Text B Some Guidancefor Comprehensive Diabetes Care

Intensive insulin therapy or intensive glycemic control is central to optimal diabetes therapy，but comprehensive diabetes care of both type 1 and type 2 DM（type 1 DM namely Insulin－dependent Diabetes Mellitus；type 2 DM namely Non－insulin－dependent Diabetes Mellitus）should also detect and manage DM－specific complications and modify risk factors for DM－associated diseases．This text provides guidance for this comprehensive level of diabetes care．

Patient Education about DM，Nutrition，and Exercise

Education topics important for optimal diabetes care include self－monitoring of blood glucose，urine ketone monitoring（type 1 DM），insulin administration， guidelines for diabetes management during illnesses，management of hypoglycemia， foot and skin care，diabetes management before，during，and after exercise， and risk factor—modifying activities．

As for the general population，a diet that includes fruits，vegetables，fiber－containing foods，and low－fat milk is advised．Historically，nutrition education imposed restrictive，complicated regimens on the patient．Current practices have greatly changed，though many patients and health care providers still view the diabetic diet as monolithic and static．For example，MNT（medical nutrition therapy，which is the optimal coordination of caloric intake with other aspects of diabetes therapy）now includes foods with sucrose and seeks to modify other risk factors such as hyperlipidemia and hypertension rather than focusing exclusively on weight loss in individuals with type 2 DM．Consumption of foods with a low glycemic index appears to reduce postprandial glucose excursions and improve glycemic control．Reduced calorie and non－nutritive sweeteners are useful．Presently，evidence does not support supplementation of the diet with vitamins，antioxidants（vitamin C and vitamin E），or micronutrients （chromium）in patients with diabetes．The goal of MNT in the individual with type 1 DM is to coordinate and match the caloric intake，both temporally and quantitatively，with the appropriate amount of insulin．MNT in type 1 DM and self－monitoring of blood glucose must be integrated to define the optimal insulin regimen．The ADA encourages patients and providers to utilize carbohydrate counting or exchange systems to estimate the nutrient content of a meal or snack．1 Based on the patient's estimate of the carbohydrate content of meal，an insulin－to－carbohydrate ratio determines the bolus insulin dose for a meal or snack．MNT must be flexible enough to allow for exercise，and the insulin regimen must allow for deviations in caloric intake．An important component of MNT in type 1 DM is to minimize the weight gain often associated with intensive diabetes management．

The goals of MNT in type 2 DM are slightly different and address the greatly increased prevalence of cardiovascular risk factors（hypertension，dyslipidemia， obesity）and disease in this population．Hypocaloric diets and modest weight loss （5％—7％）often result in rapid and dramatic glucose lowering in individuals with new－onset type 2 DM．Nevertheless，numerous studies document that long－term weight loss is uncommon．MNT for type 2 DM should emphasize medium caloric reduction，reduced fat intake，increased physical activity，and reduction of hyperlipidemia and hypertension．Increased consumption of soluble，dietary fiber may improve glycemic control in individuals with type 2 DM while weight loss and exercise improve insulin resistance．

Exercise has multiple positive benefits including cardiovascular risk reduction，reduced blood pressure，maintenance of muscle mass，reduction in body fat，and weight loss．Exercise is also useful for lowering plasma glucose and increasing insulin sensitivity．

Despite its benefits，exercise presents challenges for individuals with DM because they lack the normal glucoregulatory mechanisms（normally，insulin falls and glucagon rises during exercise）．The increased muscle activity during vigorous，aerobic exercise greatly increases fuel requirements．Individuals with type 1 DM are prone to either hyperglycemia or hypoglycemia during exercise， depending on the preexercise plasma glucose，the circulating insulin level，and the level of exercise－induced catecholamines．If the insulin level is too low，the rise in catecholamines may increase the plasma glucose excessively，promote ketone body formation，and possibly lead to ketoacidosis．Conversely，if the circulating insulin level is excessive，this relative hyperinsulinemia may reduce hepatic glucose production（decreased glycogenolysis，decreased gluconeogenesis） and increase glucose entry into muscle，leading to hypoglycemia．

