全科与2型糖尿病

nullThe Diabetes Epidemic 糖尿病流行病学The Diabetes Epidemic 糖尿病流行病学2007全球糖尿病病例总共2.46亿－中国3980万Diabetes 糖尿病 Type 1 I型 Type 2 2型Diabetes 糖尿病 Type 1 I型 Type 2 2型Rare少见 Dramatic Onset起病急剧 Not enough Insulin胰岛素不足 Thin体型瘦 Complications late并发症出现晚 Easy to manage较易处理 Medication 1st 首先药物治疗 Lifestyle 2nd其次改变生活方式 Disease focus疾病为中心 Specialist important专业医生重要 Common常见 Subtle Onset起病缓慢 Insulin Resistant胰岛素抵抗 Fat肥胖 Complications early并发症出现晚 Difficult to manage较难处理 Lifestyle 1st 首先改变生活方式 Medication 2nd其次药物治疗 Whole person focus个人整体为中心 GP important全科医学重要 GP - key to Type 2 DiabetesII全科医学－型糖尿病的关键GP - key to Type 2 DiabetesII全科医学－型糖尿病的关键cheap 便宜 simple 简便 save lives拯救生病 save feet拯救患肢 save kidneys拯救肾脏 save sight拯救视力 80% prevention 预防 diet + exercise饮食+运动nullThe Diabetes Epidemic糖尿病流行病学The Diabetes Epidemic糖尿病流行病学Diabetes affects 246 million people worldwide and is expected to affect 380 million by 2025.糖尿病影响了全世界2.46亿人，到2025年，可能会影响到3.80亿人。 In 2007, the five countries with the largest numbers of people with diabetes are截至2007年，糖尿病人数最多的5个国家： India 印度 (40.9 million) China 中国 (39.8 million) United States 美国 (19.2 million) Russia 俄罗斯 (9.6 million) Germany 德国 (7.4 million)‏The Diabetes Epidemic糖尿病流行病学The Diabetes Epidemic糖尿病流行病学In 2007, the five countries with the highest diabetes prevalence in the adult population are截至2007年，糖尿病病人占成人总数比例最高的5个国家 Nauru 瑙鲁 (30.7%)‏ United Arab Emirates 阿联酋 (19.5%)‏ Saudi Arabia   沙特阿拉伯 (16.7%)‏ Bahrain 巴林 (15.2%)‏ Kuwait 科威特 (14.4%). By 2025, the largest increases in diabetes prevalence will take place in developing countries.到2025年，糖尿病病人比率上升最快的将在发展中国家The Diabetes Epidemic糖尿病流行病学The Diabetes Epidemic糖尿病流行病学Each year a further 7 million people develop diabetes.每年都要新增糖尿病病人700万人。 Each year 3.8 million deaths are attributable to diabetes. 每年380万人死于糖尿病 An even greater number die from cardiovascular disease made worse by diabetes-related lipid disorders and hypertension.糖尿病相关的脂质紊乱和高血压造成心血管疾病恶化引起的死亡人数更多 Every 10 seconds a person dies from diabetes-related causes.每隔10秒钟就有1人死于糖尿病相关疾病 Every 10 seconds two people develop diabetes.每隔10秒钟新增2名糖尿病病人 Diabetes is the fourth leading cause of global death by disease.糖尿病是全球由于疾病导致死亡的第四大病因The Diabetes Epidemic糖尿病流行病学 Unrecognised未诊断The Diabetes Epidemic糖尿病流行病学 Unrecognised未诊断At least 50% of all people with diabetes are unaware of their condition.至少有50％的糖尿病病人没有意识到他的疾病情况 In some countries 80% of all people with diabetes are unaware of their condition.在一些国家大约有80％的病人没有意识到The Diabetes Epidemic糖尿病流行病学 Preventable可预防The Diabetes Epidemic糖尿病流行病学 Preventable可预防Up to 80% of type 2 diabetes is preventable by adopting a healthy diet and increasing physical activity.大约有80％的II型糖尿病病人通过健康饮食和体育锻炼是可预防的The Diabetes Epidemic糖尿病流行病学 Kidney Failure肾衰竭The Diabetes Epidemic糖尿病流行病学 Kidney Failure肾衰竭Diabetes is the largest cause of kidney failure in developed countries and is responsible for huge dialysis costs.在发达国家，糖尿病是引起肾衰竭的最大病因并且导致高昂的肾透析。 