《中国糖尿病医学营养治疗指南》(2010年版)上

中国医师协会营养医师专业委员会 中国糖尿病医学营养 治疗指南（2010） China Medical Nutrition Therapy Guideline for Diabetes 2010 本指南由默克保健中国赞助出版 中华医学会糖尿病学分会 中国糖尿病医学营养治疗指南(2010) 2 缩略语 英文全称 中文 ADA American Diabetes Association 美国糖尿病学会 AOAC Association of Analytical Communities 美国化学家学会 BCAA Branch-chain amino acids 支链氨基酸 BCMI Body cell mass index 体细胞指数 BMI Body mass index 体重指数 CKD Chronic kidney disease 慢性肾脏病 CVD Cardiovascular disease 心血管病 DHA C22:6n-3, docosahexaenoic acid 二十二碳六烯酸 DRIs Dietary reference intakes 膳食推荐摄入量 DPN Diabetic peripheral neuropathy 糖尿病周围神经病变 EPA C20:5n-5,eicosapentaenoic acid 二十碳五烯酸 ESLD End stage liver disease 终末期肝病 FDA Food and Drug Administration 美国食品药品管理局 GDM Gestational diabetes mellitus 妊娠期糖尿病 GI Glycemic index （血）糖指数 GL Glycemic load （血）糖负荷 GSHPx Gluthatione peroxidase 谷胱甘肽过氧化酶 HbA1c Glycosylated hemoglobin 糖化血红蛋白 HDL-C High density lipoprotein cholesterol 高密度脂蛋白胆固醇 IBW Ideal body weight 理想体重 IFG Impaired fasting glucose 空腹血糖受损 IGT Impaired glucose tolerance 糖耐量受损 LDL-C Low density lipoprotein cholesterol 低密度脂蛋白胆固醇 MNT Medical nutrition therapy 医学营养治疗 MUFA Monounsaturated fatty acid 单不饱和脂肪酸 NAFLD Nonalcoholic fatty liver disease 非酒精性脂肪肝 NRS Nutritional risk screening 营养风险筛查 OCEBM Oxford Center for Evidence-based Medicine 牛津循证医学中心 OGTT Oral glucose tolerance test 口服葡萄糖糖耐量试验 PD-CAAS Protein digestibility corrected amino acid score 经蛋白质消化率校正的氨基酸评分 PUFA Polyunsaturated fatty acids 多不饱和脂肪酸 RCT Randomized controlled trial 随机对照试验 SGA Subject global assessment 主观全面评定（法） SOD Superoxide dismutase 超氧化物歧化酶 TC Total cholesterol 总胆固醇 USDA United States Department of Agriculture 美国农业部 VLDL-C Very low density lipoprotein cholesterol 极低密度脂蛋白胆固醇 WHO World Health Organization 世界卫生组织 主要缩略语-汉语对照表 中国糖尿病医学营养治疗指南(2010) 3 目 录 前言 ····························································································································4 制定2010年中国糖尿病医学营养治疗指南的学 ····················································4 一、糖尿病医学营养治疗的循证基础 ··········································································6 1.MNT的目标 ······································································································6 2.推荐意见 ···········································································································6 3.证据 ··················································································································6 二、营养素推荐 ··········································································································8 1.能量 ··················································································································8 2.蛋白质 ··············································································································9 3.脂肪 ··················································································································10 4.碳水化合物 ·······································································································12 5.