【medical-news】预防心血管疾病和糖尿病：美国心脏病学会和美国糖尿病学会的行动号召

Preventing Cardiovascular Disease and Diabetes: A Call to Action From the American Diabetes Association and the American Heart Association

Robert H. Eckel, MD; Richard Kahn, PhD; Rose Marie Robertson, MD; Robert A. Rizza, MD
Excess body weight has become a major public health problem in the U.S., with nearly two-thirds of adults either overweight or obese. The steady gain in the prevalence of obesity over the last 25 years has affected our entire population—no racial or ethnic group, no region of the country, and no socioeconomic group has been spared. Perhaps most worrisome is the observation that the rise in the rate of obesity has been greatest in children and minorities, which suggests that future generations of Americans, and our fastest growing populations, may bear the ultimate burden of this condition.
Overweight or obesity results in a wide range of elevated risk factors and many fatal and nonfatal conditions. Paradoxically, although we have witnessed decades in which heart disease and stroke have steadily declined and cancer mortality has at worse remained stable, the prevalence of diabetes has soared. The increase in diabetes can largely be attributed to weight gain, and it threatens the enormous advances in disease prevention we have seen. Among individuals with diabetes, cardiovascular disease (CVD)is the leading cause of morbidity and mortality; adults with diabetes have a two- to fourfold higher risk of CVD compared with those without diabetes. Diabetes is also accompanied by a significantly increased prevalence of hypertension and dyslipidemia.
It is reasonable to postulate that in many individuals, excess weight gives rise to diabetes, hypertension, and dyslipidemia, thereby leading to frank CVD. This seemingly simple algorithm is undoubtedly more complex because (1) many studies show that hyperglycemia at pre-diabetic levels is an independent risk factor for CVD, (2) central obesity (i.e., intra-abdominal or visceral fat) may have a greater detrimental effect than overall weight/BMI,and (3) there is a complex relationship between lipid metabolism and hyperglycemia. Moreover, obesity in the absence of glucose intolerance is associated with CVD, including coronary heart disease, stroke, and heart failure.
The association among diabetes, hypertension, and dyslipidemia has been known for many decades, but the seminal paper by Reaven ascribing much of the etiology of these risk factors to insulin resistance ushered in a new era of research and awareness and the call for a better appreciation of the impact of obesity on CVD. Also, the concept that these “metabolic” abnormalities can cluster in many individuals gave rise to the term “metabolic syndrome,” and this construct has been the subject of many thousands of publications and extensive reviews. Although the metabolic syndrome has been embraced by many individuals and organizations,others have questioned its clinical utility.
Unfortunately, some of the medical press have positioned the scientific issues related to the metabolic syndrome as a “battle”between the American Diabetes Association and the American Heart Association, implicitly suggesting that CVD risk factor identification and treatment is now questionable. We are concerned that the presumed dispute will lead to a reduction in the favorable trend of many aspects of CVD risk factor reduction.
The intent of this article is to clarify and reinforce the notion that our organizations remain unified and committed to reducing the burden of diabetes and CVD. The importance of identifying and treating a core set of risk factors (pre-diabetes, hypertension, dyslipidemia, and obesity) cannot be overstated, and our commitment is evidenced by other previous joint publications. While unrelated to an underlying metabolic abnormality, tobacco use also deserves special attention. Moreover, since recent evidence suggests that risk assessment and adherence to national guidelines remains woefully suboptimal,we call for a renewed effort to prevent and treat these conditions.
Risk Assessment
Although there are many approaches for estimating the risk of diabetes and CVD, virtually none have been validated much beyond the population from which they were constructed. There is one such tool, however (available free on the Internet at http://www.diabetes.org/diabetesphd), that has been extensively validated across many widely differing clinical trials, and it incorporates virtually all known CVD risk factors. Although it can be used to predict the risk of developing CVD/diabetes or the effects of treatment after developing diabetes/CVD, this tool and other risk-assessment algorithms are rarely used in clinical practice.
