,adolescents,and adults.The true diagnosis may become more obvious over time.B.DiagnosisRecommendations●The FPG is the preferred test to diag-nose diabetes in children and nonpreg-nant adults.(E)●Use of the A1C for the diagnosis of di-abetes is not recommended at this time.(E)Criteria for the diagnosis of diabetes innonpregnant adults are shown in Table2.Three ways to diagnose diabetes are avail-able,and each must be conﬁrmed on asubsequent day unless unequivocalsymptoms of hyperglycemia are present.Although the75-g oral glucose tolerancetest(OGTT)is more sensitive and mod-estly more speciﬁc than fasting plasmaglucose(FPG)to diagnose diabetes,it ispoorly reproducible and rarely performedin practice.Because of ease of use,accept-ability to patients,and lower cost,theFPG is the preferred diagnostic test.Itshould be noted that the vast majority ofpeople who meet diagnostic criteria fordiabetes by OGTT,but not by FPG,willhave an A1C valueϽ7.0%.The use of theA1C for the diagnosis of diabetes is notrecommended at this time.Hyperglycemia not sufﬁcient to meetthe diagnostic criteria for diabetes is cate-gorized as either IFG or impaired glucosetolerance(IGT),depending on whether itis identiﬁed through an FPG or an OGTT:●IFGϭFPG100mg/dl(5.6mmol/l)to125mg/dl(6.9mmol/l)●IGTϭ2-h plasma glucose140mg/dl(7.8mmol/l)to199mg/dl(11.0mmol/l)Recently,IFG and IGT have been ofﬁ-cially termed“pre-diabetes.”Both catego-ries,IFG and IGT,are risk factors forfuture diabetes and cardiovascular dis-ease(CVD).In the absence of unequivocal hyper-glycemia,these criteria should be con-ﬁrmed by repeat testing on a differentday.The OGTT is not recommended forroutine clinical use but may be requiredin the evaluation of patients with IFG(seetext)or when diabetes is still suspecteddespite a normal FPG,as with the post-partum evaluation of women with GDM.II.SCREENING FORDIABETESRecommendations●Screening to detect pre-diabetes(IFGor IGT)and diabetes should be consid-ered in individualsՆ45years of age,particularly in those with a BMIՆ25kg/m2.Screening should also be con-sidered for people who areϽ45years ofage and are overweight if they have an-Table1—ADA evidence grading system for clinical practice recommendationsLevel ofevidence DescriptionA Clear evidence from well-conducted,generalizable,randomized controlledtrials that are adequately powered,including:●Evidence from a well-conducted multicenter trial●Evidence from a meta-analysis that incorporated quality ratings in theanalysis●Compelling nonexperimental evidence,i.e.,“all or none”ruledeveloped by Center for Evidence Based Medicine at OxfordSupportive evidence from well-conducted randomized controlled trialsthat are adequately powered,including:●Evidence from a well-conducted trial at one or more institutions●Evidence from a meta-analysis that incorporated quality ratings in theanalysisB Supportive evidence from well-conducted cohort studies●Evidence from a well-conducted prospective cohort study or registry●Evidence from a well-conducted meta-analysis of cohort studiesSupportive evidence from a well-conducted case-control studyC Supportive evidence from poorly controlled or uncontrolled studies●Evidence from randomized clinical trials with one or more major orthree or more minor methodologicalﬂaws that could invalidate theresults●Evidence from observational studies with high potential for bias(suchas case series with comparison to historical controls)●Evidence from case series or case reportsConﬂicting evidence with the weight of evidence supporting therecommendationE Expert consensus or clinical experienceTable2—Criteria for the diagnosis of diabetes1.Symptoms of diabetes and a casual plasma glucoseՆ200mg/dl(11.1mmol/l).Casual is deﬁned as any time of day without regard to time since last meal.Theclassic symptoms of diabetes include polyuria,polydipsia,and unexplainedweight loss.OR2.FPGՆ126mg/dl(7.0mmol/l).Fasting is deﬁned as no caloric intake for atleast8h.OR3.2-h plasma glucoseՆ200mg/dl(11.1mmol/l)during an OGTT.The testshould be performed as described by the World Health Organization,using aglucose load containing the equivalent of75-g anhydrous glucose dissolved inwater.Position Statementother risk factor for diabetes(Table3). Repeat testing should be carried out at 3-year intervals.(E)●Screen for pre-diabetes and diabetes in high-risk,asymptomatic,undiagnosed adults and children within the health care setting.(E)●To screen for diabetes/pre-diabetes,ei-ther an FPG test or2-h OGTT(75-g glucose load)or both are appropriate.(B)●An OGTT may be considered in pa-tients with IFG to better deﬁne the risk of diabetes.