膳食纤维 ···········································································································14 6.无机盐及微量元素 ····························································································15 7.维生素 ··············································································································17 8.植物化学物 ·······································································································19 9.甜味剂 ··············································································································21 10.膳食结构 ·········································································································22 三、糖尿病并发症的医学营养治疗 ··············································································24 1.糖尿病肾病及透析 ····························································································24 2.糖尿病视网膜病变 ····························································································26 3.糖尿病合并肝功能损害 ·····················································································26 4.糖尿病合并高血压 ····························································································28 5.糖尿病合并神经病变 ·························································································29 6.糖尿病合并脂代谢紊乱 ·····················································································29 7.糖尿病合并高尿酸血症 ·····················································································30 8.糖尿病合并肥胖 ································································································31 9.应激性高血糖 ···································································································32 四、特殊状态下的医学营养治疗 ·················································································34 1.儿童糖尿病 ·······································································································34 2.妊娠期糖尿病 ···································································································35 3.患糖尿病的老年人 ····························································································36 4.糖尿病前期 ·······································································································37 5.糖尿病与肠外肠内营养支持 ··············································································38 五、医学营养治疗的执行与贯彻 ·················································································41 1.营养教育 ···········································································································41 2.糖尿病医学营养治疗管理 ·················································································42 中国糖尿病医学营养治疗指南(2010) 4 检索时限 从1995年1月1日到2010年1月1日 语言 英语、汉语 数据库 一级文献数据库：Medline、EMBASE、SCI、 中国生物医学文献数据库 二级文献数据库：Guideline ClearingHouse、 Cochrane Library、SumSearch 筛选项目 人 类 文献出版 类型 有效性：指南、Meta-分析、系统评价、随机 对照研究、观察研究、病例报告、共识意见 安全性：指南、Meta-分析、系统评价、随机 对照研究、不良反应报告、共识意见 主要 检索词 Medical Nutrition Therapy、Parenteral Nutrition、Enteral Nutrition、Diabetes、营养 治疗、肠外营养、肠内营养、糖尿病等 各专题内容结合相关领域进一步确定检索词 中国糖尿病医学营养治疗指南(2010) 5 推荐 意见 证据 级别 描述 A 1a 基于RCTs的SR（有同质性） 1b 单个RCT研究 1c “全或无”证据（有治疗以前所有患者全 都死亡，有治疗之后有患者能存活。 