To avoid exercise－related hyper－or hypo－glycemia，individuals with type 1 DM should：（1）monitor blood glucose before，during，and after exercise；（2）delay exercise if blood glucose is＞14 mmol／L（250 mg／d L）and ketones are present；（3）if the blood glucose is＜5．6 mmol／L（100 mg／d L），ingest carbohydrate before exercising；（4）monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia；（5）decrease insulin doses（based on previous experience）before exercise and inject insulin into a nonexercising area；and（6）learn individual glucose responses to different types of exercise and increase food intake for up to 24 h after exercise，depending on intensity and duration of exercise．In individuals with type 2 DM，exercise－related hypoglycemia is less common but can occur in individuals taking either insulin or insulin secretagogues．

Because asymptomatic cardiovascular disease appears at a younger age in both type 1 and type 2 DM，formal exercise tolerance testing may be warranted in diabetic individuals with any of the following：age＞35 years，diabetes duration＞15 years（type 1 DM）or＞10 years（type 2 DM），microvascular complications of DM（retinopathy，microalbuminuria，or nephropathy），PAD， other risk factors of CAD，or autonomic neuropathy．2 Untreated proliferative retinopathy is a relative contraindication to vigorous exercise，as this may lead to vitreous hemorrhage or retinal detachment．

Monitoring the Level of Glycemic Control

Optimal monitoring of glycemic control involves plasma glucose measurements by the patient and an assessment of long－term control by the physician（measurement of hemoglobin A1c and review of the patient's self－measurements of plasma glucose）．3 These measurements are complementary：the patient's measurements provide a picture of short－term glycemic control，whereas the hemoglobin A1c reflects average glycemic control over the previous 2—3 months．

Self－Monitoring of Blood Glucose

Self－monitoring of blood glucose（SMBG）is the standard of care in diabetes management and allows the patient to monitor his or her blood glucose at any time．In SMBG，a small drop of blood and an easily detectable enzymatic reaction allow measurement of the capillary plasma glucose．

The frequency of SMBG measurements must be individualized and adapted to address the goals of diabetes care．4 Individuals taking multiple insulin injections each day should routinely measure their plasma glucose three or more times per day to estimate and select mealtime boluses of short－acting insulin and to modify long－acting insulin doses．Individuals with type 2 DM who are taking insulin should utilize SMBG more frequently than those on oral agents and who are on oral medications should utilize SMBG as a means of assessing the efficacy of their medication and the impact of diet．5 Since plasma glucose levels fluctuate less in these individuals，one to two SMBG measurements per day（or fewer in patients who are on oral agents or are diet－controlled）may be sufficient．Most measurements in individuals with DM should be performed prior to a meal and supplemented with postprandial measurements to assist in reaching postprandial glucose targets．

Devices for continuous blood glucose monitoring are the subject of intense investigation，as some systems have been approved by the FDA and others are in various stages of development．6 The use of these devices in routine diabetes management is limited，and they do not replace the need for a traditional glucose meter．This rapidly evolving technology requires substantial expertise on the part of the diabetes management team and the patient．Continuous glucose monitoring systems measure the glucose in interstitial fluid that is in equilibrium with the blood glucose．Alarms notify the patient if the blood glucose falls into the hypoglycemic range．The FDA refers to these as“minimally invasive”or“non－invasive”depending on how the interstitial fluid is obtained．Several devices use an indwelling subcutaneous catheter to monitor interstitial fluid glucose and provide either real time or retrospective glucose values．Although clinical experience with these devices is limited，they appear to provide useful short－term information about the patterns of glucose changes as well as an enhanced ability to detect hypoglycemic episodes．

Ketones are an indicator of early diabetic ketoacidosis and should be measured in individuals with type 1 DM when the plasma glucose is consistently＞16．7 mmol／L（300 mg／d L），during a concurrent illness or with symptoms such as nausea，vomiting，or abdominal pain．

