【原】指南共識 l 2023ADA標(biāo)準(zhǔn)-肥胖和體重管理以預(yù)防和治療2型糖尿病(全)**

CK醫(yī)學(xué)Pro 2022-12-14 發(fā)布于北京

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指南共識 l 2023ADA糖尿病診療標(biāo)準(zhǔn)-內(nèi)容修訂摘要**

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對語言進(jìn)行了修改，以強(qiáng)調(diào)肥胖是一種慢性病。
增加推薦8.5，以強(qiáng)調(diào)應(yīng)將較小和較大的體重減輕視為個(gè)體基礎(chǔ)上的治療目標(biāo)。值得注意的是，較大(10%或更多)的體重減輕可能具有疾病緩解效應(yīng)，包括糖尿病緩解，并可能改善長期心血管結(jié)局。
增加雙重GLP-1/葡萄糖依賴性促胰島素多肽(GIP)受體激動劑(替西帕替/ tirzepatide)作為有減重效力的降糖選擇。

指南共識 l 2023 l ADA糖尿病標(biāo)準(zhǔn) l 08

肥胖和體重管理

以預(yù)防和治療糖尿病

編譯：陳康

本部分核心推薦意見

肥胖評估

8.1 使用以患者為中心、非主觀（判斷）的語言，促進(jìn)個(gè)人與醫(yī)務(wù)人員之間的合作，包括以人為本的語言(例如，“伴肥胖人士/ person with obesity”而非“肥胖人士/obese person”)。E
8.2 在每年訪視或更頻繁的訪視中測量身高和體重并計(jì)算身體質(zhì)量指數(shù)（BMI）。評估體重軌跡，以獲得信息知曉治療注意事項(xiàng)。E
8.3 基于臨床考慮，例如存在合并癥心力衰竭或明顯的無法解釋的體重增加或減少，可能需要更頻繁地監(jiān)測和評估體重（B）。如果醫(yī)療狀況惡化與體重顯著增加或減少相關(guān)，則應(yīng)考慮住院評估，尤其應(yīng)關(guān)注藥物使用、食物攝入和血糖狀態(tài)之間的關(guān)聯(lián)。E
8.4 在稱重過程中，應(yīng)提供便利條件以保護(hù)隱私。E
8.5 糖尿病、超重或肥胖者可受益于輕中度或較大幅度的體重減輕。
相對較小的體重減輕(約為基線體重的3-7%)可改善血糖和其他中度心血管風(fēng)險(xiǎn)因素（A）。
較大的持續(xù)體重減輕(> 10%)通常帶來較大的獲益，包括疾病緩解效應(yīng)和2型糖尿病可能緩解，并可能改善長期心血管結(jié)局和死亡率。B

