2024+DDG临床实践指南：2型糖尿病患者的饮食建议.pdf

Skurk T et al.Dietary Recommendations for Persons Exp Clin Endocrinol Diabetes|2024.Thieme.All rights reserved.German Diabetes Associaton:Clinical Practice GuidelinesThieme Notice of UpdateThe DDG clinical practice guidelines are updated regularly during the second half of the calendar year.Please ensure that you read and cite the respective current version.Dietary Recommendations for Persons with Type 2 Diabetes Mellitus Authorsthomas Skurk1,anja Bosy-Westphal2,arthur Grnerbel3,Stefan Kabisch4,5,Winfried Keuthage6,peter Kronsbein7,Karsten Mssig8,Helmut Nussbaumer9,Andreas F.H.Pfeiffer10,Marie-christine Simon11,astrid tombek12,Katharina S.Weber13,diana Rubin14,15,for the Nutrition committee of the ddGAffiliations 1 ZIEL Institute for Food&Health,Technical University of Munich,Freising,Germany 2 Institute of Human Nutrition,Faculty of Agriculture and Nutritional Sciences,Christian-Albrechts University of Kiel,Kiel,Germany 3 Diabetes Centre Munich South,Munich,Germany 4 German Institute of Human Nutrition Potsdam-Re-hbrcke,Potsdam,Germany 5 German Center for Diabetes Research(DZD),Munich,Germany 6 Specialist Practice for Diabetes and Nutritional Medi-cine,Mnster,Germany 7 Faculty of Nutrition and Food Sciences,Niederrhein University of Applied Sciences,Mnchengladbach Campus,Mnchengladbach,Germany 8 Department of Internal Medicine,Gastroenterology and Diabetology,Niels Stensen Hospitals,Franziskus Hospital Harderberg,Georgsmarienhtte,Germany 9 Diabetologikum Burghausen,Burghausen,Germany 10 Department of Endocrinology,Diabetes and Nutritional Medicine,Charit Universittsmedizin Berlin,Berlin,Germany 11 Institute of Nutrition and Food Sciences,Rheinische Friedrich-Wilhelms-Universitt Bonn,Bonn,Germany 12 Diabetes Centre Bad Mergentheim,Bad Mergentheim,Germany 13 Institute for Epidemiology,Christian-Albrechts University of Kiel,Kiel,Germany 14 Vivantes Hospital Spandau,Berlin,Germany 15 Vivantes Humboldt Hospital,Berlin,Germanypublished online 2024BibliographyExp Clin Endocrinol Diabetes DOI 10.1055/a-2166-6772ISSN 0947-7349 2024.Thieme.All rights reserved.Georg Thieme Verlag,Rdigerstrae 14,70469 Stuttgart,GermanyGerman Diabetes Association:Clinical Practice Guidelines This is a translation of the DDG clinical practice guidelinepublished in Diabetol Stoffwechs 2023;18(Suppl 2):S270S304DOI 10.1055/a-1997-7924CorrespondenceProf.Dr.med.Thomas SkurkTechnical University of Munich,ZIEL Institute for Food&HealthGregor-Mendel-Str.285354 FreisingGermany Tel.:[phone]skurktum.deSkurk T et al.Dietary Recommendations for Persons Exp Clin Endocrinol Diabetes|2024.Thieme.All rights reserved.German Diabetes Associaton:Clinical Practice GuidelinesThieme UpdateS to coNteNt coMpaRed to tHe pRevi-oUS YeaRS veRSioNchange 1:Reference to the still insufficient data available regarding the reclassification of the types of slides with regard to nutrition in the“Preamble”Reason:necessary to update the reclassification of diabetes typeschange 2:Optional offer of different weight loss methods as a possible strategy to increase complianceif applicable,supporting references:395Reason:new studychange 3:“Body weight recommendations”.A one-year lifestyle intervention with a combination of initial meal replacement method(very-low-calorie diet=VLCD)followed by a mixed diet leads to sustainable remissionReason:published dataif applicable,supporting references:13change 4:Indication of benefits for body weight,body fat percentage,all-cause mortality,e.g.from replacing sugar-sweetened beverages with non-nutritively sweetened alternatives or waterReason:new dataif applicable,supporting references:210,217change 5:Fermented foods for supportive therapy of glycaemiaReason:current studiesif applicable,supporting references:316IntroductionThis clinical practice guideline is aimed at all professional groups car-ing for people with type 2 diabetes mellitus(T2Dm).In addition to the multifaceted aspects of nutrition in diabetes,there is a particu-lar call for individualisation of therapy,counseling,empowerment,and diabetes self-management 13 Therefore,the Nutrition Com-mittee of the DDG has set the goal to compile clinical practice guide-lines on nutrition as target group-specific as possible with the high-est available evidence.In doing so,it is considered necessary to pre-sent treatment forms separately since the therapeutic significance of nutrition differs significantly in each case and must be seen against the background of different drug therapy components.T2Dm is characterised by a progressive course in terms of-cell insufficiency,which progresses at different rates in different indi-viduals 47.Against this background,patients with T2Dm exhib-it quite different characteristics and treatment regimens 8.Wher-ever possible,the clinical practice guidelines attempt to address the new diabetes classification into mild age-related diabetes(MARD),mild obesity-related diabetes(MOD),severe autoimmune diabetes(SAID),severe insulin-resistant