Type 2 diabetes has become the most frequent condition in people with kidney failure in countries of the Western world. The reported incidence varies between 30% and 40% in countries such as Germany and the USA.II型糖尿病成为西方国家肾衰病人的主要疾病，据报道发病率在30％－40％之间（德国和美国）The Diabetes Epidemic糖尿病流行病学 Blindness失明The Diabetes Epidemic糖尿病流行病学 Blindness失明It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy. 据估计全世界有超过250万人患有糖尿病视网膜病 Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialized countries.糖尿病视网膜病是发达国家成人（20－65岁）中引起失明的首要原因The Diabetes Epidemic糖尿病流行病学 Heart Attack心脏病The Diabetes Epidemic糖尿病流行病学 Heart Attack心脏病On average, people with type 2 diabetes will die 5-10 years before people without diabetes, mostly due to cardiovascular disease.II型糖尿病病人平均寿命比无糖尿病的人短5－10年，往往死于心血管疾病。 Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and much disability.心血管疾病是糖尿病的主要死因，占了全部死亡人数的50％ Type 2 diabetics are as likely to suffer a heart attack as people without diabetes who have already had a heart attack.II型糖尿病病人比那些有过心脏事件的非糖尿病病人更容易发生心脏事件Diabetes 糖尿病 Type 1 I型 Type 2 2型Diabetes 糖尿病 Type 1 I型 Type 2 2型Rare少见 Dramatic Onset起病急剧 Not enough Insulin胰岛素不足 Thin体型瘦 Complications late并发症出现晚 Easy to manage较易处理 Medication 1st 首先药物治疗 Lifestyle 2nd其次改变生活方式 Disease focus疾病为中心 Specialist important专业医生重要 Common常见 Subtle Onset起病缓慢 Insulin Resistant胰岛素抵抗 Fat肥胖 Complications early并发症出现晚 Difficult to manage较难处理 Lifestyle 1st 首先改变生活方式 Medication 2nd其次药物治疗 Whole person focus个人整体为中心 GP important全科医学重要 nullType 2 Diabetes 寻找II型糖尿病 Looking for itType 2 Diabetes 寻找II型糖尿病 Looking for itBlood Glucose is the only useful test血糖是唯一有用的检查 Urine testing misses most cases 仅尿液检查会漏过大多数病例 Opportunistic screening on GP visit全科医生随访检查 Plasma血浆 Fasting BSL > 7 (126 US units)‏空腹血糖 Random BSL > 11 (200 US units)‏随机血糖 Blood - Fingerprick glucometer指血血糖仪 Fasting BSL > 6空腹血糖 Random BSL > 10随即血糖 Repeat Fasting test to confirm diagnosis重复空腹血糖检查来确定诊断 Check Blood Glucose every year in High Risk Groups 在高危人群中每年检测血糖Check Blood Glucose every year in High Risk Groups 在高危人群中每年检测血糖IGT - Impaired Glucose Tolerance糖耐量减退 IFG - Impaired Fasting Glucose空腹血糖受损 CVD - Vascular Disease血管疾病 PCOS – Polycystic Ovarian Syndrome多囊卵巢综合症 Hypertension > 45 years 高血压>45岁 Obesity > 45 years 肥胖>45岁 Past gestational diabetes妊娠高血压病史 Past Big Baby > 4 Kg 巨大儿 Low HDL < 0.9 IU HDL低 High TG > 2.82 IU TG高 Ethnic Risk > 35 years 特定人种风险>35岁 ( Chinese, Indian, Pacific, Aboriginal )中国，印度，‏Type 2 Diabetes II型糖尿病Management Goals控制目标Type 2 Diabetes II型糖尿病Management Goals控制目标Waist Slim减肥瘦腰围 Exercise Daily 每天锻炼 Non-Smoking戒烟 Low GI “heart healthy” Diet低糖，对心脏健康的饮食 Systolic BP < 120mm Hg 收缩压<12mmHg HBA1c = 7% or less Monitor Eye, Kidney, Foot Health 监测眼、肾、足情况 Avoid blindness, renal failure, amputation防止失明、肾衰、截肢手术 Drugs as indicated by Evidence 循证医学的药物治疗 ( “Poly-Pill” = Aspirin+Statin+ACE-i for all?) “合剂治疗”Retina Check every year by an Expert 每年由专家检查视网膜情况Retina Check every year by an Expert 每年由专家检查视网膜情况GP and Physician and Nurse cannot diagnose early Retinopathy全科医生、内科医生和护士并不能早期诊断视网膜病 Must dilate pupils unless retinal camera available必须扩瞳；视网膜照相技术 Must refer to Opthalmologist or Optometrist必须有相关眼科医生或验光师the error rates for detecting serious sight threatening diabetic eye lesions with opthalmoscopy is shown above. Intern's may miss 70% of sight threatening lesions, while the diabetologists may miss 50% of sight threatening lesions.the error rates for detecting serious sight threatening diabetic eye lesions with opthalmoscopy is shown above. Intern's may miss 70% of sight threatening lesions, while the diabetologists may miss 50% of sight threatening lesions.