營養(yǎng)、體育活動和行為治療

8.6 對于大多數(shù)2型糖尿病伴超重或肥胖人群，推薦進(jìn)行營養(yǎng)、體育活動和行為治療，以實(shí)現(xiàn)并保持體重減輕≥5%。額外的體重減輕通常會進(jìn)一步改善糖尿病和心血管風(fēng)險(xiǎn)的管理。B
8.7 此類干預(yù)應(yīng)包括高頻率咨詢(6個(gè)月內(nèi)≥16次)，并側(cè)重于營養(yǎng)變化、身體活動和行為策略，以實(shí)現(xiàn)500-750 kcal/天的能量赤字（energy deficit）。A
8.8 當(dāng)推薦采取減重干預(yù)措施時(shí)，應(yīng)考慮個(gè)人的意愿、動機(jī)和生活環(huán)境以及醫(yī)療狀況。C
8.9 造成能量赤字的行為改變，無論其常量營養(yǎng)成分如何，均可導(dǎo)致體重減輕。營養(yǎng)推薦應(yīng)根據(jù)個(gè)人喜好和營養(yǎng)需求進(jìn)行個(gè)體化。A
8.10 評估可能影響營養(yǎng)模式和食物選擇的系統(tǒng)性、結(jié)構(gòu)性和社會經(jīng)濟(jì)因素，如糧食不安全和饑餓、獲得健康食物的機(jī)會、文化環(huán)境和健康的社會決定因素。C
8.11 對于達(dá)到減重目標(biāo)的人群，推薦在可能的情況下實(shí)施長期(≥1年)的體重維持計(jì)劃。此類計(jì)劃應(yīng)至少每月提供聯(lián)系和支持，建議持續(xù)監(jiān)測體重(每周或更頻繁)和其他自我監(jiān)測策略，并鼓勵(lì)定期體育活動(200-300分鐘/周)。A
8.12 受過培訓(xùn)的執(zhí)業(yè)醫(yī)師可在醫(yī)療環(huán)境中并在密切監(jiān)測下，為仔細(xì)選擇的個(gè)人開出使用結(jié)構(gòu)化、極低卡路里膳食(800–1000 kcal/天)的短期營養(yǎng)干預(yù)處方。應(yīng)整合長期、全面的體重維持策略和咨詢，以維持體重減輕。B
8.13 沒有明確證據(jù)表明營養(yǎng)補(bǔ)充劑對減重有效。A

藥物治療

8.14 2型糖尿病伴超重或肥胖人群在選擇降糖藥物時(shí)，應(yīng)考慮藥物對體重的影響。B
8.15 盡可能減少與體重增加相關(guān)的合并癥的藥物治療。E
8.16 對于2型糖尿病伴BMI≥27 kg/m2的特定人群，肥胖藥物治療作為營養(yǎng)、體育活動和行為咨詢的輔助治療有效。必須考慮潛在的獲益和風(fēng)險(xiǎn)。A
8.17 如果肥胖藥物治療有效(通常定義為使用3個(gè)月后體重減輕≥5%)，繼續(xù)使用可能會進(jìn)一步減輕體重。當(dāng)早期反應(yīng)不足(使用3個(gè)月后體重通常下降< 5%)或存在顯著的安全性或耐受性問題時(shí)，考慮停用藥物，并評估替代藥物或治療方法。A

代謝手術(shù)

8.18 對于篩選出的BMI≥40 kg/m2(亞裔美國人BMI≥37.5 kg/m2)的手術(shù)候選人和BMI35.0–39.9kg/m2(亞裔美國人32.5–37.4kg/m2)的成年人，如果通過非手術(shù)方法未能實(shí)現(xiàn)持久的體重減輕和合并癥(包括高血糖癥)改善，則應(yīng)推薦選擇代謝手術(shù)治療2型糖尿病。A
8.19 對于BMI30.0–34.9kg/m2(亞裔美國人為27.5–32.4kg/m2)的成人患者，通過非手術(shù)方法未能實(shí)現(xiàn)持久的體重減輕并改善合并癥(包括高血糖癥)者，代謝手術(shù)可被視為治療2型糖尿病的一種選擇。A
8.20 代謝手術(shù)應(yīng)在有多學(xué)科團(tuán)隊(duì)的高容量中心進(jìn)行，這些團(tuán)隊(duì)?wèi)?yīng)熟悉并有管理肥胖、糖尿病和胃腸手術(shù)的經(jīng)驗(yàn)。E
8.21 應(yīng)評估考慮接受代謝手術(shù)的患者是否存在可能影響手術(shù)結(jié)果的共病心理狀況以及社會和情境情況。B
8.22 接受代謝手術(shù)的人員應(yīng)接受長期的醫(yī)療和行為支持以及常規(guī)的微量營養(yǎng)素、營養(yǎng)和代謝狀態(tài)監(jiān)測。B
8.23 如果懷疑有減重后低血糖癥，臨床評估應(yīng)排除導(dǎo)致低血糖癥的其他潛在疾病，管理包括教育、由具有減重后低血糖癥經(jīng)驗(yàn)的營養(yǎng)師進(jìn)行的醫(yī)學(xué)營養(yǎng)治療，以及根據(jù)需要進(jìn)行的藥物治療。應(yīng)考慮將持續(xù)血糖監(jiān)測作為一項(xiàng)重要輔助措施，通過提醒個(gè)體注意低血糖癥來提高安全性，尤其是對于嚴(yán)重低血糖癥或無癥狀低血糖的個(gè)體。E
8.24 應(yīng)對接受代謝手術(shù)的患者進(jìn)行常規(guī)評估，以評估是否需要持續(xù)的精神健康服務(wù)來幫助其適應(yīng)手術(shù)后的醫(yī)療和心理社會變化。C

