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Academy ofNutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: SystematicReview of Evidence for Medical Nutrition Therapy Effectiveness and Recommendationsfor Integration into the Nutrition Care Process 营养和饮食营养学院成人1型和2型糖尿病实践指南：医学营养治疗有效性证据及整合入营养治疗过程的系统评价和建议
王新军译海南医学院第一附属医院内分泌科，海口，570102，knewman@163.com
Screeningand referral 筛查和转诊
Screening for T2D In collaboration with other health careteam members ensure that all overweight/obese adults at risk are screened forT2D.Fair, Imperative 筛查2型糖尿病 与其他医疗团队成员协作确保所有超重/肥胖的有糖尿病危险的成人筛查2型糖尿病。中等证据水平，必须执行
Referral for MNT In collaboration with other health careteam members ensure that all adults with T1Dd and T2D are referred forMNT.Strong, Imperative 转诊医学营养治疗 与其他医疗团队成员协作确保所有成人1型糖尿病和2型糖尿病能够转诊医学营养治疗。证据水平强，必须执行
Initial series of MNT encounters Implement 3-6 MNT encounters during thefirst 6 mo, and determine whether additional MNT encounters are needed. Strong,Imperative 初步医学营养治疗 在最初6个月期间进行3~6次医学营养治疗，并确定是否需要额外的医学营养治疗。证据水平强，必须执行
Follow-up MNT encounters Implement a minimum of 1 annual MNTfollow-up encounter. Strong, Imperative 医学营养治疗的随访 每年至少进行一次医学营养治疗随访。证据水平强，必须执行
Nutrition assessment 营养评估 Assess the following to formulate thenutrition care plan: biochemical data, medical tests, and medication use; nutrition-focusedphysical findings; client history; food and nutrition-related history; assessclient’s psychological and social situation. Fair, Imperative 营养评估 评估以下内容并制定营养治疗计划：生化检查、医疗检查和药物使用情况；营养为重点的体格检查；病史；食品和营养相关的病史；评估患者的心理和社会状况。中等证据水平，必须执行
Nutrition intervention 营养干预 Nutritionprescription In collaborationwith the adult, individualize the nutrition prescription and implementevidence-based nutrition practice nutrition practice guidelines. A variety ofeating patterns are acceptable; consider personal preferences and metabolicgoals. Fair, Imperative 营养处方 与患者协作，给予个体化的营养处方并实施以证据为基础的营养实践指南。多种饮食模式是可以接受的，考虑患者的喜好和代谢目标。中等证据水平，必须执行
Eatingplan Forappropriate-weight adult, encourage a healthful eating plan with a goal ofweight maintenance and prevention of weight gain. Consensus, Conditional Foroverweight or obese adult, encourage a reduced energy, healthful eating plan, witha goal of weight loss, weight loss maintenance, and/or prevention of weightgain. Strong, Conditional 饮食计划 对于正常体重的患者，鼓励健康饮食计划，目标是维持体重和预防体重增加。共识，条件 对于超重或肥胖的成人，鼓励减少能量、健康饮食计划，目标是减轻体重、保持减轻的体重和/或预防体重增加。证据水平强，有条件的
Macronutrientcomposition Incollaboration with the adult, individualize the macronutrient composition ofthe healthful eating plan within appropriate energy intake. Fair, Imperative 宏量营养素的组成 与患者协作，在合适的能量摄入前提下，制定个体化的健康饮食计划宏量营养素组成。中等证据水平，必须执行