(E)There is a major distinction between di-agnostic testing and screening.Both uti-lize the same clinical tests,which should be done within the context of the health care setting.When an individual exhibits symptoms or signs of the disease,diag-nostic tests are performed,and such tests do not represent screening.The purpose of screening is to identify asymptomatic individuals who are likely to have diabe-tes or pre-diabetes.Separate diagnostic tests using standard criteria are required after positive screening tests to establish a deﬁnitive diagnosis as described above. Type1diabetesGenerally,people with type1diabetes present with acute symptoms of diabetes and markedly elevated blood glucose lev-els.Because of the acute onset of symp-toms,most cases of type1diabetes are detected soon after symptoms develop. Widespread clinical testing of asymptom-atic individuals for the presence of auto-antibodies related to type1diabetes cannot be recommended at this time as ameans to identify individuals at risk.Rea-sons for this include the following:1)cut-off values for some of the immune markerassays have not been completely estab-lished in clinical settings;2)there is noconsensus as to what action should betaken when a positive autoantibody testresult is obtained;and3)because the in-cidence of type1diabetes is low,testing ofhealthy children will identify only a verysmall number(Ͻ0.5%)who at that mo-ment may be“pre-diabetic.”Clinical stud-ies are being conducted to test variousmethods of preventing type1diabetes inhigh-risk individuals(e.g.,siblings oftype1diabetic patients).These studiesmay uncover an effective means of pre-venting type1diabetes,in which case tar-geted screening may be appropriate in thefuture.Type2diabetesType2diabetes is frequently not diag-nosed until complications appear,andapproximately one-third of all peoplewith diabetes may be undiagnosed.Indi-viduals at high risk should be screened fordiabetes and pre-diabetes.Criteria fortesting for diabetes in asymptomatic,un-diagnosed adults are listed in Table3.Theeffectiveness of early diagnosis throughscreening of asymptomatic individualshas not been determined(6).Screening should be carried outwithin the health care setting.Either anFPG test or2-h OGTT(75-g glucose load)is appropriate.The2-h OGTT identiﬁespeople with IGT,and thus,more peopleare at increased risk for the developmentof diabetes and CVD.It should be notedthat the two tests do not necessarily detectthe same individuals(7).It is important torecognize that although the efﬁcacy of in-terventions for primary prevention oftype2diabetes have been demonstratedamong individuals with IGT(8–10),suchdata among individuals with IFG(who donot also have IGT)are not available.TheFPG test is more convenient to patients,more reproducible,less costly,and easierto administer than the2-h OGTT(4,5).Therefore,the recommended initialscreening test for nonpregnant adults isthe FPG.An OGTT may be considered inpatients with IFG to better deﬁne the riskof diabetes.The incidence of type2diabetes inadolescents has increased dramatically inthe last decade.Consistent with screeningrecommendations for adults,only chil-dren and youth at increased risk for thepresence or the development of type2diabetes should be tested(11)(Table4).The effectiveness of screening mayalso depend on the setting in which it isperformed.In general,communityscreening outside a health care settingmay be less effective because of the failureof people with a positive screening test toseek and obtain appropriate follow-uptesting and care or,conversely,to ensureappropriate repeat testing for individualswho screen negative.That is,screeningoutside of clinical settings may yield ab-Table3—Criteria for testing for diabetes in asymptomatic adult individuals1.Testing for diabetes should be considered in all individuals at age45years and above,particularly in those with a BMIՆ25kg/m2*,and,if normal,should be repeated at3-year intervals.2.Testing should be considered at a younger age or be carried out more frequently inindividuals who are overweight(BMIՆ25kg/m2*)and have additional risk factors:●are habitually physically inactive●have aﬁrst-degree relative with diabetes●are members of a high-risk ethnic population(e.g.,African American,Latino,Native American,Asian American,Paciﬁc Islander)●have delivered a baby weighingϾ9lb or have been diagnosed with GDM●are hypertensive(Ն140/90mmHg)●have an HDL cholesterol levelϽ35mg/dl(0.90mmol/l)and/or a triglyceride levelϾ250mg/dl(2.82mmol/l)●have PCOS●on previous testing,had IGT or IFG●have other clinical conditions associated with insulin resistance(e.g.,PCOS oracanthosis nigricans)●have a history of vascular disease*May not be correct for all ethnic groups.PCOS,polycystic ovary syndrome.Table4—Testing for type2diabetes in chil-drenCriteria●Overweight(BMIϾ85th percentile forage and sex,weight for heightϾ85thpercentile,or weightϾ120%of ideal forheight)Plus any two of the following risk factors:●Family history of type2diabetes inﬁrst-or second-degree relative●Race/ethnicity(Native American,AfricanAmerican,Latino,Asian American,Paciﬁc Islander)●Signs of insulin resistance or conditionsassociated with insulin resistance(acanthosis nigricans,hypertension,dyslipidemia,or PCOS)●Maternal history of diabetes or GDMAge of initiation:age10years or at onset ofpuberty,if puberty occurs at a younger ageFrequency:every2yearsTest:FPG preferredClinical judgment should be used to test for diabetesin high-risk patients who do not meet these criteria.PCOS,polycystic ovary syndrome. Standards of Medical Carenormal tests that are never discussed with a primary care provider,low compliance with treatment recommendations,and a very uncertain impact on long-term munity screening may also be poorly targeted,i.e.,it may fail to reach the groups most at risk and inappropri-ately test those at low risk(the worried well)or even those already diagnosed (12,13).On the basis of expert opinion, screening should be considered by health care providers at3-year intervals begin-ning at age45,particularly in those with BMIՆ25kg/m2.The rationale for this interval is that false negatives will be re-peated before substantial time elapses, and there is little likelihood of an individ-ual developing any of the complications of diabetes to a signiﬁcant degree within3 years of a negative screening test result. Testing should be considered at a younger age or be carried out more frequently in individuals who are overweight and have one or more of the other risk factors for type2diabetes.III.DETECTION AND DIAGNOSIS OF GDM Recommendations●Screen for diabetes in pregnancy using risk factor analysis and,if appropriate, use of an OGTT.