介紹

肥胖癥是一種慢性且常為進(jìn)行性疾病，具有多種醫(yī)療、軀體和心理社會并發(fā)癥，包括2型糖尿病風(fēng)險(xiǎn)大幅增加(1)。有強(qiáng)力且一致的證據(jù)表明，肥胖管理可延遲從糖尿病前期向2型糖尿病的進(jìn)展(2–6)；并且在2型糖尿病治療中有很大的獲益(7–18)。

在2型糖尿病伴超重或肥胖患者中，輕中度體重減輕可改善血糖，減少對降糖藥物的需求(7–9)，較大的體重減輕顯著降低A1C和空腹血糖，并且已經(jīng)顯示可促進(jìn)持續(xù)的糖尿病緩解至少2年(11,19–23)。

強(qiáng)化行為咨詢、肥胖藥物治療和減重手術(shù)等多種方式可能有助于實(shí)現(xiàn)和維持有意義的體重減輕并降低肥胖相關(guān)的健康風(fēng)險(xiǎn)。代謝手術(shù)可顯著改善血糖，通常可緩解糖尿病、改善生活質(zhì)量、改善心血管結(jié)局和降低死亡率。眾多研究表明，肥胖和糖尿病都會增加更嚴(yán)重的冠狀病毒疾病2019(COVID-19)感染的風(fēng)險(xiǎn)，這進(jìn)一步強(qiáng)調(diào)解決肥胖問題的重要性(24–27)。本部分旨在為2型糖尿病患者和高危人群的肥胖管理提供循證推薦，包括行為、藥物和手術(shù)干預(yù)。本節(jié)重點(diǎn)介紹成人肥胖管理；關(guān)于老年人和兒童肥胖的進(jìn)一步討論分別見第13部分“老年人（糖尿?。保偷?4部分”兒童和青少年”。

1. 肥胖評估

2. 營養(yǎng)、體育活動和行為治療

Look AHEAD試驗(yàn)

盡管糖尿病健康行動(Look AHEAD/ the Action for Health in Diabetes)試驗(yàn)未顯示強(qiáng)化生活方式干預(yù)可減少2型糖尿病伴超重或肥胖成人的心血管事件(39)，它確實(shí)證實(shí)了在2型糖尿病患者中實(shí)現(xiàn)并維持長期體重減輕的可行性。在強(qiáng)化生活方式干預(yù)組中，8年時(shí)平均體重減輕4.7%(40)。約50%的強(qiáng)化生活方式干預(yù)參與者在8年時(shí)減重≥5%的初始體重，并維持，27%的參與者在8年時(shí)減重≥10%的初始體重并維持 (40)。與隨機(jī)分配到標(biāo)準(zhǔn)治療組的受試者相比，被分配到強(qiáng)化生活方式組的受試者需要更少的血糖、血壓和降脂藥物。Look AHEAD試驗(yàn)和其他大型心血管結(jié)局研究的二級分析記錄了2型糖尿病患者的額外減重獲益，包括改善的活動能力、軀體功能和性功能以及健康相關(guān)的生活質(zhì)量(32)。此外，幾個(gè)分組的心血管結(jié)局有所改善，包括那些體重減輕> 10%的分組(41)和基線時(shí)輕度或管理不善糖尿病(A1C >6.8%)的患者(42)。

