美国糖尿病协会（ADA）最近出版了能够改善糖尿病患者预后情况的临床实践指南，涉及到糖尿病的筛查、诊断和治疗干预等。2008年1月的《糖尿病护理》（Diabetes Care）杂志详细描述了ADA的临床建议，也介绍了ADA的分级系统，即根据每条临床建议的证据程度将其分为A，B，C，D或E，并提出了大部分糖尿病患者的治疗目标。

该指南的作者表示：“这些护理标准的目的是为临床医师、患者、研究人员、付费会员和感兴趣的个人，提供糖尿病护理、治疗目标以及评估护理质量方面的工具。虽然在对患者进行个体化治疗时，医生会根据患者的共病情况和其他因素等对治疗目标进行修改，但是它依然能够满足大部分糖尿病患者的治疗需求。同时，本指南并不排斥其他专家根据患者的需求而发表的更广泛的评估和治疗管理。”

该实践指南主要涉及以下几个主题：糖尿病的诊断、前驱糖尿病和糖尿病的检测、儿童Ⅱ型糖尿病的检测、妊娠性糖尿病的发现和诊断、预防和延缓Ⅱ型糖尿病、血糖水平的自我监测、糖化血红蛋白A1C水平、血糖目标、医学营养治疗（MNT）、糖尿病自我管理教育（DSME）、体育锻炼、心理评估和护理、低血糖、免疫、高血压和血压控制、血脂异常和脂质管理等。

同时，该实践指南还包括以下几点：抗血小板药物的使用、戒烟、冠心病的筛查和治疗、肾病的筛查和治疗、视网膜病的筛查和治疗、神经系统疾病的筛查和治疗、足部护理、治疗儿童和青少年时的一些特殊情况、孕前护理、治疗老年人的特殊情况、医院内的糖尿病（包括血糖水平）护理、学校内的糖尿病日常护理、糖尿病社区内的护理、矫正机构内的糖尿病管理、急诊和灾害防备、低血糖和就业/执照、糖尿病护理的第三方支付、自我管理教育和支持等。

以下是部分具体的推荐：

--- 儿童和非妊娠期成人优先选择使用空腹血糖检测（FPG），目前还不推荐使用A1C水平作为诊断糖尿病的标准（E）。

--- 对无症状的前驱糖尿病和Ⅱ型糖尿病患者进行筛查时，筛查人群应该是体重超标或肥胖（BMI≥25 kg/m2），且至少伴有一种额外风险因素的成人。否则，筛查就应该从45岁的年龄段开始（B）；如果检测结果显示正常，那么下次筛查的间隔时间不得大于3年（E）。

--- FPG检测或2小时口服葡萄糖耐量试验（OGTT；75g葡萄糖负荷）都能够用来检测前驱糖尿病或糖尿病（B）。对空腹血糖受损（IFG）的患者进行OGTT试验能够更好的确定罹患糖尿病的风险（E）。

--- 对前驱糖尿病的个人应该进行相应的评估和治疗，如果有可能的话，同时还应该关注其在心血管方面的风险因素。

--- 为了预防或延缓糖尿病的发生，建议葡萄糖耐量损害（IGT；A）或IFG（E）患者至少减掉体重的5%-10%，同时每周至少进行150分钟的体育锻炼，例如散步等。随访咨询似乎能够提高成功的可能性（B）。由于潜在的成本节约与糖尿病的预防有关，因此第三方支付项目也应该包含在咨询范围之内（E）。

--- 对糖尿病的高风险人群（在联合IFG和IGT的基础上存在其他风险因素）、肥胖且年龄低于60岁的患者，可以考虑应用二甲双胍治疗（E）。

--- 前驱糖尿病患者每年都应该接受监测，以便观察糖尿病的发展（E）。

--- 由于将A1C水平降低到平均值的7%能够减少微血管疾病、神经疾病和大血管疾病（很有可能）等糖尿病并发症的发生，所以非妊娠期成人的A1C目标水平通常都低于7%（A）。

--- 对于特定的个体化患者，A1C的目标水平是在不发生明显低血糖的情况下，尽量接近正常值（<6%）（B）。流行病学的研究显示，将A1C水平从7%降至正常范围能够使患者轻微受益。

--- 对以下儿童的A1C目标水平可以不做严格要求：有严重低血糖病史、生存预期有限、出现共病、长期患有糖尿病且伴有轻微或稳定的微血管并发症等（E）。

--- 前驱糖尿病或糖尿病患者应该接受个性化的医学营养治疗（MNT）以达到治疗的目的，最好是由对糖尿病MNT非常了解的注册营养师来制定MNT方案。应该包括保险公司和其他付款人在内（E）。

--- MNT的具体组成部分应该包括能量均衡的管理、超重、肥胖与饮食、体育锻炼、行为矫正（B）；Ⅱ型糖尿病高风险患者的初级预防（A）；纤维和全谷物的摄入量达到美国农业部的建议摄入量（B）；通过将饱和脂肪摄入量限制在总卡路里量的7%以内以及尽量减少脂肪摄入量（E）等方法，来控制饮食中的脂肪摄取量（A）；有效管理碳水化合物的摄入量。

--- 在实现血糖控制时，无论是通过碳水化合物计算、换算，还是根据经验来估算，监测碳水化合物的摄入量都是一个关键的策略。对于糖尿病患者来说，与仅考虑总碳水化合物含量相比，血糖指数和血糖负荷的使用更有利于改善血糖控制（B）。

--- 在确诊为糖尿病时就应该对患者进行糖尿病自我管理教育（DSME），并为患者在今后的生活中能够改变自我管理行为（E）和解决心理问题奠定基础。第三方付款人应该为DSME付费。

--- 糖尿病患者每周应该进行150分钟中等强度的有氧运动（50%-70%的最高心率；[A]）。Ⅱ型糖尿病患者每周还应该进行3次阻力训练，有禁忌症的患者除外（A）。

本实践指南的作者最后总结道：“糖尿病患者在就业时应该根据自身情况综合考虑到工作的特殊需求、个人的身体状况、治疗方案和治疗史等（E）。患者和医生应该能够避免不必要的管制，自由获得所有类别的降糖药品、设备及其他所需用品（E）。保险和第三方支付项目应该包括MNT和DSME（E）。”
Diabetes Care. 2008;31(suppl 1):S5-S11.

Practice Guidelines Issued for Screening, Diagnosing, and Treating Diabetes CME/CE
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).

"People with diabetes should be individually considered for employment based on the requirements of the specific job and the individual's medical condition, treatment regimen, and medical history (E)," the guidelines authors conclude. "Patients and practitioners should have access to all classes of antidiabetic medications, equipment, and supplies without undue controls (E). MNT and DSME should be covered by insurance and other payors (E)."