(C)●Women with GDM should be screened for diabetes6–12weeks postpartum and should be followed up with subse-quent screening for the development of diabetes or pre-diabetes.(E)Risk assessment for GDM should be un-dertaken at theﬁrst prenatal visit.Women with clinical characteristics consistent with a high risk for GDM(e.g.,those with marked obesity,personal history of GDM or delivery of a previous large-for-gestation-age infant,glycosuria,polycys-tic ovary syndrome,or a strong family history of diabetes)should undergo glu-cose testing as soon as possible(14).An FPGՆ126mg/dl or a casual plasma glu-coseՆ200mg/dl meets the threshold for the diagnosis of diabetes and needs to be conﬁrmed on a subsequent day as soon as possible unless unequivocal symptoms of hyperglycemia are present.High-risk women not found to have GDM at the initial screening and average-risk women should be tested between24and28 weeks of gestation.Testing should follow one of two approaches:●One-step approach:perform a diagnos-tic100-g OGTT●Two-step approach:perform an initialscreening by measuring the plasma orserum glucose concentration1h after a50-g oral glucose load(glucose chal-lenge test)and perform a diagnostic100-g OGTT on that subset of womenexceeding the glucose threshold valueon the glucose challenge test.When thetwo-step approach is used,a glucosethreshold valueՆ140mg/dl identiﬁesϳ80%of women with GDM,and theyield is further increased to90%by us-ing a cutoff ofՆ130mg/dl.Diagnostic criteria for the100-g OGTTare as follows:Ն95mg/dl fasting,Ն180mg/dl at1h,Ն155mg/dl at2h,andՆ140mg/dl at3h.Two or more of theplasma glucose values must be met or ex-ceeded for a positive diagnosis.The testshould be done in the morning after anovernight fast of8–14h.The diagnosiscan be made using a2-h,75-g glucosetolerance test,but that test is not as wellvalidated for detection of at-risk infants ormothers as the3-h,100-g OGTT.Low-risk status requires no glucosetesting,but this category is limited tothose women meeting all of the followingcharacteristics:●AgeϽ25years●Weight normal before pregnancy●Member of an ethnic group with a lowprevalence of diabetes●No known diabetes inﬁrst-degree rela-tives●No history of abnormal glucose toler-ance●No history of poor obstetric outcomeBecause women with a history of GDMhave an increased subsequent risk for di-abetes,they should be screened for diabe-tes6–12weeks postpartum and shouldbe followed up with subsequent screen-ing for the development of diabetes orpre-diabetes.For information on the Na-tional Diabetes Education Program(NDEP)campaign to prevent type2dia-betes in women with GDM,go to www./diabetes/pubs/NeverTooEarly_Tipsheet.pdf.IV.PREVENTION/DELAYOF TYPE2DIABETESRecommendations●Individuals at high risk for developingdiabetes need to become aware of themany beneﬁts of modest weight lossand participating in regular physical ac-tivity.(A)●Patients with IGT should be givencounseling on weight loss as well as in-struction for increasing physical activ-ity.(A)(Reimbursement for suchcounseling is encouraged.)●Patients with IFG should be givencounseling on weight loss as well as in-struction for increasing physical activ-ity.(E)(Reimbursement for suchcounseling is encouraged.)●Follow-up counseling appears to be im-portant for success.(B)●Monitoring for the development ofdiabetes in those with pre-diabetesshould be performed every1–2years.(E)●Close attention should be given to,andappropriate treatment given for,otherCVD risk factors(e.g.,tobacco use,hy-pertension,dyslipidemia).(A)●Because of possible side effects andcost,there is insufﬁcient evidence tosupport the use of drug therapy.(E)Many studies have shown that individualsat high risk for developing diabetes(thosewith IFG,IGT,or both)can be given awide variety of interventions that signiﬁ-cantly delay,and sometimes prevent,theonset of diabetes(8–10,15–18).An in-tensive lifestyle modiﬁcation program hasbeen shown to be very effective(ϳ58%reduction after3years).Use of the phar-macologic agents metformin,acarbose,orlistat,and rosiglitazone has also beenshown to decrease incident diabetes tovarious degrees.Of note,however,eachof these drugs may cause side effects ofvarying severity in a small number of in-dividuals.Lifestyle modiﬁcationIn well-controlled studies that included alifestyle intervention arm,substantial ef-forts were necessary to achieve only mod-est changes in weight and exercise,butthose changes were sufﬁcient to achievean important reduction in the incidenceof diabetes.In the DPP lifestyle group,alow-fat(Ͻ25%fat)intake was recom-mended;if reducing fat did not produceweight loss to goal,calorie restriction wasalso recommended.Participants weigh-ing120–174lb(54–78kg)at baselinewere instructed