检眼镜错误率nullRetinoscopy – get an expertnullRetinoscopy – get an expert检眼镜检查－需要专业医生Retinoscopy – get an expert检眼镜检查－需要专业医生Retinoscopy – get an expert检眼镜检查－需要专业医生Retinoscopy – get an expert检眼镜检查－需要专业医生Monofilament testing for Neuropathy单丝纤维测试神经病变Monofilament testing for Neuropathy单丝纤维测试神经病变Avoid Amputation Monofilament prevents Ulcers避免截肢－单丝纤维预防溃疡Avoid Amputation Monofilament prevents Ulcers避免截肢－单丝纤维预防溃疡..if cannot feel the monofilament at certain specified sites on the foot, he/she has lost enough sensation to be at risk of developing a neuropathic ulcer. 如果不能够感觉到足部特定部位的单丝纤维，则代该病人感觉丧失，有发生神经性溃疡的风险 ... calibrated to make sure it is exerting a force of 10 grams.校准后相当于施加10g的力 http://www.diabetes.usyd.edu.au/foot/Fexam1.html http://www.d4pro.com/footcare/Fexam1.htmlStandard Neuropathy Testing Sites神经病测试位置Standard Neuropathy Testing Sites标准神经病测试位置Avoid neuropathic ulcers防止神经病变引起的溃疡Avoid neuropathic ulcers防止神经病变引起的溃疡Neuropathy – keep it simple nylon monofilament best神经病变－简单化操作：尼龙单丝纤维Neuropathy – keep it simple nylon monofilament best神经病变－简单化操作：尼龙单丝纤维Detect Neuropathy in timeDetect Neuropathy in timeNeuropathy 神经病变 1gm and 10gm Monofilament 7cm and 2.5cm length of 17Kg line 1g和10g单丝纤维分别为7厘米和2.5厘米长，17kgNeuropathy 神经病变 1gm and 10gm Monofilament 7cm and 2.5cm length of 17Kg line 1g和10g单丝纤维分别为7厘米和2.5厘米长，17kgNeuropathy 神经病变 calibrate monofilament with 2.4gm spatula用2.4gm的压舌板校准单丝纤维Neuropathy 神经病变 calibrate monofilament with 2.4gm spatula用2.4gm的压舌板校准单丝纤维nullGlucose control prevents retinopathy控制血糖可以预防视网膜病变Glucose Control血糖控制Glucose Control血糖控制Daily Exercise每天锻炼 Low GI diet低糖饮食 Metformin 500-1000mg twice daily 二甲双胍500－1000mg bid Incretin based therapies (not available yet)‏ 肠促胰岛素为基础的治疗（尚不能提供） Glitazones ( cost, ?safe – heart failure )‏ 格列酮类（价格/安全性－心衰） Insulin stimulants if not obese 胰岛素促分泌剂（非肥胖） ( glibenclamide, repaglinide )格列本脲 ，瑞格列奈 Insulin injections if not obese非肥胖病人注射胰岛素 ( If Obese – Don’t need more insulin )‏ 如果肥胖，不需要更多胰岛素Glucose Control 控制血糖Daily Exercise每天锻炼Glucose Control 控制血糖Daily Exercise每天锻炼饭后百步走， 活到九十九 Fàn hòu bǎi bù zǒu， huó dào jiǔ shí jiǔ Even just walking will make a measureable difference in IR and glucose levels for the next 24 hours即使只是步行也能改善接下去24小时内的的胰岛素抵抗情况和血糖nullnullGlucose Control控制血糖 Low GI Diet 低糖饮食http://www.glycemicindex.com/Glucose Control控制血糖 Low GI Diet 低糖饮食http://www.glycemicindex.com/nullUse of waist circumference to predict insulin resistance: 用腰围来预测胰岛素抵抗 Use of waist circumference to predict insulin resistance: 用腰围来预测胰岛素抵抗 Waist circumference is a strong independent risk factor for insulin resistance and the most powerful regressor in our model. It replaces body mass index, waist:hip ratio, and other measures of total body fat as a predictor of insulin resistance and explains more than 50% of the variation in insulin sensitivity alone.