或 者在有治疗以前一些患者死亡，有治疗以 后无患者死亡） B 2a 基于队列研究的SR (有同质性) 2b 单个队列研究（包括低质量 RCT研究，如<80% 随访） 3a 基于病例对照研究的SR（有同质性） 3b 单个病例对照研究 C 4 病例报道（低质量队列研究） D 5 专家意见或评论 中国糖尿病医学营养治疗指南(2010) 6 一、糖尿病医学营养治疗的循证基础 医学营养治疗（Medical Nutri t ion Therapy, MNT）对预防糖尿病的发生、治疗已发生的糖尿 病、预防或至少延缓糖尿病并发症的发生均有非常 重要的作用。同时MNT也是糖尿病自我教育中一个 不可或缺的部分, MNT应该贯穿于糖尿病预防的所有 阶段。本“指南”总结了糖尿病MNT近15年的循证 依据和干预模式，并参照WHO的《WHO指南编写指 南》和AGREE协作网发展的临床指南编写方法学原 则，结合中国糖尿病营养治疗共识实践现况，建立 “指南”制定的方法学原则。在AGREE协作网对全 球18个临床指南项目质量评价所得到的方法学结果 基础上，最终确立方法学细节。参照OCEBM分级系 统对可用的证据级别进行分级。 本“指南”的制定，旨在为医务工作者和糖尿 病患者提供当前阶段最佳的营养干预方法。利用现 有最佳证据，同时考虑治疗目标、治疗策略以及患 者本人意愿，使患者得以转变营养生活方式，以最 终实现长期临床结局和生活质量的改善。为实现上 述目标，建议在提供MNT的综合治疗小组中，应由 一位熟悉MNT且具备丰富营养治疗知识和经验的营 养（医）师发挥主导作用，同时小组成员（包括内 分泌科医生和护士），都应该熟知MNT内容并支持 MNT的贯彻实施。 1. MNT的目标： MNT的目标是在保证患者正常生活和儿童青少 年患者正常生长发育的前提下，纠正已发生的代谢 紊乱，减轻胰岛β细胞负荷，从而延缓并减轻糖尿 病并发症的发生和发展，进一步提高其生活质量。 具体目标为： 1.纠正代谢紊乱 通过平衡饮食与合理营养，以 控制血糖、血脂、补充优质蛋白质和预防其它必需 营养素缺乏。 2.减轻胰岛β细胞负荷 糖尿病患者存在不同程 度的胰岛功能障碍，合理的饮食可减少胰岛β细胞 负担并恢复部分功能。 3.防治并发症 个体化的医学营养治疗，可提供 适当、充足的营养素，有利于防治糖尿病并发症的 发生与发展。 4.提高生活质量，改善整体健康水平。 5.对于患有1型或2型糖尿病的儿童青少年患者、 妊娠期或哺乳期妇女及老年糖尿病患者，应满足其 在特定时期的营养需求。 6.对于无法经口进食或进食不足超过7天的高血 糖患者（包含应激性高血糖），为满足疾病代谢需 求，必要时通过合理的肠外营养或肠内营养治疗， 改善临床结局。 2. 推荐意见： 3. 证据： MNT是糖尿病预防、治疗和自我管理、教育的 一个重要的组成部分。营养治疗也是健康生活方式 的重要组成部分。ADA自2006年起就从全方位描述 营养治疗在预防糖尿病和控制糖尿病及其并发症发 生发展中的重要作用，并于2008年进行更新[1]。MNT 的实施需要一个由医生、护士、营养（医）师以及 患者组成的经验丰富的团队（小组）来完成，对糖 尿病治疗有丰富经验的营养（医）师应该在MNT治 疗小组中担当重任，除了各种形式的营养治疗（包 括肠外营养、肠内营养、治疗膳食）外，通过糖尿 病教育使患者学会自我管理的能力是营养治疗的重 推荐意见 推荐 级别 证据 1.任何糖尿病及糖尿病前期患者都需 要依据治疗目标接受个体化MNT， 建议由熟悉糖尿病治疗的营养（医） 师指导下完成更佳 A 多中心RCT 及队列研究 2.MNT可节约医疗费用、改善临床 结局 建议纳入相关医疗保险报销范围 B D 指南推荐 专家意见 3.对于2型糖尿病高危人群，强调生 活方式的改变，包括：适度减轻体 重（7%）和规律、适度的体力活 动（每周150分钟）、合理饮食控制 A RCT研究 4.制定MNT时，应考虑患者的 具体需求、是否愿意改变及做出改 变的能力 D 专家意见 中国糖尿病医学营养治疗指南(2010) 7 要保证[2]。随机对照研究/队列研究均提示，短期坚持 MNT，可使2型糖尿病患者HbA1c在治疗3-6个月后出 现显著下降（0.25%-2.9%)。1型糖尿病患者的HbA1c 可降低约1%，具体下降幅度取决于糖尿病的病程和 初始的血糖水平[3-5]。多中心随机对照研究显示，如 果有专职营养（医）师提供每年4-12次的随访观察， 可使患者的HbA1c获得12个月甚至更长时间的显著 性改善[6-9]。Meta-分析结果表明，MNT亦可降低非 糖尿病的LDL-C水平（15mg/dl-25mg/dl[10]或降幅达 16%[11]）。同时有助于降低体重及降低血压[12,13]。生 活方式调整除能有效改善患者的临床结局外，MNT 还有助于糖尿病患者以健康的方式最大程度的继续 享受他们喜爱的食物。如果需要应用药物降低血 糖，亦应与饮食和运动习惯相配合。但是，MNT的 不利之处也可能包括口感差、选食欠灵活、影响患 者主动意愿等。由于代谢应激或者临床治疗变化导致 的饮食内容变化等，均可能影响MNT的效果[14-17]。为 充分发挥MNT的作用，应建立以营养（医）师为主 体的多层面人员构建的健康管理团队，以确保营养 治疗的实施并长期随访管理、患者教育，最终 达到控制血糖、改善整体健康的目标。 参考文献： 1.American Diabetes Association. Standards of Medical Care in Diabetes-2010. Diabetes Care 2010;33(suppl 1):S23-S28. 2.American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008;31(suppl 1):S61-S79. 3.Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Trista`n ML, et al. Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care 2003;26:24-29. 4.Lemon CC, Lacey K, Lohse B, et al. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. J Am Diet Assoc 2004;104:1805-15. 5.Deakin TA, McShane CE, Cade JE, et al. