对于糖尿病患者进行筛查、诊断，以及治疗等干预性措施的实践指南

2007年12月28日——美国糖尿病学会（ADA）已出版了对于糖尿病患者进行筛查、诊断，以及治疗等干预性措施的实践指南。这些指南的内容被认为可以改善糖尿病患者的预后。2008年1月号的《Diabetes Care》杂志对此进行了一些综述，其中对ADA推荐的每一条时间指南进行了详细的解读，对其分级系统进行了介绍（ADA依据每一条推荐指南的证据情况把其分为A、B、C、E四级），并且对于大多数糖尿病患者给出了建议的治疗目标。
“这些护理标准是为临床医生、患者、研究者、医保机构，以及其他涉及糖尿病护理、治疗目标及护理评价工具等环节的人员制定的，”指南的作者说，“当进行个体化治疗时，也许会依据并发症及病人因素对治疗目标进行修订，但对大多数病人来说，这些推荐目标仍是相当有效的。同时，指南中所涉及的标准也并不排斥必要时其他领域专家对于病人的评价与治疗。”
实践指南所涉及的主题主要包括：糖尿病的诊断、对于糖尿病前期及糖尿病期的筛查、对于儿童发生的2型糖尿病的筛查、对于妊娠期糖尿病的诊断与筛查、对于成人2型糖尿病的干预、自我血糖监测、糖化血红蛋白(A1C)水平、血糖目标、饮食控制、糖尿病自我管理教育（DSME）、体育锻炼、心里评价与护理、低血糖、免疫、高血压与血压控制、血脂异常与血脂管理等等。
此外，指南还涉及：抗血小板药物的使用，戒烟，冠心病的筛查与治疗，肾病、视网膜病变以及神经系统病变的筛查与治疗，足部护理。另外，还有一些特殊情况，比如对于儿童及青少年以及孕前妇女治疗的内容，对于老年人治疗的特殊情况，对于医院内、学校内糖尿病社区内患者护理以及每日护理安排，在如急诊、混乱情况下糖尿病人的护理，低血糖和就业以及糖尿病第三方赔偿者、自我管理教育和支持等。

具体的推荐指南如下：
 对于儿童糖尿病及非妊娠期的成人糖尿病的诊断，目前优选空腹血糖试验（FPG），当前尚不推荐用(A1C)作为糖尿病的诊断标准（E）。
 对于无症状人群进行的糖尿病前期及2型糖尿病筛查应该在超重或肥胖（BMI>=25kg/m2）且至少伴一项危险因素的人群中进行。另外，筛查试验应该在45岁年龄段开始（B），如果结果显示正常，下一次进行筛查的间隔时间不应大于3年（E）。
 FPG或者OGTT试验之一阳性或者两者皆阳性对于确定糖尿病前期或者糖尿病都是合适的（B）。OGTT试验对于空腹血糖受损（IFG）的病人可以进一步确定其患糖尿病的风险（B）。
 为了预防或阻止糖尿病的发生，建议糖耐量受损（IGT，A）的病人或者IFG（E）病人至少减掉体重的5%-10%，并且每周进行至少约150分钟的适度体育活动，如走路。随访咨询似乎可以提高成功的可能性（B）。因为潜在的成本积累与糖尿病预防密切相关，故第三方支付者（如医保）的项目应包含糖尿病咨询的内容（E）。
 对于已被确认的处于糖尿病前期的病人，应进行相应的评估与治疗，如果有可能，要对其心血管方面的危险因素进行一定的干预（B）。
 对于那些有高危因素的人群（如同时存在IFG和IGT加一个其他危险因素，或者肥胖且年龄小于60岁）可以考虑开始二甲双胍治疗（E）。
 处于糖尿病前期的病人应每年进行监测以观察糖尿病进展情况（E）。
 因为降低A1C水平到7%的平均值显示可以减少糖尿病微血管病及糖尿病肾病等并发症，同时，很可能也减少大血管疾病的发生，所以对于非妊娠期成人目标A1C一般推荐小于7%（A）。
 对于特定的个体化病人，在没有低血糖发生的情况下，A1C的目标尽要尽可能的接近正常（B）。流行病学研究显示，在A1C低于7%到正常值的范围内，病人人可以轻微获益。
 对于糖尿病或糖尿病前期的病人，为了达到治疗目标，应该给予个体化的饮食治疗，最理想的是由专业的注册营养师给予相应的指导（B）。医保或其他第三方支付者的项目也应该覆盖它（E）。
 饮食指导的具体内容包括：能量平衡、超重及肥胖饮食、体育锻炼、行为矫正的管理（B）；2型糖尿病进展的高危因素的主要预防；美国农业部推荐的膳食纤维和粗粮的摄入（B）。
 在进行血糖控制时，监测碳水化合物的摄入是一个重要策略，要注意其是否经过计算、转换或者以经验为基础的评价（A）。
 医生应该在患者被确诊时或者之后给其提供糖尿病自我管理教育（DSME）的内容（B）、自我管理行为改变的目标（E）以及相应的心理辅导（C）。第三方支付者应为DSME买单（E）。
 糖尿病人每周至少应进行不少于150min的有氧运动（达最大心率的50%-70%（A）），如果存在一定的禁忌证，则这类2型糖尿病患者每周至少应进行3次抵抗性训练（A）

原文：
December 28, 2007 — The American Diabetes Association (ADA) has issued practice guidelines for screening, diagnostic, and therapeutic interventions that are known or believed to improve health outcomes of patients with diabetes. An executive summary published in the January issue of Diabetes Care provides a detailed description of each of the ADA practice recommendations, a grading system developed by the ADA that uses A, B, C, or E to indicate the level of evidence supporting each recommendation, and suggested targets for most patients with diabetes.