Carbohydratemanagement strategies Foradult taking multiple daily injections of insulin or insulin pump therapy:educate on CHOe counting using insulin: CHO based onabilities, preferences, and management goals. Strong, Conditional Foradult taking fixed insulin doses or insulin secretagogues, educate on CHOconsistency (timing and amount) using CHO counting alone, plate method, portioncontrol, simplified meal plan, or food lists, and CHO choices, based onabilities, preferences, and management goals. Fair, Conditional Foradult taking MNT alone or noninsulin secretagogues, educate on CHO managementstrategies using CHO counting alone, plate method, portion control, simplifiedmeal plan, or food lists and CHO choices, based on abilities, preferences, andmanagement goals. Fair, Conditional 碳水化合物的管理策略 对于每日多次注射胰岛素或胰岛素泵治疗的患者：进行根据碳水化合物摄入量使用胰岛素的教育：糖水化合物的摄入量应基于患者的能力、偏好和管理目标。证据水平强，有条件的执行 对于使用固定剂量胰岛素或胰岛素促泌剂的患者，教育患者规律摄入糖水化合物（时间和量），可单独使用糖水化合物计数法、餐盘法、比例控制、简单的膳食计划或食物列表和糖水化合物的选择，基于患者的能力、偏好、管理目标。中等证据水平，有条件的执行 对于仅采用医学营养治疗或非胰岛素促泌剂的患者，教育患者糖水化合物管理策略，可仅使用糖水化合物计算法、餐盘法、比例控制，基于患者能力、偏好和管理目标制定简化的膳食计划或食物列表和糖水化合物的选择。中等证据水平，有条件的执行
Fiber Encouragefiber from foods such as fruits, vegetables, whole grains, legumes, asrecommended by DRI(21-25 g/d for adult women and 30-38 g/d foradult men) or USDA(14 g/1,000 kcal) due to overall health benefits.Fair, Imperative 纤维 因为对整体健康的益处，鼓励从水果、蔬菜、全谷类、豆类食物中摄入纤维，推荐根据DRI（成年女性21-25克/天和成年男性30-38克/天）或美国农业部（14 g /1000千卡）的建议进行。中等证据水平，必须执行
GIand GL Advise that lowering GI or GL may or may not have a significanteffect of glycemic control. Fair, Conditional 升糖指数和糖负荷 建议低升糖指数和糖负荷可能会也可能不会有显著的血糖控制效果。中等证据水平，有条件的执行
Nutritivesweeteners Educatethat NSwhen substituted isocalorically for otherCHOs, will not have a significant effect on HbA1cor insulin levels. Fair, Imperative Adviseagainst excessive intake of NS to avoid displacing nutrient-dense foods and toavoid excessive caloric and CHO intake. Fair, Imperative 营养性甜味剂 教育患者用营养性甜味剂取代等热量的其他糖水化合物，不会对糖化血红蛋白和胰岛素水平产生明显的影响。中等证据水平，必须执行 建议避免摄入过量的营养性甜味剂，以避免取代营养丰富的食物，并避免过多的热量和糖水化合物摄入量。中等证据水平，必须执行
Nonnutritivesweeteners Educatethat intake of FDA-approved NNS(suchas aspartame, sucralose, and stevia) within recommended intake will not have asignificant effect on glycemic control. Weak, Imperative Educatethat substituting foods and beverages containing NNS can reduce overall calorieand CHO intake. However, other sources of calories and/or CHO in these foodsand beverages need to be considered. Fair, Imperative 无营养甜味剂 教育患者摄入FDA批准的推荐摄入量以内的无营养甜味剂（如阿斯巴甜、蔗糖素、和甜叶菊）不会对血糖控制的产生影响。证据水平弱，必须执行 教育患者替代食品和饮料含有无营养甜味剂可以减少总的热量和糖水化合物摄入。然而，需要考虑其他来源的热量和/或糖水化合物在这些食品和饮料。中等证据水平，必须执行
Protein Educatethat adding protein to meals and snacks does not prevent or assist in thetreatment of hypoglycemia. Ingested protein appears to increase insulinresponse without increasing glucose levels. Fair, Imperative Foradult with diabetic kidney disease, advise that a protein restriction is notneeded. Protein intake (range=0.7-2.0 g/d) had no significant influence onglomerular filtration rate. Strong, Conditional Foradult with diabetic kidney disease, advise that the type of protein(vegetable-based vs animal-based) has no significant effect on glomerular filtrationrate. Weak, Conditional 蛋白质 教育患者在膳食和零食中增加蛋白质并不能预防或辅助治疗低血糖。摄入的蛋白质似乎可以增加胰岛素的反应，但不能升高血糖水平。中等证据水平，必须执行 对于患有糖尿病肾病的患者，不需要限制蛋白质的摄入。蛋白质摄入（范围= 0.7-2.0 g／d）对肾小球滤过率无显著影响。证据水平强，有条件的执行 对于糖尿病肾病的患者，蛋白类型（植物蛋白vs动物蛋白）对肾小球滤过率无显著影响。证据水平弱，有条件的执行