diabetes(SIRD)and severe insulin deficient diabetes(SIDD).For patients with special life circumstances,e.g.,sarcopenia and the need for long-term care,diets must be designed taking strong consideration of personal preferences and with an emphasis on meeting protein requirements.Overall,this means that nutritional therapy needs to be highly individualised to realize its full potential.The option of individualised nutritional counseling,including via telemedicine,should therefore be used more widely and inten-sively in people with T2Dm.The general goals are to promote bal-anced eating habits,provide training on appropriate portion sizes,and address individual dietary needs while maintaining enjoyment of food and providing practical tools for meal planning.Individual-ised nutrition counseling includes evidence-based topics that should be provided by qualified and appropriately certified nutri-tion professionals.The nutritional therapy plan must also be coordinated and con-tinuously aligned with the overall management strategy,including medications administered,physical activity,etc.In addition,people with prediabetes and excess weight/obesity should be referred to an intensive lifestyle intervention program that includes individualised goal-setting components,as defined,for example,by the S3 Guideline Prevention and Therapy of Obe-sity(S3-Leitlinie Prvention und Therapie der Adipositas).Since this service is not yet a standard benefit of the statutory health insur-ance,at minimum individualised nutrition counseling should be provided with partial cost coverage according to 43 German So-cial Security Code(SGB).Another important recommendation is the referral of adults with diabetes to comprehensive diabetes self-management train-ing and support(Diabetes-Selbstmanagementschulung und-un-tersttzung DSMES)in accordance with national standards.This clinical practice guideline presents the summary and eval-uation of the literature by the Nutrition Committee of the DDG on selected nutritional aspects in the management of T2Dm.These are regularly updated and,if necessary,supplemented.In doing so,the evidence if available was evaluated in the context of litera-ture research based on systematic reviews or meta-analyses.Orig-inal papers were also used for topics without the availability of such reviews.Body weight recommendationsGeneral recommendations RecoMMeNdatioN In cases of excess weight,the goal should be to lose weight.Weight cycling should be mentWith age comes a weight gain leading to an increase in body mass index(BMI)of 5 points and is associated with a 3-fold(weight gain between 18 and 24 years)or 2-fold(weight gain 25 years)higher risk of T2Dm 9.Obesity alone is also an independent risk factor for coronary heart disease(CHD).Moderate weight reduction,on the other hand(510%of current weight),reduces risks such as insulin resistance,hyperglycaemia,and dyslipidaemia 10 and can reduce Skurk T et al.Dietary Recommendations for Persons Exp Clin Endocrinol Diabetes|2024.Thieme.All rights reserved.secondary complications.A very-low-calorie diet(VLCD;624 kcal/d)for 8 weeks can also lead to a temporary diabetes remission of at least 6 months 11.The effectiveness of a VLCD diet is greater with a shorter duration of diabetes and with higher fasting insulin and C-peptide levels 12.Intensive weight management leads to a sus-tained remission with a one-year lifestyle intervention with a com-bination of initial meal replacement method(VLCD)and subsequent mixed diet 13.In this context,a stable body weight seems to be as-sociated with a better cardiovascular outcome than a high weight variability 14,15,16.Weight gain or weight variability in T2Dm is associated with higher mortality 15,17.However,especially in elderly patients,greater weight loss(25%)is associated with loss of muscle mass 18.Studies also show that individuals with T2Dm with a normal weight have high-er mortality than those with higher body weight 19,20,which has been repeatedly described as the obesity paradox 21.A pos-sible explanation for this effect is a larger,more metabolically-ac-tive muscle mass in obese patients 22;this must be factored into weight goals and,if necessary,included in a physical activity pro-gram for muscle maintenance 23.Quantitative statements on targeted weight reduction,diabetes remission RecoMMeNdatioN The extent of weight reduction is based on individual therapy goals.For diabetes remission,a weight reduction of 15 kg should be aimed at in mentThe association of obesity with all components of the metabol-ic syndrome makes weight reduction a priority therapy goal.The normal and realistic consensus was a 35 kg weight reduction in the context of dietary and exercise behavior modification.Achiev-ing these goals allowed a reduction in T2Dm manifestation of about 60%in people with prediabetes and has been demonstrated in large studies 24.A greater weight loss of 10 kg was significantly more effective and prevented diabetes manifestation in over 