to follow a1,200kcal/daydiet(33g fat),those175–219lb(79–99kg)were instructed to follow a1,500kcal/day diet(42g fat),those220–249lb(100–113kg)were instructed to followan1,800kcal/day diet(50g fat),andPosition StatementthoseϾ250lb(114kg)were instructed to follow a2,000kcal/day diet(55g fat).On average,50%of the lifestyle group achieved the goal ofՆ7%weight reduc-tion and74%maintained at least150 min/week of moderately intense activity (8).In the Finnish Diabetes Prevention Study,weight loss averaged9.2lb at1 year,7.7lb after2years,and4.6lb after5 years(9);“moderate exercise,”such as brisk walking,for30min/day was sug-gested.In the Finnish study,there was a direct relationship between adherence with the lifestyle intervention and the re-duced incidence of diabetes.Lifestyle or medication?Many factors must be considered when undertaking the effort to modify the course of glucose intolerance.Lifestyle modiﬁcation may have other beneﬁcial ef-fects(e.g.,reduced CVD),but is often very difﬁcult to sustain,and its cost-effectiveness is questionable if the regi-men is similar to what was employed in clinical trials.Even so,lifestyle interven-tion still may be cost-effective compared with some pharmacologic treatments. Drug therapy can be very costly(except for metformin,which is a generic drug), and side effects can range from mild/ moderate discomfort to serious cardio-vascular events.Finally,whether diabetes prevention efforts can,over the long term, inﬂuence the development of micro-or macrovascular events is unknown.It is possible that at least microvascular com-plications will be delayed or diminished, since they are more closely related to hy-perglycemia.In light of the above,health care pro-fessionals shouldﬁrst actively counsel pa-tients to maintain normal weight and exercise regularly(even before glucose in-tolerance occurs).Because of potential side effects and cost,there is insufﬁcient evidence to support the use of drug ther-apy as a substitute for,or routinely used in addition to,lifestyle modiﬁcation to pre-vent diabetes.Public health messages, health care professionals,and health care systems should all encourage behavior changes to achieve a healthy lifestyle.Fur-ther research is necessary to understand how to better facilitate effective and efﬁ-cient programs for the primary preven-tion of type2diabetes.An ADA consensus statement offering more comprehensive guidance on diabe-tes prevention will be published in2007.V.DIABETES CAREA.Initial evaluationA complete medical evaluation should beperformed to classify the patient,detectthe presence or absence of diabetes com-plications,assist in formulating a manage-ment plan,and provide a basis forcontinuing care.If the diagnosis of diabe-tes has already been made,the evaluationshould review the previous treatment andthe past and present degrees of glycemicboratory tests appropriate tothe evaluation of each patient’s generalmedical condition should be performed.A focus on the components of compre-hensive care(Table5)will assist thehealth care team to ensure optimal man-agement of the patient with diabetes.B.ManagementPeople with diabetes should receive med-ical care from a physician-coordinatedteam.Such teams may include,but arenot limited to,physicians,nurse practitio-ners,physician’s assistants,nurses,dieti-tians,pharmacists,and mental healthprofessionals with expertise and a specialinterest in diabetes.It is essential in thiscollaborative and integrated team ap-proach that individuals with diabetes as-sume an active role in their care.The management plan should be for-mulated as an individualized therapeuticalliance among the patient and family,the Table5—Components of the comprehensive diabetes evaluationMedical history●Age and characteristics of onset of diabetes(e.g.,DKA,routine laboratory evaluation)●Prior A1C records●Eating patterns,nutritional status,and weight history;growth and development inchildren and adolescents●Diabetes education history●Review of previous treatment programs●Current treatment of diabetes,including medications,meal plan,and results of glucosemonitoring and patient’s use of data●Exercise history●DKA frequency,severity,and cause●Hypoglycemic episodes●Any severe hypoglycemia:frequency,severity,and cause●History of diabetes-related complications●Microvascular:eye,kidney,nerve●Macrovascular:cardiac,CVD,PAD●Other:sexual dysfunction,gastroparesisPhysical examination●Blood pressure determination,including orthostatic measurements when indicated●Fundoscopic examination●Thyroid palpation●Skin examination(for acanthosis nigricans and insulin injection sites)●Neurological/foot examination examination●Inspection●Palpation of DP and PT pulses●Presence/absence of patellar and Achilles reﬂexes●Determination of proprioception,vibration,and monoﬁlament sensationLaboratory evaluation●A1C●Fasting lipid proﬁle,including total LDL and HDL cholesterol and triglycerides●Liver function tests●Test for microalbuminuria●Serum creatinine and calculated GFR●Thyroid-stimulating hormone●Screen for celiac disease in type1diabetes and as indicated in type2diabetes Referrals●Eye exam,if indicated●Family planning for women of reproductive age●MNT●Diabetes educator if not provided by physician or practice staffDP,dorsalis pedis;PT,posterior tibial;PAD,peripheral arterial disease.Standards of Medical Care。