Cardioprotectiveeating pattern Encouragea cardioprotective eating pattern, within the recommended energy intake;decrease in saturated fat intake and increase in unsaturated fat shown toreduce total cholesterol and low-density lipoprotein cholesterol. Nonsignificanteffect of differing amounts of saturated fat, unsaturated fat, and n-3 fattyacids on glycemia and insulin levels. Strong, Imperative 保护心脏的饮食模式 在推荐的能量摄入范围内鼓励保护心脏饮食模式；减少饱和脂肪摄入和增加不饱和脂肪可以降低总胆固醇和低密度脂蛋白胆固醇。不同量的饱和脂肪、不饱和脂肪、n-3脂肪对血糖和胰岛素水平影响不显著。证据水平强，必须执行
Sodium Individualizedreduction in sodium intake. Recommendation to reduce to <2,300 mg/d isappropriate. In context of hypertension, further reduction in sodium intakeshould be individualized. Fair, Imperative 钠 个体化减少钠摄入量。建议减少到2300毫克/天是适当的。在高血压的情况下，进一步减少钠摄入量应个性化。中等证据水平，必须执行
Vitamin,mineral, and herbal supplements Advisethat there is no clear evidence from benefit of supplementation in people whodo not have underlying deficiencies; routine supplementation with antioxidants,other micronutrients (such as chromium, magnesium, and vitamin D), and herbalsupplements (such as cinnamon) not advised. Fair, Conditional 维生素、矿物质和中草药补充剂 没有明确的证据显示在不缺乏的患者可以从补充剂受益；不建议常规补充抗氧化剂、其他微量营养素（如铬、镁、维生素D）以及中草药补充剂（如肉桂）。中等证据水平，有条件的执行
Alcohol Whenchoosing to drink alcohol, advise moderation (1 drink per day or less for adultwoman and 2 drinks per day or less for adult men). If using insulin or insulinsecretagogues, alcohol can increase risk for delayed hypoglycemia. Weak,Conditional 酒精 当选择饮酒时，建议适度饮酒（成年女性每天喝1杯，成年男性每天喝2杯或更少）。如果使用胰岛素或胰岛素促泌剂，酒精会增加迟发性低血糖的风险。证据水平弱，有条件的执行
Physicalactivity Individualizephysical activity plan, advise gradually achieving at least 150 min/wk moderate-intensityaerobic physical activity (50%-70% of maximum heart rate), spread over at least3 d/wk with no more than 2 consecutive days without exercise. Strong,Imperative Foradults using insulin or insulin secretagogoue, educate on prevention and treatmentof exercise-related hypoglycemia; use blood glucose monitoring as individualglycemic response patterns can differ markedly with exercise. Consensus,Conditional 体力活动 制定个性化的体力活动计划，建议逐步实现至少150分钟/周的中等强度有氧运动（最大心率的50% -70%），每周至少活动3天，不超过连续2天不运动。证据水平强，必须执行 对于使用胰岛素或胰岛素促泌剂的患者，教育患者预防及处理运动相关的低血糖；可以使用血糖监测作为锻炼个体的血糖反应模式。共识，有条件的执行
Glucosemonitoring Educateon blood glucose monitoring and using data to adjust therapy. Consensus,Conditional Coordinationof care Implement MNT and coordinate care with an interdisciplinary health careteam, the adult with diabetes, and important others (eg, family, friends, andcolleagues). Strong, Imperative 血糖监测 教育患者进行血糖监测，并根据监测数据调整治疗。共识，有条件的执行 糖尿病的成人与重要他人（如家庭、朋友和同事）进行医学营养治疗协作和跨学科的医疗团队协作。证据水平强，必须执行
Nutrition monitoring and evaluation 营养监测和评估 Monitoring and evaluation Monitor and evaluate the following to determine theeffectiveness of MNT: biochemical data, medical tests and medication use;nutrition-focused physical findings; client history; food and nutrition-relatedhistory; and monitor and evaluate client’s psychological and social situation. Fair,Imperative 监测和评估 监测和评估以下医学营养治疗的效果：生化数据、医疗检查和用药；营养体格检查；病史；食品和营养相关的病史；监测和评估患者的心理和社会状况。中等证据水平，必须执行
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