90%of study participants 25 over 3 years.Remission of T2Dm after an average of 5 years of diabetes du-ration and 1 year of intensive lifestyle modification program with 8.9%weight reduction(baseline BMI 35 kg/m2)was 11.5%in the Look Ahead study.After 4 years,weight reduction was still 4.7%of baseline weight,and 7.3%showed remission defined as fasting blood glucose below 126 mg/dl without diabetes medications 26.In the DIRECT study,a weight reduction of 15 kg with formula diets resulted in an 86%remission of T2Dm after a maximum pre-vious diabetes duration of 6 years.The success rate decreased sig-nificantly with less weight loss,but only 24%of patients achieved such a large weight loss after 1 year.The data shows a quantitative effect of weight loss on diabetes remission 13.Patients should therefore be offered appropriate therapy as early as possible after diagnosis of T2Dm 21.What is the role of the weight loss strategy of a formula diet ver-sus slow moderate weight loss?In the long term,the likelihood of regaining weight after cessation of the diet program is more than 80%.Long-term structured weight management concepts,which implement a special focus on weight stabilisation in terms of per-sonnel,time and methodology,are not widespread.Formula diets result in faster and more significant weight loss and still show great-er weight loss in the long-term 27.Weight loss leads to rapid improvement in hepatic insulin resist-ance,so that blood glucose levels decrease rapidly while the insu-lin secretory capacity remains unchanged.With insulin therapy and insulin resistance,insulin levels must be reduced rapidly(15 days),often by two-thirds of the initial dose.The patient must either be prepared for this or the therapy should be performed as an inpa-tient for the first few days,and as an outpatient only with daily pa-tient contact.Using telehealth for type 2 diabetes mellitus RecoMMeNdatioN Telehealth applications can support the implementation of behavioural modifications recommended in the treatment of T2Dm.Telehealth can increase adherence to weight loss programs and mentThe coronavirus disease 2019(COVID-19)pandemic has in-creased the need for digital consultation methods in the therapy of diabetes mellitus.Telehealth refers to the use of audio-visual communication technologies for the purpose of diagnosis,consul-tation,and emergency medical services 28.Telehealth care for diabetes patients had already been used before the COVID-19 pan-demic and has established itself as a proven form of therapy.As part of a telehealth program,therapy-relevant data(e.g.,blood glucose level,insulin dose,body weight)is transmitted to the healthcare professional,whereupon the patient receives feed-back.A distinction is made between telehealth therapy via text messages/e-mail and via telephone/video conferencing.A meta-analysis by Su et al.from 2015 of 92 included studies showed a significant reduction of the HbA1c value in type 1(T1Dm)and type 2(T2Dm)diabetes mellitus patients through telehealth nutrition therapy 29.However,no significant difference was found between telehealth programs via messaging(cell phone or email)and a face-to-face consultation(telephone call or video confer-ence).In Germany,a randomised controlled trial by Kempf et al.re-ported a 0.6%lower HbA1c value and a 5 kg greater weight reduc-tion at the 1-year follow-up in the telehealth-assisted group vs.standard therapy 30.Telehealth applications can be prescribed by physicians and psy-chotherapists and reimbursed by the statutory health insurance companies if they are included in the Federal Institute of Drugs and Medical Devices(Bundesinstitut fr Arzneimittel und Medizin-Skurk T et al.Dietary Recommendations for Persons Exp Clin Endocrinol Diabetes|2024.Thieme.All rights reserved.German Diabetes Associaton:Clinical Practice GuidelinesThiemeprodukte BfArM)directory as digital health applications(Digitale Gesundheitsanwendungen DiGA).This is regulated in the Digital Health Care Act(Digitales Versorgungsgesetz DVG),which came into effect in December 2019.Digital health applications are usual-ly used by the patients on their own.However,it is also possible for patients and providers to make use of digital health applications to-gether,for example in the form of teleconsultation or chats.At the time of publication of these clinical practice guidelines,a“Diabetes”DiGA with the indication“Diabetes&Depression”is listed in the BfArM directory.The DiGA“Zanadio”with the indication“obesity”is permanently included in the BfArM directory.Zanadio works on the basis of the guideline recommendations for the therapy of obe-sity and supports a conservative obesity therapy consisting of exer-cise,diet and behavioural change.Zanadio includes telehealth ele-ments in that users are supported by a dietitian via a chat function.An example of a telehealth application though not approved as a digital health application is the TeLiPro telehealth lifestyle in-tervention program.In this program