美国糖尿病协会糖尿病诊疗指南

美国糖尿病协会目前糖尿病的诊断标准A1C≥%。

试验应该用美国糖化血红蛋白标准化计划组织（National Glycohemoglobin Standardization Program，NGSP）认证的方法进行，并与糖尿病控制和并发症研究（Diabetes Control and Complications Trial，DCCT）的检测进行标化。

或空腹血糖（FPG）≥ mmol/L。

空腹的定义是至少8小时未摄入热量。

或OGTT 2h血糖≥ mmol/L。

试验应按世界卫生组织（WHO）的标准进行，用相当于75 g无水葡萄糖溶于水作为糖负荷。

或在有高血糖的典型症状或高血糖危象的患者，随机血糖≥ mmol/L。

如无明确的高血糖，结果应重复检测确认。

在无症状患者中进行糖尿病筛查在无症状的成人，如超重或肥胖（BMI≥25kg/m2）并有一个以上其他糖尿病危险因素（见“2012年糖尿病诊疗标准”中的表4），应该从任何年龄开始筛查糖尿病并评估将来糖尿病的风险。

对没有这些危险因素的人群，应从45岁开始筛查。

（B）如果检查结果正常，至少每3年复查一次。

（E）为筛查糖尿病或评估未来糖尿病的风险，A1C、 FPG或2h 75g OGTT均可使用。

（B）对于那些已经明确未来糖尿病风险增加的人群，应该进一步评估并治疗其他心血管疾病（CVD）危险因素。

（B）妊娠期糖尿病的筛查和诊断在有危险因素的个体中，产前首次就诊时用标准的诊断方法筛查未诊断的2型糖尿病。

（B）未知是否具有糖尿病的孕妇，在妊娠24~28周用75g 2h OGTT 筛查妊娠糖尿病，诊断切点见“2012年糖尿病诊疗标准”表6。

（B）妊娠糖尿病的妇女在产后6~12周用除A1C以外的方法筛查永久性糖尿病。

（E）有妊娠糖尿病病史的妇女应至少每3年筛查是否发展为糖尿病或糖尿病前期。

（B）如发现有妊娠糖尿病病史的妇女为糖尿病前期，应接受生活方式干预或二甲双胍治疗以预防糖尿病（A）预防/延缓2型糖尿病对于糖耐量异常（IGT）（A）、空腹血糖受损（IFG）（E）或A1C 在～%之间（E）的患者，应转诊到具有有效持续支持计划的单位，以减轻体重7%，增加体力活动，每周进行至少150分钟中等强度（如步行）的体力活动。