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003417. DOI: 10.1002/14651858.CD003417.pub2 6.Miller CK, Edwards L, Kissling G, et al. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med 2002;34:252-59. 7.Wilson C, Brown T, Acton K, et al. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian health service. Diabetes Care 2003;26:2500-04. 8.Graber AL, Elasy TA, Quinn D, et al. Improving glycemic control in adults with diabetes mellitus: shared responsibility in primary care practices. South Med J 2002;95:684-90. 9.Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. J Am Diet Assoc 2006;106:109-12. 10.Yu-Poth S, Zhao G, Etherton T, et al. Effects of the National Cholesterol Education Program's Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta analysis. Am J Clin Nutr 1999;69:632-46. 11.Van Horn L, McCoin M, Kris-Etherton PM. The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 2008;108:287-331. 12.Appel LJ, Moore TJ, Obarzanek E. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-24. 13.Daly A, Michael P, Johnson EQ. Diabetes white paper: Defining the delivery of nutrition services in Medicare medical nutrition therapy vs Medicare diabetes self-management training programs. J Am Diet Assoc 2009;109(3):528-39. 14.Reader D, Splett P, Gunderson EP. Diabetes Care and Education Dietetic Practice Group. Impact of gestational diabetes mellitus nutrition practice guidelines implemented by registered dietitians on pregnancy outcomes. J Am Diet Assoc. 2006;106(9):1426-33. 15.Swift CS, Boucher JL. Nutrition therapy for the hospitalized patient with diabetes. Endocr Pract 2006;12(Suppl 3):61-67. 16.Li WH, Xiao XH, Sun Q. Relationship between hemoglobin A1c and blood glucose throughout the day in well-glycemic-controlled medical nutrition therapy alone type 2 diabetic patients. Chin Med Sci J 2006;21(2):90-94. 17.Burani J, Longo PJ. Low-glycemic index carbohydrates: an effective behavioral change for glycemic control and weight management in patients with type 1 and 2 diabetes. Diabetes Educ 2006;32(1):78-88. 中国糖尿病医学营养治疗指南(2010) 8 1. 能 量 推荐意见： 背景： 能量控制对于糖尿病乃至预防糖尿病相关风险 均至关重要。一方面要求符合中国居民膳食推荐摄 入量，满足营养需求，防止营养不良的发生[1]；另一 方面需要控制相应的能量摄入，以期达到良好的体 重以及代谢控制。能量摄入的标准，在成人以能够 达到或维持理想体重为标准；儿童青少年则保持正 常生长发育为标准；妊娠期糖尿病则需要同时保证 胎儿与母体的营养需求。最理想的基础能量需要量 测定为间接能量测定法，并结合患者的活动强度、 疾病应激状况确定每日能量需要量[2-5]。但由于间接 能量测定法受仪器、环境等因素的限制，也可以采 用多元回归的经验公式进行估计，或者采用通用系 数方法，每人按照25-30kcal/kg IBW/d计算基本能 量摄入推荐，再根据患者的身高、体重、性别、年 二、营养素推荐 推荐意见 推荐 级别 证据 1.对于所有患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.在超重或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限制能量 的饮食在短期内（1年内）可有效 减轻体重 B RCT研究 4.就减重效果而言，限制能量摄入 较单纯调节营养素比例更关键 B RCT研究、Meta-分析 5.坚持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（DRIs），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）的营养治疗 D 指南推荐、 专家意见 龄、活动度、应激状况调整为个体化能量标准[6-8]。 证据： 由于近60%的糖尿病患者属于超重或肥胖，因 此其能量推荐标准需要考虑能量平衡代偿和减肥等 因素[9-11]。 短期研究表明，适度减肥可使2型糖尿病 患者胰岛素抵抗减轻，并有助于改善血糖和血脂状 况，降低血压 [12]。长期研究（≥52周）表明，药物 减肥对于2型糖尿病患者，可适度减轻体重，降低 HbA1c水平。运动不但具有减肥效果，还可改善胰岛 素敏感性、降糖及有助于长期维持减肥效果等功 能 [13,15]。但是，大多数人不能长期坚持减肥计划，这 与中枢神经系统在调节能量摄入和消耗方面发挥重 要作用有关。