Conversely, emerging evidence suggests that simply ascertaining a person’s blood glucose level, blood pressure, LDL cholesterol level, and tobacco use and noting the presence of obesity may be sufficient to initiate the appropriate interventions to prevent
or identify diabetes and emerging CVD.Even borderline abnormalities, especially if they are multiple, may well presage future problems and should be addressed. Certainly,
a number of intriguing scientific questions remain regarding the relative impact
of each risk factor, the hierarchy of risk factors, the inclusion of other risk factors, and the relationships among all of them; however, at the very least, we encourage providers to be cognizant of these key parameters.
Risk Factor Management
Numerous studies have shown that attention to lifestyle modification can dramatically reduce progression to type 2 diabetes. Weight loss of as little as 7% of body weight during the 1st year of intervention, with lesser amounts to follow, is extremely effective and well within the capability of most patients. Weight reduction also improves all cardiometabolic risk factors, although there has been no controlled clinical trial evidence documenting the effect of weight loss on CVD events. Current guidelines also recommend regular, moderate physical activity, and here too, all cardiometabolic risk factors improve with sustained physical activity.Other strategies for the early detection and treatment of diabetes and CVD have been published by our organizations.
Summary
Both the American Heart Association and the American Diabetes Association remain jointly committed to a reduction in heart disease, stroke, and new-onset diabetes. We strongly recommend that all providers assess patients for their global risk for CVD and diabetes. Despite many unresolved scientific issues, a number of cardiometabolic risk factors have been clearly shown to be closely related to diabetes and CVD: fasting/postprandial hyperglycemia, overweight/obesity, elevated systolic and diastolic blood pressure, and dyslipidemia. Although pharmacologic therapy is often indicated when overt disease is detected, in the early stages of these conditions, lifestyle modification with attention to weight loss and physical activity may well be sufficient.