糖尿病诊断标准

糖尿病诊断标准糖尿病是一种常见的慢性疾病，中老年人是高发群体，典型特征是血糖水平持续增高。

近年来，随着人们生活水平提高，糖尿病患病率也在增加，早诊断、早治疗，才能改善患者预后。

那么，糖尿病的诊断标准是什么？下面对此进行简单论述。

1．什么是糖尿病？糖尿病，是胰岛素分泌不足或胰岛功能障碍，导致蛋白质、脂肪、碳水化合物代谢紊乱，主要标志是血糖升高。

患者发病后，症状表现为三多一少，即多食、多饮、多尿、体重减轻。

随着病情进展，会损害眼睛、肾脏、心脏、神经、血管等器官组织，成为心衰、肾衰、截肢、心脑血管疾病的重要原因。

流行病学调查显示，2017年全球范围内，有糖尿病患者 4.25亿，预计到2045年超过6亿。

在国内，糖尿病患者人数约为1.2亿，居世界首位；但诊断率仅有30%-40%，即10个患者中，只有3-4人知道自己有糖尿病。

明确糖尿病的诊断标准，并加大宣传力度，是防治糖尿病的第一步，能提高人们的保健意识。

2．糖尿病的分类(1)I型糖尿病。

该类患者是在幼年或青少年时期发病，病因是胰岛细胞破坏，导致胰岛素分泌不足。

在我国，I型糖尿病很少见，占比不足1%，但起病突然，三多一少症状明显，不少患者以酮症酸中毒为首发症状，单用口服降糖药无效，需使用胰岛素治疗。

(2)II型糖尿病。

该类患者是胰岛素抵抗、胰岛素分泌不足、或两者兼有引起的，占比超过95%。

常见于中老年人，肥胖者发病率高，常伴有高血压、高血脂、动脉硬化等疾病。

II型糖尿病的起病隐匿，早期无任何症状，或仅有轻度乏力、口渴的表现，必要时需做糖耐量试验才能确诊。

(3)特殊类型糖尿病。

该类患者的病因复杂多样，例如遗传缺陷、分泌或代谢疾病、药物影响、感染，以及和糖尿病相关的遗传综合征等。

3．糖尿病的诊断标准(1)2007版。

糖尿病症状（多饮、多尿、不明原因体重减少），①加随机血糖≥11.1mmol/L，或②空腹血糖≥7.0mmol/L，或③葡萄糖负荷后2h血糖≥11.1mmol/L。

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附录3美国糖尿病学会2007版糖尿病诊疗标准【编者按】　美国糖尿病学会(ADA)多年来积极致力于糖尿病医疗保健标准和指南的制定与传播,每年修订代表ADA立场的声明,并将临床实用的ADA立场声明、专家共识和述评报告等汇集,以增刊形式发表。

ADA临床实用指南的学术权威性,已广为各国认可和采用。

我刊2003年得到ADA的同意将“ADA Clinical Practice Recommendations2003”全书译为中文在内部出版,在2004年正式付印时又参考2004年版作了补充。

《ADA临床应用指南》中译本出版后受到读者的广泛欢迎。

近两年来,我们注意到ADA每年都对增刊内容有所修改,特别是自2005年开始主要刊登糖尿病诊疗标准(Standards of Med2 ical Care in Diabetes)和有选择的重要的立场声明,对其他内容则大量删简,目的在于突出“糖尿病诊疗标准”内容。

应国内广大读者要求,我刊决定继续翻译ADA2007版糖尿病诊疗标准的重点内容,并从本期开始连载供广大读者参考。

一、有关ADA2007版糖尿病诊疗标准的科学循证评级ADA第一次公布实用指南时就已经充分考虑到科学依据和循证基础,建立了支持ADA指南的循证质量评级系统,适用于所有ADA新的和修订的立场声明,指南已标注的A、B或C的分级决定于循证质量(表1)。

表1　ADA临床实用指南的循证分级循证分级说明A 证据明确:来自良好的指导与总结的随机、对照临床试验,包括:・证据来自良好指导的多中心临床试验・证据来自包含高质量分析的荟萃分析・来自按牛津循证医学中心的“全或无”规则而必须接支持性证据来自良好指导的随机对照临床试验,包括:・来自一个或多个研究单位的有良好指导的临床试验・来自包含高质量分析的荟萃分析B支持性证据来自良好指导的队列研究,包括:・证据来自良好指导的前瞻性队列研究或登记・证据来自良好指导的队列研究的荟萃分析・支持证据来自良好的病例对照研究C支持证据来自对照差或无对照的研究,包括:・证据来自随机临床试验带有一个或更多较大的、或有3个以上小的缺点以致影响其结果・证据来自带有高度倾向的研究(如与过去的对照组比较的病例系列)・证据来自病例系列或病例报告・在支持指南的证据分量上有争论的证据E专家共识或临床经验当然循证只是做临床决定的一个组成部分,临床医生对病人的医疗指南总是以具体病人需要来解释,ADA将继续改善和更新临床实用指南,以便临床工作者、保健计划和政策制定者继续有信心将ADA临床实用指南作为最具权威和最新的糖尿病临床应用指南。