腰围在我们模型中是胰岛素抵抗一个很强的独立危险因素以及最显著的回归变量。它取代了BMI指数、腰臀比以及其他测量整体脂肪的测量值，成为胰岛素抵抗的预测指标，并且可以单独解释超过50％的胰岛素敏感性的变异值。 BMJ 2005;330:1363–4Measure That Waist!测量腰围Measure That Waist!测量腰围Waist Height Ratio 腰围身高比 the Bogalusa Heart Study 心脏研究Waist Height Ratio 腰围身高比 the Bogalusa Heart Study 心脏研究BMI-for-age and waist-to-height ratio do not differ in their abilities to identify children with adverse risk factors. ...waist-to-height ratio may be preferred because of its simplicity年龄身高体重指数和腰围身高比在发现高危险因素的儿童方面的作用没有差异，由于腰围身高比非常简单，所以更多选用。 Relation of body mass index and waist-to-height ratio to cardiovascular disease risk factors in children and adolescents : the Bogalusa Heart Study Bogalusa心脏研究关注的就是在儿童和成人中身高体重指数与腰围身高比和心血管疾病危险因素之间的关系 FREEDMAN et al; The American journal of clinical nutrition. 2007, vol. 86, no1, pp. 33-40 (BMI-for-age Z-score > 95th percentile corresponds to waist-to-height ratio of 0.512 )Waist Height Ratio Harmonises Chinese and Western population studies 腰围身高比在令中国和西方研究结果保持一致Waist Height Ratio Harmonises Chinese and Western population studies 腰围身高比在令中国和西方研究结果保持一致EGIR - The European Group for the Study of Insulin Resistance (1999) – male waist circumference over 94cm is significant 胰岛素抵抗欧洲研究组显示：男性腰围超过94cm的组有显著差异 WGOC – Working Group on Obesity in China (2004) meta-analysis of 13 databases – male waist circumference over 85cm is significant 中国糖尿病工作组13个数据库的荟萃显示：腰围超过85cm的有明显差异 Waist / Height ratio explains the difference due to relative stature of past chinese generations 腰围身高比解释了两者的差异，是由于中国人群的相关身高差异造成的。 Yearly Albumenuria Check 每年检测白蛋白尿 ACR vs 24 hour urine ACR/24小时尿检测Yearly Albumenuria Check 每年检测白蛋白尿 ACR vs 24 hour urine ACR/24小时尿检测The marginal benefit of using a timed urine collection over a spot ACR to detect microalbuminuria in the screening of diabetic patients is small, and not worth the cost and inconvenience of collecting a timed sample. 发现微量白蛋白尿的方法：定期收集尿样和检测一次尿液的尿ACR相比优势有限，然而花费大，取样不便 Ewald and Attia. Systematic Review. Australian Family Physician. July 2004 Yearly Albumenuria Check 24 hour collection Inconvenient 每年的白蛋白尿检测：24小时收集尿液不方便Yearly Albumenuria Check 24 hour collection Inconvenient 每年的白蛋白尿检测：24小时收集尿液不方便Yearly Albumenuria Check ACR spot urine Convenient 每年的白蛋白尿检测：单次尿液ACR检测应用方便Yearly Albumenuria Check ACR spot urine Convenient 每年的白蛋白尿检测：单次尿液ACR检测应用方便Albumenuria Control白蛋白尿的控制Albumenuria Control白蛋白尿的控制Daily Exercise 每天锻炼 Low GI – Heart Healthy Diet 低糖－心脏健康饮食 Systolic Blood Pressure < 120mmg Hg 收缩压 Start with ACEi or ARB首选ACEi或ARB治疗 Many patients need 3 anti-hypertensives.许多病人需要3种抗高血压治疗 Group Activities Each One do One组内活动Group Activities Each One do One组内活动Calculate Waist / Height Ratio ( ideal less than 52%)‏ 计算腰围身高比（理想值小于52％） Check Random Glucose Fingerprick 检测随即指血血糖 Visual Inspection of bare feet 足部检查 Palpate Foot Pulses – P.Tibial, D.Pedis 触足部动脉波动 Calibrate Monofilament with spatula 用压舌板校准单丝纤维 Check Foot sensation with Monofilament 用单丝纤维测足部感觉 Ask – ACR in last year? 询问：去年的ACR值？ Ask – Retinoscopy in last year? 询问：去年检眼镜检查结果 Ask – on Aspirin or Poly-Pill? (statin+aspirin+Ace ) 询问：但用阿司匹林还是合剂治疗？