NEJM：糖尿病治疗领域的进展与不足

国际权威杂志《新英格兰医学杂志》2013年4月25日网络版发表的一项研究显示，自1999年以来，成人糖尿病治疗领域在推行预防措施的依从性和控制糖尿病并发症风险因素方面取得了显著进展。
然而，仍有多达半数的成人患者未达到血糖控制、血压和血脂控制目标，并且有半数患者表示未接受过糖尿病相关知识的教育，推荐的每年1次的疫苗接种、牙科检查和眼部检查也常被忽视。在这项研究中，亚特兰大疾病防控中心的Mohammed K. Ali医生及其同事采用数次全国健康与营养调查(NHANES 1999~2002、2003~2006和2007~2010)和行为危险因素监测系统调查(BRFSS 2000、2004和2008)数据，研究了糖尿病治疗领域近年的进展情况。这两种调查纳入的人群样本均具有全国代表性，并且均基于健康相关行为的自我报告。
在该研究中，Ali博士及其同事对报告患有糖尿病的3,355名NHANES受访者和97,310名BRFSS受访者的数据进行了分析。结果显示，在最早一次调查(1999~2002)和最近一次调查(2007~2010)之间，血糖控制不佳的患者比例降低了5.8%，而达到糖化血红蛋白、血压和LDL胆固醇推荐的目标水平的患者比例分别增加7.9%、11.7%和20.8%，均具有统计学意义。
同样，随着时间的推移，糖化血红蛋白水平、LDL胆固醇水平和血压水平的人群分布也都获得显著性改善。平均糖化血红蛋白水平降低0.4%，平均LDL胆固醇水平降低17.7 mg/dl至99.5 mg/dl。平均血压降低4/2 mmHg至130/68 mmHg。而同期无微量白蛋白尿的成人糖尿病患者比例增加4.0%，10年冠心病风险显著性降低2.8%。
然而，最近的调查显示，多达半数的糖尿病患者仍未达到糖化血红蛋白、血压或LDL胆固醇的推荐目标水平，超过22%的患者仍有吸烟习惯。仅14.3%的受访者达到所有4个危险因素的指标。仅有22.4%的受访者接受推荐的每年1次的流感疫苗注射、每年1次的眼部检查和每年1次的脚部检查等。
根据患者年龄对数据进行分析后发现，年龄较小(≤44岁)的成人糖尿病患者在达到治疗目标或遵循预防建议方面并无改善，原因尚不清楚，但这一结果表明需进一步关注较年轻的成人糖尿病患者。Ali博士及其同事这样表示。
获取医疗服务的渠道有限的患者和社会经济地位较低的患者在整个研究期间比其他患者更易存在危险因素控制不佳的情况。研究者表示，这与既往研究结果一致，即扩大医疗保险覆盖面有助于较好地控制危险因素及促进对预防措施的依从。令人遗憾的是，在研究期间，虽然平均收入和教育水平均有所提高，但无医保的糖尿病患者比例仍保持不变。他们总结道。
此报道无相关利益冲突。
与糖尿病相关的拓展阅读：

• JAMA：研究支持对糖尿病患者进行更强力的抗血小板治疗
• Obes Surg：减重手术可能不能“治愈”糖尿病
• Cell Metab:新的血清标志物提前数年预测糖尿病风险
• Circulation：精氨酸酶抑制剂治疗糖尿病患者并发症
• Diabetologia：维生素D缺乏与1型糖尿病
• JBC：维生素D或可抑制糖尿病患者动脉的阻塞
更多信息请点击：有关糖尿病更多资讯

原文阅读：Diabetes care has improved but still falls short
Adults with diabetes made substantial gains since 1999 in adherence to preventive practices and in control of risk factors for diabetic complications, according to a report published online April 25 in the New England Journal of Medicine.
However, up to half of these patients still failed to meet targets for glycemic control, blood pressure, and lipid control, and approximately half reported that they never received diabetes education, usually neglected getting the recommended yearly vaccinations, and failed to get the recommended annual dental and eye examinations, said Dr. Mohammed K. Ali of the Centers for Disease Control and Prevention, Atlanta, and his associates (N. Engl. J. Med. 2013;368:1613-24).
The investigators examined changes over time in diabetes care by analyzing data from a series of National Health and Nutrition Examination Surveys (NHANES 1999-2002, 2003-2006, and 2007-2010) and Behavioral Risk Factor Surveillance System surveys (2000, 2004, and 2008). Both sets of surveys include nationally representative samples of the population, and both also rely on self-reports of health-related behavior.
For this study, Dr. Ali and his colleagues included data from 3,355 NHANES participants and 97,310 BRFSS participants who reported having diabetes.
Between the earliest (1999-2002) and the most recent (2007-2010) survey, the proportion of patients with poor glycemic control decreased by 5.8 percentage points, while the proportion who met recommended targets for glycated hemoglobin level, blood pressure, and LDL cholesterol levels rose substantially (by 7.9, 11.7, and 20.8 percentage points, respectively).
Similarly, the population distributions of glycated hemoglobin levels, LDL cholesterol levels, and blood pressure levels all improved significantly over time. The mean glycated hemoglobin levels dropped by 0.4 percentage points, and the mean LDL cholesterol level declined by 17.7 mg/dL, to 99.5 mg/dL. The mean blood pressure decreased by 4/2 mm Hg, to 130/68 mm Hg.
At the same time, the proportion of adults with diabetes who were free of microalbuminuria rose by 4.0 percentage points, and the 10-year risk of coronary heart disease dropped significantly by 2.8 percentage points.
However, up to half of the diabetes patients in the most recent surveys still failed to meet targets for glycated hemoglobin level, blood pressure, or LDL cholesterol levels, and more than 22% still smoked. Only 14.3% of the survey participants met the targets for all four risk factors, the investigators said.
Only 22.4% of the respondents got their annual flu vaccines, annual eye exams, and annual foot exams as recommended.
When the data were analyzed by patient age, younger adults with diabetes (those aged 44 years and younger) showed no improvements in meeting their treatment goals or in following preventive recommendations. The reason for this lack of improvement isn’t clear, but the finding "suggests that younger adults with diabetes need further attention," Dr. Ali and his associates said.
Respondents with limited access to health care and those of lower socioeconomic status were more likely than others to have suboptimal control of risk factors throughout the study period.
"Our findings concur with previous reports: Health insurance coverage was significantly and consistently associated with better, more improved risk-factor profiles and preventive practices during the 12 years examined in our study," the investigators noted.
"Unfortunately, the proportion of persons with diabetes who do not have health insurance has remained the same, despite increases in mean income and educational level over the study period," they concluded.
No financial conflicts of interest were reported.