二、ADA2007版糖尿病诊疗标准(Standards of Medical Care in Diabetes———2007)1.诊断与分型A分型:ADA1997年发布了新的诊断与分型标准,2003年进行了修改,提出空腹血糖受损(IF G)诊断标准。

糖尿病通讯作者:钱荣立,E2mail:journal@ 包括4类临床型:・1型糖尿病(T1DM):由于β细胞受到破坏导致胰岛素绝对缺乏・2型糖尿病(T2DM):由于在胰岛素抵抗背景下进行性的胰岛素分泌缺陷・其他特殊型糖尿病:即由其他原因如β细胞功能的遗传缺陷,胰岛素作用的遗传缺陷,胰腺外分泌疾病(如囊性纤维病)以及药物或化学原因引起的(如治疗A IDS病或器官移植后)糖尿病・妊娠糖尿病(G DM):妊娠期间诊断的糖尿病有些病人不能明确归为1型或2型,其临床表现和疾病进展同时具有两型的特征,如个别表现为T2DM可能有酮症酸中毒,同样有的T1DM病人尽管有自身免疫疾病表现,但其发病晚进展缓慢,这种诊断困难可见于儿童、青少年和成年人,确切诊断将会随着时间推移而明确。

B诊断建议・可选用FP G作为儿童和非妊娠成人的糖尿病诊断试验(E)・目前不推荐用糖化血红蛋白(A1c)诊断糖尿病(E)非妊娠成年人糖尿病诊断指标如表2,有3种方法可用于诊断糖尿病,但无论哪种方法都必须次日重复确认,除非病人已有明确的高血糖症状,虽然口服75g葡萄糖耐量试验(O GT T)对诊断糖尿病比FP G更敏感和正规,但其重复性差而且实际很少用,而FP G因其应用方便,病人易接受和费用低,建议可选用FP G作为糖尿病诊断试验,必须指出绝大多数由O GT T而不是由FP G试验结果诊断的人,其A1c< 7%,所以目前不主张用A1c诊断糖尿病。

・IF G=FP G100～125mg/dl・IGT=2hP G140～199mg/dl最近已将IF G与IGT正式命名为“糖尿病前期(Pre2 diabetes)”,两者都是糖尿病与心血管病(CVD)的危险因素。

对没有明确的高血糖表现者,这些指标都必须在改日重复,O GT T不推荐作临床常规检查,但在评价IF G或FP G正常而仍疑为糖尿病者以及对G DM产后评价需要作O GT T。

表2　糖尿病诊断指标1.有糖尿病症状和随意血糖≥200mg/dl。

“随意”是指一天内任何时间,无论进食与否。

糖尿病典型症状包括多尿、多饮和不可解释的体重减轻2.FP G≥126mg/dl。

“空腹”指至少8h未进食(未摄入热量)3.OGTT试验2hPG≥200mg/dl。

试验需按WHO要求用75g无水葡萄糖溶于水中国糖尿病杂志2007年第15卷第2期　Chin J Diabetes,February2007,Vol15,No2 2.糖尿病筛查建议・年龄≥45岁特别是BMI≥25者、年龄<45岁和超重并有其他糖尿病危险因素者均需进行糖尿病前期和糖尿病筛查(表3)。

每3年定期复查(E)・有高危因素但无症状和未诊断的成人和儿童保健对象(E)・单用FP G或2h O GT T或两者同时应用进行糖尿病前期和糖尿病筛查均可(B)・对IF G者O GT T能更好确定其患糖尿病风险(E)诊断试验与筛查之间的主要区别在于两者用同一临床试验,当病人有症状和体征表现,进行的则是诊断试验而不代表筛查,筛查的目的是确定疑似为糖尿病前期或糖尿病的无症状者,要求在筛查出阳性结果后,分别用诊断指标按表2确定诊断。