行為干預(yù)

通過達(dá)到500–750 kcal/天能量赤字的生活方式方案，可顯著減輕體重，在大多數(shù)情況下，經(jīng)個(gè)體基線體重調(diào)整后，女性約為,200–1,500 kcal /天，男性約為1,500–1,800 kcal/天。臨床獲益通常始于體重減輕3-5%(20,51)，并且體重減輕的獲益是漸進(jìn)的；如果需要實(shí)現(xiàn)進(jìn)一步的健康改善和/或如果個(gè)體更有動力并且可以可行地和安全地實(shí)現(xiàn)更強(qiáng)化的目標(biāo)，則更強(qiáng)化的減重目標(biāo)(> 5%、> 7%、> 15%等)是可尋求的。

營養(yǎng)干預(yù)可能因宏觀營養(yǎng)目標(biāo)和食物選擇而不同，只要它們產(chǎn)生促進(jìn)體重減輕所需的能量赤字(20,52–54)。在密切監(jiān)測下，使用由訓(xùn)練有素的從業(yè)人員規(guī)定的膳食替代（meal replacement）計(jì)劃可能是有益的。例如，在Look AHEAD試驗(yàn)的強(qiáng)化生活方式干預(yù)組中，使用部分膳食替代計(jì)劃與營養(yǎng)質(zhì)量改善和體重減輕有關(guān)(51)。營養(yǎng)選擇應(yīng)基于個(gè)人的健康狀況和喜好，包括確定食物供應(yīng)和可能影響營養(yǎng)模式的其他文化環(huán)境(55)。

強(qiáng)化行為干預(yù)應(yīng)包括在最初6個(gè)月內(nèi)進(jìn)行≥16場次，重點(diǎn)關(guān)注營養(yǎng)變化、體力活動和行為策略，以達(dá)到500-750 kcal/天的能量赤字。干預(yù)應(yīng)由經(jīng)過培訓(xùn)的干預(yù)醫(yī)生在個(gè)人或小組會議中提供(51)。當(dāng)推薦和啟動減重干預(yù)措施時(shí)，應(yīng)考慮評估個(gè)人的動機(jī)水平、生活環(huán)境和實(shí)施行為改變以實(shí)現(xiàn)減重的意愿以及醫(yī)療狀況(37,56)。

應(yīng)向體重減輕的2型糖尿病伴超重或肥胖患者提供長期(≥1年)綜合減重維持計(jì)劃，至少每月與經(jīng)過培訓(xùn)的干預(yù)醫(yī)生聯(lián)系一次，并重點(diǎn)關(guān)注持續(xù)的體重監(jiān)測(每周或更頻繁)和/或其他自我監(jiān)測策略，如跟蹤攝入量、步數(shù)等；繼續(xù)關(guān)注營養(yǎng)和行為變化；和參加高水平的體力活動(200-300分鐘/周) (57)。一些商業(yè)和專有的減重計(jì)劃已經(jīng)顯示出有希望的減重效果。然而，大多數(shù)缺乏有效性證據(jù)，許多不能滿足指南推薦，有些提倡不科學(xué)和可能危險(xiǎn)的做法(58,59)。

當(dāng)由醫(yī)療機(jī)構(gòu)中經(jīng)過培訓(xùn)的執(zhí)業(yè)醫(yī)師在持續(xù)監(jiān)測的情況下提供時(shí)，可能會為經(jīng)過仔細(xì)選擇的個(gè)體處方短期(通常長達(dá)3個(gè)月)強(qiáng)化營養(yǎng)干預(yù)，例如那些需要在手術(shù)前減重的個(gè)體以及那些需要更大減重和血糖改善的個(gè)體。當(dāng)與行為支持和咨詢相結(jié)合時(shí)，與標(biāo)準(zhǔn)行為干預(yù)相比，使用高蛋白食物和膳食替代產(chǎn)品的結(jié)構(gòu)性極低卡路里膳食(通常為800–1000 kcal/天)可增加初始體重減輕和血糖改善的速度和/或幅度(21,22)。由于體重再增加很常見，此類干預(yù)措施應(yīng)包括長期、全面的體重維持策略和咨詢，以維持體重減輕和行為改變(60,61)。