运动结合饮食生活方式调整，有更好 的减肥效果[14]。极低能量饮食（≤800kcal/d），可迅 速减轻2型糖尿病患者体重、改善血糖和血脂状况。 但该治疗非常难以坚持且终止后容易出现体重反 弹。因此，极低能量饮食不适宜用于长期治疗2型糖 尿病，应当考虑结合其他生活方式干预措施[16,17]。 参考文献： 1.蔡美琴,沈秀华,王少墨.糖尿病患者的营养状况及影响血糖控制 的非药物因素分析. 卫生研究 2002;31(suppl):38-40. 2.Iff S, Leuenberger M, Rösch S. Meeting the nutritional requirements of hospitalized patients: an interdisciplinary approach to hospital catering. Clin Nutr 2008;27(6):800-05. 3.Astrup A, Rössner S, Van Gaal L. Effects of liraglutide in the treatment of obesity: a randomised, double-blind, placebo-controlled study. Lancet 2009;374(9701):1606-16 4.Bao J, de Jong V, Atkinson F. Food insulin index: physiologic basis for predicting insulin demand evoked by composite meals. Am J Clin Nutr 2009;90(4):986-92. 5.Sievenpiper JL, Carleton AJ, Chatha S. Heterogeneous effects of fructose on blood lipids in individuals with type 2 diabetes: systematic review and meta-analysis of experimental trials in humans. Diabetes Care 2009;32(10):1930-37. 6.Liese AD, Nichols M, Sun X. Adherence to the DASH Diet is inversely associated with incidence of type 2 diabetes: the insulin resistance atherosclerosis study. Diabetes Care 2009;32(8):1434-36. 7.Vanschoonbeek K, Lansink M, van Laere KM. Slowly digestible carbohydrate sources can be used to attenuate the postprandial glycemic response to the ingestion of diabetes-specific enteral formulas. Diabetes Educ 2009;35(4):631-40. 8.American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008;31(suppl 1):S61-S79. 9.Sacks FM, Bray GA, Carey VJ. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N 中国糖尿病医学营养治疗指南(2010) 9 Engl J Med 2009;360(9):859-73. 10.Claessens M, van Baak MA, Monsheimer S. The effect of a low- fat, high-protein or high-carbohydrate ad libitum diet on weight loss maintenance and metabolic risk factors. Int J Obes (Lond) 2009;33(3):296-304. 11.Shai I, Schwarzfuchs D, Henkin Y. Weight loss with a low- carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008;359(3):229-41. 12.Manders RJ, Koopman R, Beelen M. The muscle protein synthetic response to carbohydrate and protein ingestion is not impaired in men with longstanding type 2 diabetes. J Nutr 2008;138(6):1079-85. 13.Norris SL, Zhang X, Avenell A. Longterm effectiveness of weight- loss interventions in adults with pre-diabetes: a review. Am J Prev Med 2005;28:126-39. 14.Klein S, Sheard NF, Pi-Sunyer X. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Diabetes Care 2004;27:2067-73. 15.Corpeleijn E, Feskens EJ, Jansen EH. Improvements in glucose tolerance and insulin sensitivity after lifestyle intervention are related to changes in serum fatty acid profile and desaturase activities: the SLIM study. Diabetologia 2006;49(10):2392-401. 16.Mayer-Davis EJ, Nichols M, Liese AD. Dietary intake among youth with diabetes: the SEARCH for Diabetes in Youth Study. J Am Diet Assoc 2006;106(5):689-97. 17.Sargrad KR, Homko C, Mozzoli M. Effect of high protein vs high carbohydrate intake on insulin sensitivity, body weight, hemoglobin A1c, and blood pressure in patients with type 2 diabetes mellitus. J Am Diet Assoc 2005;105(4):573-80. 