\"These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care,\" the guidelines authors write. \"While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed.\"

Specific topic areas covered include diagnosis of diabetes, testing for prediabetes and diabetes, testing for type 2 diabetes in children, detection and diagnosis of gestational diabetes mellitus, prevention and delay of type 2 diabetes, self-monitoring of blood glucose levels, hemoglobin A1c (A1C) levels, glycemic goals, medical nutrition therapy (MNT), diabetes self-management education (DSME), physical activity, psychosocial assessment and care, hypoglycemia, immunization, hypertension and blood pressure control, and dyslipidemia and lipid management.

Also covered are use of antiplatelet agents, smoking cessation, coronary heart disease screening and treatment, nephropathy screening and treatment, retinopathy screening and treatment, neuropathy screening and treatment, foot care, special issues in treating children and adolescents, preconception care, special issues in treating older adults, diabetes care in the hospital (including goals for blood glucose levels), diabetes care in the school and day care setting, diabetes care at diabetes camps, diabetes management in correctional institutions, emergency and disaster preparedness, hypoglycemia and employment/licensure, and third-party reimbursement for diabetes care, self-management education, and supplies.

Some of the specific recommendations are as follows:

To diagnose diabetes in children and nonpregnant adults, fasting plasma glucose (FPG) is the preferred test, and use of A1C levels to diagnose diabetes is not currently recommended (E).
Screening for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults who are overweight or obese (body mass index [BMI] ≥25 kg/m2) with at least 1 more additional risk factor. Otherwise, testing should begin at age 45 years (B), and if results are normal, testing should be repeated at least at 3-year intervals (E).
Either an FPG test or 2-hour oral glucose tolerance test (OGTT; 75-g glucose load), or both, is appropriate (B) to test for prediabetes or diabetes, and an OGTT may be considered in patients with impaired fasting glucose (IFG) to better define the risk of diabetes (E).
Individuals found to have prediabetes should be evaluated and treated, if appropriate, for other cardiovascular risk factors (B).
To prevent or delay onset of diabetes, patients with impaired glucose tolerance (IGT; A) or IFG (E) should be advised to lose 5% to 10% of body weight and to increase physical activity to at least 150 minutes per week of moderate activity such as walking. Follow-up counseling seems to improve the likelihood of success (B). Because of the potential cost savings associated with diabetes prevention, third-party payors should cover counseling (E).
Metformin therapy should also be considered in patients who are at very high risk for diabetes, based on combined IFG and IGT plus other risk factors, and who are obese and younger than 60 years of age (E).
Individuals with prediabetes should be monitored every year for the development of diabetes. (E).
Because lowering A1C levels to an average of about 7% has been shown to reduce microvascular and neuropathic complications of diabetes and, possibly, macrovascular disease, the target A1c goal for nonpregnant adults is generally less than 7% (A).
For selected individual patients, the A1C goal is as close to normal (< 6%) as possible without significant hypoglycemia (B), in light of epidemiologic studies showing a small but incremental benefit to lowering A1C from 7% into the normal range.
For children, patients with a history of severe hypoglycemia, those with limited life expectancies, individuals with comorbid conditions, and those with long duration of diabetes and minimal or stable microvascular complications, less stringent A1C goals may be appropriate (E).
Individuals with prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, ideally by a registered dietitian who is knowledgeable about diabetes MNT (B). This should be covered by insurance and other payors (E).
Specific components of MNT should include management of energy balance, overweight, and obesity with diet, physical activity, and behavior modification (B); primary prevention of diabetes among individuals at high risk of developing type 2 diabetes (A); promoting fiber and whole-grain intake meeting US Department of Agriculture recommendations (B); controlling dietary fat intake by limiting saturated fat intake to less than 7% of total calories (A) and minimizing trans fat intake (E); and managing carbohydrate intake.
Monitoring carbohydrate intake is a key strategy in achieving glycemic control, whether by carbohydrate counting, exchanges, or experience-based estimation (A). For patients with diabetes, glycemic index and glycemic load use may modestly improve glycemic control vs that observed when considering only total carbohydrate (B).
DSME should be offered to patients with diabetes at the time of diagnosis and as needed thereafter (B), with the goal of changing self-management behavior (E) and addressing psychosocial issues (C). Third-party payors should reimburse for DSME (E).
People with diabetes should perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50% - 70% of maximum heart rate; [A]), and unless there are contraindications, those with type 2 diabetes should perform resistance training 3 times per week (A).