盡管市場營銷廣泛且過渡宣傳功效，但沒有明確證據(jù)表明營養(yǎng)補(bǔ)充劑(如草藥和植物性藥物、高劑量維生素和礦物質(zhì)、氨基酸、酶、抗氧化劑等)對于肥胖管理或體重減輕是有效的(62–64)。幾項(xiàng)大型系統(tǒng)綜述顯示，大多數(shù)評估減重營養(yǎng)補(bǔ)充劑的試驗(yàn)質(zhì)量較低，且存在較高偏倚風(fēng)險(xiǎn)。高質(zhì)量的已發(fā)表研究表明，很少或沒有減重獲益。相反，維生素/礦物質(zhì)（如鐵、維生素B12、維生素D）補(bǔ)充可用于有記錄的缺乏癥，蛋白質(zhì)補(bǔ)充可作為醫(yī)學(xué)監(jiān)測下減重治療的補(bǔ)充。

健康差距對那些因種族或族裔、社會經(jīng)濟(jì)地位、性別、殘疾或其他因素而系統(tǒng)地遭遇更大健康障礙的人產(chǎn)生不利影響。大量研究表明，這些差異可能會顯著影響健康結(jié)局，包括增加肥胖、糖尿病和糖尿病相關(guān)并發(fā)癥的風(fēng)險(xiǎn)。醫(yī)務(wù)人員應(yīng)評估：

可能影響食物選擇、健康食物獲取和營養(yǎng)模式的系統(tǒng)性、結(jié)構(gòu)性和社會經(jīng)濟(jì)因素；
行為模式，如鄰里安全和安全戶外活動空間的可用性；
環(huán)境暴露；
獲得醫(yī)療保?。?/span>
社會背景；
以及最終的糖尿病風(fēng)險(xiǎn)和結(jié)局。

有關(guān)健康的社會決定因素的詳細(xì)討論，請參閱“健康的社會決定因素:科學(xué)綜述”(65)。

3. 藥物治療

降糖治療

對2型糖尿病227項(xiàng)降糖治療隨機(jī)對照試驗(yàn)的薈萃分析發(fā)現(xiàn)，A1C變化與基線BMI無關(guān)，這表明肥胖人群可從與正常體重個(gè)體相同的糖尿病治療類型中獲益(66)?？紤]用藥計(jì)劃時(shí)，有許多有效藥物可用，因此醫(yī)務(wù)人員應(yīng)考慮每種藥物對體重的影響。

與不同程度體重減輕相關(guān)的藥物包括：

二甲雙胍、
α-葡萄糖苷酶抑制劑、
鈉-葡萄糖共轉(zhuǎn)運(yùn)體2抑制劑、
胰高血糖素樣肽1受體激動劑、
雙重胰高血糖素樣肽1/葡萄糖依賴性促胰島素多肽受體激動劑(替西帕肽/ tirzepatide)
胰淀素模擬物。

二肽基肽酶4抑制劑是重量中性的。

相反，胰島素促分泌素、噻唑烷二酮類藥物和胰島素通常與體重增加有關(guān)(參見第9部分，“血糖治療的藥物方法")。

合并用藥

醫(yī)務(wù)人員應(yīng)仔細(xì)審查患者的合用藥物，并盡可能減少促進(jìn)體重增加藥物或提供替代藥物。

與體重增加相關(guān)的藥物實(shí)例包括(67)：

抗精神病藥物(如氯氮平、奧氮平、利培酮)、
一些抗抑郁藥物(如三環(huán)類抗抑郁藥物、
一些選擇性5-羥色胺再攝取抑制劑和單胺氧化酶抑制劑)、
糖皮質(zhì)激素、
可注射孕激素、
一些抗驚厥藥物(如加巴噴丁、普瑞巴林)
可能的鎮(zhèn)靜性抗組胺藥物和抗膽堿能藥物。