It must be remembered that obesity is far more than an unattractive appearance but can be prevented. Moreover, it is often a visible marker of other underlying risk factors that can be addressed. Thus, the overweight or obese patient deserves major clinical attention. The growing prevalence of this condition threatens to undermine all of our recent gains to prevent and control chronic disease.
《circulation》Volume 113, Issue 25; June 27, 2006
预防心血管疾病和糖尿病：来自美国心脏病学会和美国糖尿病学会的行动号召
在美国，过量体重已经成为主要的公共卫生问题，近三分之二的成年人不是超重就是肥胖。在最近的25年里肥胖的患病率稳步增长已经影响了我们全部人口－没有任何种族和人种、国家的任何地区、没有任何社会经济的团体可以幸免。大概最令人烦恼的是观察到在儿童和少数民族中肥胖率的急剧上升，暗示美国的未来几代，和我们最快的成长人口数，也许要忍受该情况的极端负担。
超重和肥胖导致提高的风险因子广泛范围和许多致命的和非致命的情况。自相矛盾地的是，尽管我们见证了数十年来心脏病和中风已经稳定的下降、癌死亡率仍然糟糕的维持稳定，糖尿病的发病率剧增。糖尿病的增加很大部分归因于体重增加，这已经威胁到我们已经看到的疾病预防的巨大益处。在糖尿病的个体中心血管疾病是患病率和致死率的首要原因；与没有糖尿病的成人相比，有糖尿病的成年人患心血管疾病的风险高2－4倍。并且糖尿病伴随着高血压和血脂障碍发病率的显著增加。
可以合理的推断出在许多个体中，超重引发了糖尿病、高血压、血脂障碍，从而导致（直接的）心血管疾病。这似乎看来简单的算法 毫无疑问是复杂的，因为（1）许多研究表明在糖尿病前期水平高血糖症是心血管疾病的独立危险因子，（2）向心性肥胖（即腹内或内脏脂肪）也许比全体重/身体代谢指数有更大的有害效应，（3）在脂代谢和高血糖症中存在复杂的联系。此外，糖耐受不良缺乏的肥胖与心血管疾病相关，包括冠心病、中风、心力衰竭。
糖尿病、高血压和血脂障碍之间的联系已经了解好几十年了，但是Reaven的原始论文？将这些危险因子的多数病因学归因于胰岛素抵抗开创了一个研究和觉醒的新时代，呼吁更好的评价在心血管疾病中肥胖的影响作用。并且，这些代谢异常情况的概念在许多个体中成簇出现产生术语“代谢综合征”，这样的建构已经成为成百上千杂志和多方面综述的主体。尽管代谢综合征为很多个体和机构采纳，其他的已经怀疑它的临床应用。
不幸的是，某些医学出版社将有关代谢综合征地位于美国心脏病协会和美国糖尿病协会见的“战争”，暗中的提示现在心血管疾病危险因子确认和对待是只得怀疑的。我们关心假定的争论将导致心血管疾病危险因子减少的许多方面的良好发展减少。
本文的目的是澄清和加强概念，我们的机构仍然是团结的和承诺减少糖尿病和心血管疾病的负担。确认和对待危险因子核心组合（糖尿病前期、高血压、血脂障碍和肥胖）的重要性不能被高估，我们的承诺已经为先前其他相关杂志所证明。虽然与潜在的代谢异常无联系，烟草的使用也应得到特别关注。而且，自从最近的证据提示危险率估计和信奉国家指导方针仍然不幸在最适度以下，我们号召以更新的努力来避免和对待这些情况。
危险率估计
尽管有许多方法来估计糖尿病和心血管疾病的风险，事实上没有一个被确证远超它们组成的总体？有一件这样的工具，然而（可免费在互联网上获得 http://www.diabetes.org/diabetesphd ），通过很大程度上不同临床试验，已经为广泛地确证，并结合事实上众所周知地心血管危险因子。尽管能为用于预测发展地心血管/糖尿病的危险率或心血管/糖尿病后治疗效应，该工具和其它危险率估计的算法鲜有在临床使用。
相反的是，出现的证据暗示简单的查明个人的血糖水平、血压、LDL胆固醇水平、烟草使用和注意肥胖的存在也许就足够着手适当的干预来预防或鉴定糖尿病和出现的心血管疾病，甚至界定异常，特别地是，假如它们是多重的（因素）也许能很好的预示将来的问题并为记录。确定的是，许多吸引人的科学问题依然关注于每个危险因子的相关影响，危险因子分级，包括其它危险因子及它们整体间的关系；然而，（这些是）在非常少（程度上），我们鼓励（危险因子的）提供者应该知道这些关键性的参数。
危险因子处理
很多的研究显示注意调整生活方式能显著减少2型糖尿病的进程。在第一年的干预中体重减轻很少的7％体重，随后（减）较少的量，在许多患者能力范围之内，是非常有作用的和很好的。体重减少也会改善所有的心脏代谢危险因子，尽管没有对照临床试验证明心血管疾病事件中体重减轻的效果。目前的知道方针也推荐规律、适度的体力活动，这里也是，随着持续的体力活动所有的心脏代谢危险因子改善。其他针对糖尿病和心血管疾病的早期诊断和治疗策略已经为我们的组织发表。
概要
美国心脏病协会和美国糖尿病协会一起，仍然共同的承诺在心脏疾病、中风、新发糖尿病等方面减少（发病）。我们强烈的推荐所以（危险因子）提供者从患者糖尿病和心血管疾病总体风险率上来评估患者。尽管有许多没有解决的科学问题，但已经清楚的表明许多心脏代谢危险因子与糖尿病和心血管疾病有接近的联系：禁食/餐后高血糖症，超重/肥胖，升高血压收缩压和舒展压及血脂障碍。尽管当明显的疾病检测后常指明药物治疗，在这些情况的早期阶段，伴随体重减轻和体力活动的生活方式调整有充分理由足够有效。必需记住的是肥胖远不是仅仅无魅力的外表，但可以预防。此外，肥胖经常是其它能被发表的潜在危险因子的可见标记。因此，超重或肥胖患者应得到主要的临床关注。这种情况（肥胖）渐长的流行有破坏所有我们最近来自预防和控制慢性疾病获益的危险。
《循环》Volume 113, Issue 25; June 27, 2006