表3　无症状成人糖尿病诊断指标1.年龄≥45岁特别是BMI≥25者必须筛查,如正常则每3年复查2.年青超重(BMI≥25)并有其他危险因素者・习惯于不活动者・1级亲属为糖尿病者・高危种族(如非裔美国人,拉丁美洲人,土著美国人,亚裔美国人,太平洋岛民)・分娩>9磅胎儿或诊断GDM・高血压(≥140/90mm Hg)・HDL2C<35mg/dl及或T G>250mg/dl・有多囊卵巢综合征(PCOS)・有过IGT或IF G・伴有其他胰岛素抵抗临床表现(如PCOS或黑棘皮病)・有血管病病史 T1DM:T1DM病人通常有糖尿病急性症状和急性高血糖,因为急性起病大多数病人出现症状能很快诊断,目前不推荐对无症状者在临床广泛使用与T1DM有关的自身抗体检测确定高危者。

理由如下:(1)某些免疫标志物测定的截点值尚未在临床确定;(2)对自身抗体阳性者需采取什么处理尚无共识;(3)因为T1DM发病率低,在健康儿童中至多只有很少数(0.5%)可能是“糖尿病前期”。

在高危人群中(即T1DM病人的兄弟姐妹)已进行的各种预防T1DM临床试验,可能发现某种预防T1DM的有效办法,以这种情况为目的筛查将来可能适合。

T2DM:T2DM往往直到出现合并症才诊断,约1/3糖尿病病人未获诊断,因此对高危者应进行糖尿病和糖尿病前期筛查,对无症状未诊断的成人进行筛查试验的指标见表3。

通过对无症状者筛查而提早诊断的实际效果尚未确定。

筛查需在保健机构内进行。

FP G或2hO GT T任一试验结果均可,必须指出同一个人不需要同时作这两种试验,重要的是承认尽管已证实对IGT者进行初级干预的有效性,但这些资料不适用于IF G(无IGT)者。

FP G试验对病人比较方便,更易重复和经济,也比2hO GT T更容易操作,同时推荐对非妊娠成年人首先用FP G筛查,对IF G病人如需进一步确定其发生糖尿病的危险可考虑作O GT T。

近10年在年青人中T2DM患病率显著增加,和成年人一样,对有发生T2DM危险的儿童和年青人也应进行筛查(表4)。

筛查的效果取决于其安排,一般在保健机构以外的社区筛查效果差,因为对筛查阳性者的失访率高,也很难达到区分高危者和低危者或已诊断者的目的。

根据专家意见自45岁起特别是BMI≥25者应由保健机构每3年筛查一次,理由是遗漏者可在随后失访前得到复查,而且即使遗漏,3年内也很少可能发生任何明显的糖尿病合并症,对年青超重者及同时伴有一个或更多其他T2DM 危险因素者应进行多次筛查。

表4　儿童T2DM筛查试验指标　・超重(BMI>相应年龄、性别第85百分位点,体重对比身高>第85百分位点或体重>120%理想身高),加下列任何两个危险因素・1级或2级亲属中有T2DM家族史・民族/种族(土著美国人,非洲裔美国人,拉丁民族,亚裔美国人,太平洋岛民)・有胰岛素抵抗或合并胰岛素抵抗情况的体征(黑棘皮病,高血压,血脂异常或PCOS)・母亲为糖尿病或GDM:起病年龄为10岁或青春期频率　每两年复查试验　选用FP G 3.妊娠糖尿病(G DM)的诊断建议・孕期内宜作O GT T筛查糖尿病(C)・G DM妇女产后6～12周重复O GT T以筛查糖尿病,并在以后定期随诊,筛查是否发生糖尿病或糖尿病前期(E)在孕妇第一次产前检查时就应进行G DM的危险评估,孕妇G DM高危因素的临床特征及明显肥胖,有过G DM病史或生产过大于孕龄的新生儿、尿糖阳性、PCOS或糖尿病家族史,均应尽快测血糖,如果FP G≥126mg/dl或任意血糖≥200mg/dl,需尽快于次日重复检查以确定诊断,除非病人已有明显的高血糖症状,如果第一次检查排除G DM需在孕24～28周间按下列两种方案之一进行复查。

・一步法:作葡萄糖100g O GT T・两步法:先作50g葡萄糖负荷后1h血糖筛查试验,血糖值超过者再作100g O GT T。

两步法结果80%G DM血糖≥140mg/dl,90%G DM血糖≥130mg/dl。

100g OGTT诊断指标:空腹≥95mg/dl,1h≥180mg/dl, 2h≥155mg/dl,3h≥140mg/dl。

试验需过夜空腹8～14h,诊断也可用75g OGTT2h结果,但此结果对发现危险婴儿或母亲不如100g OGTT3h结果更可靠。

对低危者不需作血糖检查:・年龄<25岁・妊娠前体重正常・为糖尿病患病率低的民族・1级亲属无糖尿病者・无糖耐量异常者・无产科异常病史因为G DM妇女发生糖尿病的危险增加,必须产后6～12周和以后定期进行糖尿病筛查。