經(jīng)批準(zhǔn)（美國）的肥胖藥物治療方案

美國FDA已批準(zhǔn)將短期和長期體重管理藥物作為營養(yǎng)、體育活動和行為治療的輔助藥物。幾乎所有FDA批準(zhǔn)的肥胖藥物均已顯示可改善2型糖尿病患者的血糖，并延緩高危個(gè)體向2型糖尿病的進(jìn)展(23)。芬特明/ Phentermine和其他較老的腎上腺素能藥物適用于短期(≤12周)治療(68)。五種藥物經(jīng)FDA批準(zhǔn)可長期(> 12周)用于BMI≥27 kg/m2且有一種或多種與肥胖相關(guān)的合并癥(如2型糖尿病、高血壓和/或血脂異常)且有減重動機(jī)的成人 (23)。(已批準(zhǔn)用于肥胖青少年的藥物參考第14部分“兒童和青少年”)。FDA批準(zhǔn)的用于治療肥胖的藥物，匯總于表8.2，包括奧利司他、芬特明/托吡酯ER、納曲酮/安非他酮ER、利拉魯肽3 mg和司美格魯肽2.4 mg。另外，一種黑皮質(zhì)素4受體激動劑setmelanotide被批準(zhǔn)用于導(dǎo)致嚴(yán)重?cái)z食過度和極度肥胖的罕見基因突變病例，如瘦素受體缺乏和前黑皮質(zhì)素缺乏。原則上，藥物治療有助于提高對營養(yǎng)建議的依從性，在大多數(shù)情況下是通過調(diào)節(jié)食欲或飽腹感來實(shí)現(xiàn)的。醫(yī)務(wù)人員應(yīng)了解產(chǎn)品標(biāo)簽（適應(yīng)證），并權(quán)衡成功減重的潛在獲益和每個(gè)人使用藥物的潛在風(fēng)險(xiǎn)。這些藥物在妊娠或積極嘗試懷孕的個(gè)體中禁用，不建議在哺乳期婦女中使用。有生殖潛力個(gè)人應(yīng)接受關(guān)于使用可靠避孕方法的咨詢。值得注意的是，雖然減重藥物也常常被用于1型糖尿病患者，但該人群的臨床試驗(yàn)數(shù)據(jù)有限。

表8.2 FDA批準(zhǔn)的治療成人超重或肥胖的藥物

妊娠或可能懷孕的人禁用所有藥物。必須就使用可靠的避孕方法向有生殖潛力的個(gè)人提供咨詢。提供選擇安全性和副作用信息；有關(guān)安全注意事項(xiàng)的全面討論，請參閱各藥劑的處方信息。b.i.d .，每日兩次；ER，緩釋；OTC,非處方藥；NA，數(shù)據(jù)不可用；PBO，安慰劑；q.d .，每日；Rx，處方；t.i.d .，每日三次。