2. 蛋白质 推荐意见： 背景： 根据膳食营养素参考摄入量（DRIs）的推荐， 可接受的蛋白质摄入量范围为占能量摄入1 0 % - 35%[1,2]。而美国和加拿大的成人平均蛋白质摄入量占 能量摄入的10%-15% [3]。 优质蛋白来源的定义是，PD-CAAS（经蛋白质 消化率校正的氨基酸评分）评分高且能够提供9种必 需氨基酸，例如，肉类、禽类、鱼类，蛋、牛奶、 奶酪和大豆。不属于优质蛋白的食物来源包括：谷 物类、坚果和蔬菜、水果。 证据： 糖尿病患者的蛋白质摄入量与一般人群类似， 通常不超过能量摄入量的20%。在健康人和2型糖尿 病患者中开展的大量研究表明，食物蛋白质经糖异 生途径生成的葡萄糖并不会影响血糖水平，但会导 致血清胰岛素反应性升高[1,4]。在糖尿病患者中开展 的小规模、短期研究显示，蛋白质含量>20%总能量 的饮食可降低食欲，增加饱腹感[5-7]。不过，目前尚 无充分研究高蛋白饮食对能量摄入、饱腹感、体重 的长期调节的影响，以及个体长期遵循此类饮食的 能力。 蛋白质的不同来源对血糖的影响不大，但是植 物来源的蛋白质，尤其是大豆蛋白质对于血脂的控 制较动物蛋白质更有优势[8,9]。研究发现，乳清蛋白 具有降低超重者餐后糖负荷的作用[10]，可有效减少 肥胖相关性疾病发生的风险[11]。 参考文献： 1.Franz MJ, Bantle JP, Beebe CA. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25:148-98 2.American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008;31(suppl 1):S61-S79. 3.Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC, National Academies Press, 2002. 4.Gannon MC, Nuttall JA, Damberg G. Effect of protein ingestion on the glucose appearance rate in people with type 2 diabetes. J Clin Endocrinol Metab 2001;86:1040-47. 5.Gougeon R, Styhler K, Morais JA. Effects of oral hypoglycemic agents and diet on protein metabolism in type 2 diabetes. Diabetes Care 2000;23:1-8. 6.Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes 2004;53:2375-82. 7.Gannon MC, Nuttall FQ, Saeed A, et al. An increase in dietary protein improves the blood glucose response in persons with type 2 diabetes. Am J Clin Nutr 2003;78:734-41. 8.Sacks FM, Bray GA, Carey VJ. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360(9):859-73. 9.Pipe EA, Gobert CP, Capes SE. Soy protein reduces serum LDL cholesterol and the LDL cholesterol: HDL cholesterol and apolipoprotein B:apolipoprotein A-I ratios in adults with type 2 diabetes. J Nutr 2009;139(9):1700-06. 推荐意见 推荐 级别 证据 1.对于患有糖尿病且肾功能正常的个 体，推荐蛋白质的摄入量占供能比的 10%-15% D 专家意见 2.2型糖尿病患者中，摄入蛋白质不易引 起血糖升高但可增加胰岛素反应。纯 蛋白质食品不能用于治疗急性低血糖 或预防夜间低血糖 B 指南推荐 3.目前不建议采用高蛋白饮食作为减肥 方法。蛋白质摄入>20%能量对糖尿 病管理及其并发症的长期影响目前尚 不清楚 D 专家意见 4.在控制血脂相关指标方面，植物蛋白 质较动物蛋白质更有优势 B 小样本RCT研究 5.乳清蛋白有助于降低超重者的体重和 餐后糖负荷，降低肥胖相关性疾病发 生的风险 B RCT研究 中国糖尿病医学营养治疗指南(2010) 10 10.Petersen BL, Ward LS, Bastian ED, et al. A whey protein supplement decreases post-prandial glycemia. J Nutr 2009:8:47. 11.Frestedt JL, Zenk JL, Kuskowski MA, et al. A whey protein supplement increases fat loss and spares lean muscle in obese subjects: a randomized human clinical study. Nutr Metab (Lond) 2008;5:1-7. 3. 脂 肪 推荐意见： 背景： 脂肪是重要的供能物质，糖尿病条件下对脂肪 的关注主要在于摄入不同种类/剂量脂肪后对糖代 谢、胰岛素抵抗及血脂的的影响，及其随后表现在 各系统器官的后果。有明确的研究证据表明，长期 摄入高脂肪膳食可损害糖耐量，促进肥胖、高血脂 和心血管病的发生。 自上世纪认识到过量脂肪摄入对患者长期心血 管健康有不良影响后，减少脂肪摄入总量就成为糖 尿病营养治疗中重要的环节。各种研究证据均指 向，脂肪占总能量摄入不宜超过30%[1,2]。 上世纪90年代以来，随着对各种类型的具有预 防和治疗性作用的脂肪的深入认识，出现了越来越 多对膳食和/或营养制剂中脂肪种类、比例及摄入量 进行调整的临床和流行病学研究。但是，专注于以 糖尿病患者为特定研究对象的膳食脂肪摄入的随机 对照研究很少，大部分此类研究主要以非糖尿病患 者为对象。 证据： 1)脂肪摄入量 近10年中国人群食物摄入的显著变化特点之 一，是脂肪摄入量逐渐攀高，尤其在城市人群中， 脂肪在成人食物能量来源中的占比已从1991年的 27.7%上升至2004年的33.1%，且还在逐年上升[3]。对 糖尿病患者，国内部分地区有专项调查研究发现， 其脂肪摄入量往往比一般未患病者更高[4,5]。有的系 统评价证据表明，过高的脂肪