* 使用最低有效劑量；最大適宜劑量為37.5 mg。

? 一般成年肥胖人群的治療持續(xù)時(shí)間為28周。

? 納入的參與者糖耐量正常(79%)或受損(21%)。

§ 最大劑量(取決于反應(yīng))為15 mg/92 mg q.d。

∥ 約68%的納入?yún)⑴c者2型糖尿病或糖耐量異常。

**藥物已在一項(xiàng)專門的心血管結(jié)局試驗(yàn)中證明心血管安全性(47)。

評估療效和安全性

開始使用減重藥物后，前3個(gè)月至少每月一次，此后至少每季度一次評估療效和安全性。來自已發(fā)表的臨床試驗(yàn)的模型一致顯示，早期應(yīng)答者具有改善的長期結(jié)局(69–71)。除非臨床情況(如耐受性差)或其他考慮因素(如財(cái)務(wù)費(fèi)用或個(gè)人意愿)另有說明，否則在開始使用慢性減重藥物后實(shí)現(xiàn)足夠早期體重減輕(通常定義為使用3個(gè)月后體重減輕> 5%)的患者應(yīng)繼續(xù)使用該藥物。當(dāng)早期使用無效時(shí)(通常在使用3個(gè)月后體重減輕< 5%)，繼續(xù)使用不太可能改善體重結(jié)果；因此，應(yīng)建議停用藥物并考慮其他治療方案。

減重醫(yī)療設(shè)備

盡管近年來胃束帶裝置逐漸失寵，但自2015年以來，已有多種微創(chuàng)醫(yī)療設(shè)備獲得FDA批準(zhǔn)用于短期減重，包括植入式胃氣囊、迷走神經(jīng)刺激器和胃抽吸治療(72)。鑒于糖尿病患者的高成本、有限的保險(xiǎn)覆蓋范圍和數(shù)據(jù)匱乏，目前很少使用減重醫(yī)療設(shè)備，它們在未來的使用方式還有待觀察(73)。

一種口服水凝膠(Plenity)最近已被批準(zhǔn)在BMI> 25 kg/m2的患者中長期使用，以模擬可植入胃氣囊的占位效應(yīng)。飯前30分鐘與水一起使用，水凝膠會膨脹以填充胃容積的一部分，從而有助于減少進(jìn)餐時(shí)的食物攝入。盡管平均體重減輕相對較小(比安慰劑作用強(qiáng)2-3%)，但與整體治療(6.4%的體重減輕)和安慰劑(4.4%的體重減輕)組相比，基線時(shí)糖尿病前期或糖尿病的亞組參與者的體重減輕結(jié)果有所改善(8.1%的體重減輕)(74)。

4. 代謝手術(shù)

潛在風(fēng)險(xiǎn)和并發(fā)癥

隨著微創(chuàng)(腹腔鏡)方法的不斷完善、培訓(xùn)和認(rèn)證的加強(qiáng)以及多學(xué)科團(tuán)隊(duì)的參與，代謝手術(shù)的安全性顯著提高。圍手術(shù)期死亡率通常為0.1–0.5%，與膽囊切除術(shù)或子宮切除術(shù)等常見腹部手術(shù)的死亡率相似(104–108)。2-6%接受代謝手術(shù)的患者發(fā)生重大并發(fā)癥，這與其他通常進(jìn)行的擇期手術(shù)的發(fā)生率相比是較少(108)。術(shù)后恢復(fù)時(shí)間和并發(fā)癥發(fā)生率也大幅下降。輕微并發(fā)癥和需要再次手術(shù)干預(yù)的并發(fā)癥發(fā)生率高達(dá)15%(104–113)。經(jīng)驗(yàn)數(shù)據(jù)表明，手術(shù)醫(yī)生和手術(shù)團(tuán)隊(duì)的熟練程度是決定死亡率、并發(fā)癥、再次手術(shù)和再入院的重要因素(114)。因此，代謝手術(shù)應(yīng)在有管理糖尿病、肥胖和胃腸手術(shù)經(jīng)驗(yàn)的多學(xué)科團(tuán)隊(duì)的大容量中心進(jìn)行。

圍手術(shù)期之外，較長期的風(fēng)險(xiǎn)包括維生素和礦物質(zhì)缺乏、貧血、骨質(zhì)疏松癥、傾倒綜合征和嚴(yán)重低血糖癥(115)。營養(yǎng)和微量營養(yǎng)素缺乏癥及相關(guān)并發(fā)癥的發(fā)生頻率因手術(shù)類型而異，需要定期監(jiān)測微量營養(yǎng)素和營養(yǎng)狀況，并終生補(bǔ)充維生素/營養(yǎng)(115)。傾倒綜合征通常發(fā)生在餐后不久(10-30min)，可能表現(xiàn)為腹瀉、惡心、嘔吐、心悸和疲勞；低血糖癥通常在癥狀出現(xiàn)時(shí)不存在，但在某些情況下，可能在數(shù)小時(shí)后發(fā)生。

在RYGB、VSG和其他胃腸手術(shù)中可能會發(fā)生減重后低血糖(PBH/ Postbariatric hypoglycemia)，并可能嚴(yán)重影響生活質(zhì)量(116–118)。PBH部分是由攝入營養(yǎng)物的胃排空改變驅(qū)動的，導(dǎo)致腸道葡萄糖快速吸收以及餐后胰高血糖素樣肽1和其他胃腸肽過度分泌。因此，會出現(xiàn)胰島素釋放過度刺激和血糖急劇下降，最常見的情況是在高碳水化合物餐后1-3小時(shí)。癥狀包括出汗、震顫、心動過速、饑餓增加、認(rèn)知障礙、意識喪失和癲癇發(fā)作。傾倒綜合征通常發(fā)生在術(shù)后不久，并隨著時(shí)間的推移而改善，與此相反，PBH通常表現(xiàn)為術(shù)后> 1年。主要通過全面的病史、食物攝入、體力活動和癥狀模式的詳細(xì)記錄以及排除其他潛在原因(如營養(yǎng)不良、藥物或補(bǔ)充劑的副作用、傾倒綜合征和胰島素瘤)進(jìn)行診斷。初始管理包括教育減少快速消化碳水化合物攝入，同時(shí)確保蛋白質(zhì)和健康脂肪以及維生素/營養(yǎng)補(bǔ)充劑的充足攝入。如果有，應(yīng)由在PBH有經(jīng)驗(yàn)的營養(yǎng)師為患者提供醫(yī)療營養(yǎng)治療，并使用連續(xù)葡萄糖監(jiān)測(理想情況下為實(shí)時(shí)連續(xù)葡萄糖監(jiān)測，可在嚴(yán)重低血糖發(fā)生前檢測到葡萄糖水平下降)，特別是對于低血糖昏迷患者。如果需要，藥物治療主要旨在減緩碳水化合物吸收(如阿卡波糖)或減少胰高血糖素樣肽1和胰島素分泌(如二氮嗪、奧曲肽)(119)。

接受代謝手術(shù)的患者也可能面臨更高的藥物濫用、惡化或新發(fā)抑郁癥和/或焦慮癥以及自殺意念的風(fēng)險(xiǎn)(115,120–125)。在考慮手術(shù)前，代謝手術(shù)候選人應(yīng)由具有肥胖管理專業(yè)知識的精神健康專家進(jìn)行評估(126)。對于酒精或物質(zhì)使用障礙、重度抑郁癥、自殺意念或其他顯著精神健康疾病的患者，應(yīng)推遲手術(shù)，直至這些疾病得到充分治療。術(shù)前或新發(fā)精神病理學(xué)個(gè)體應(yīng)在術(shù)后定期評估，以優(yōu)化精神健康和術(shù)后結(jié)局。

引用：ElSayed NA, Aleppo G, Aroda VR, etal., American Diabetes Association. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S128–S139

約11000字

陳康/編譯 北京 2022-12-13

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慢性疾病和常見病會有大量的臨床研究證據(jù)，臨床決策應(yīng)盡量利用有價(jià)值、高強(qiáng)度的證據(jù)。一個(gè)好的指南或者共識，會按照一定的標(biāo)準(zhǔn)匯聚證據(jù)，會有多個(gè)該領(lǐng)域內(nèi)的專家共同討論，這樣會極大的避免個(gè)人經(jīng)驗(yàn)中的偏見，得到相對客觀的、更有利于患者的診治方案。結(jié)合指南或共識的個(gè)人診治經(jīng)驗(yàn)可能更有效。