（1，369 words）

New Words and Phrases

urine［'jʊərɪn］n． 尿

ketone［'kiːtəʊn］n． 酮

hypoglycemia［,haɪpəʊɡlaɪ'siːmɪə］n． 血糖过少，低血糖（症）

sucrose［'sjuːkrəʊs］n． 蔗糖

hyperlipidemia［'haɪpə,lɪpɪ'diːmɪə］n． 血脂过多，高脂血

postprandial［pəʊst'prændɪəl］a． 餐后的

calorie［'kælərɪ］n． 卡（路里）

micronutrient［,maɪkrəʊ'njuːtrɪənt］n． 微量营养素

chromium［'krəʊmiːəm］n． 铬

caloric［kə'lɒrɪk］a． 热量的

carbohydrate［,kɑːbəʊ'haɪdreɪt］n． 碳水化合物，糖类

bolus［'bəʊləs］n． 大丸药，冲击剂量

glucagon［'ɡluːkəɡɒn］n． 胰高血糖素

hyperglycemia［,haɪpəɡlaɪ'siːmɪə］n． 血糖过多，高血糖（症）

catecholamine［,kætɪ'kəʊləmiːn］n． 儿茶酚胺

glycogenolysis［,ɡlaɪkəʊdʒɪ'nɒlɪsɪs］n． 糖原分解（作用）

secretagogue［sɪ'kriːtəɡɒɡ］n． 促分泌素

microvascular［,maɪkrəʊ'væskjʊlə］a． 微脉管的

retinopathy［,retɪ'nɒpəθɪ］n． 视网膜病

microalbuminuria［,maɪkrəʊælbjuːmɪn'juːrɪə］n． 微量白蛋白尿

neuropathy［njʊə'rɒpəθɪ］n． 神经病

contraindication［'kɒntrə,ɪndɪ'keɪʃən］n． 禁忌证

vitreous［'vɪtriːəs］a． 玻璃（似）的；玻璃体的

hemorrhage［'hemərɪdʒ］n．＆v．（尤指大量的）出血，失血

retinal［'retɪnəl］a． 视网膜的

capillary［kə'pɪlərɪ］a． 毛细血管的

indwelling［ɪn'dwelɪŋ］a． 内在的；留置的

catheter［,kæθɪtə］n． 导管

nausea［'nɔːʃɪə］n． 作呕，恶心

vomit［'vɒmɪt］v．＆n． 呕吐

Notes

1．The ADA encourages patients and providers to utilize carbohydrate counting or exchange systems to estimate the nutrient content of a meal or snack．

参考译文：行动数据自动化系统有助于患者和护理人员使用碳水化合物计算或换算系统估算每餐或每份零食的营养素含量。

ADA：action data automation system（行动数据自动化系统）。

2．Because asymptomatic cardiovascular disease appears at a younger age in both type 1 and type 2 DM，formal exercise tolerance testing may be warranted in diabetic individuals with any of the following：age＞35 years，diabetes duration＞15 years（type 1 DM）or＞10 years（type 2 DM），microvascular complications of DM（retinopathy，microalbuminuria，or nephropathy），PAD，other risk factors of CAD，or autonomic neuropathy．

参考译文：由于无症状心血管疾病可出现在1型和2型年轻糖尿病患者身上，因此符合以下任何一项的糖尿病患者都应进行规范的运动耐量测试：年龄＞35岁，1型糖尿病病程＞15年或2型糖尿病病程＞10年，糖尿病微血管并发症（视网膜病、微量白蛋白尿或肾病），PAD，CAD的其他危险因素，或自发性神经病。

PAD：peripheral artery diseases（周围动脉病）；CAD：coronary artery disease（冠状动脉病）。

3．Optimal monitoring of glycemic control involves plasma glucose measurements by the patient and an assessment of long－term control by the physician （measurement of hemoglobin A1c and review of the patient's self－measurements of plasma glucose）．

参考译文：最佳血糖监控方式是患者自测血浆血糖，而医生则评估长期血糖控制情况（糖化血红蛋白A1c测量和患者血浆血糖自测结果分析）。

plasma glucose measurements和an assessment of long－term control是并列宾语。by the patient和by the physician是两个介词短语，做定语，分别修饰上述两个宾语。

4．The frequency of SMBG measurements must be individualized and adapted to address the goals of diabetes care．

参考译文：患者自己监测血糖的频率必须适合自身病情并进行调整以达到糖尿病护理的目的。

address：致力于；满足，实现。e．g．The government established new

policies to address the needs of the veterans．

5．Individuals with type 2 DM who are taking insulin should utilize SMBG more frequently than those on oral agents and who are on oral medications should utilize SMBG as a means of assessing the efficacy of their medication and the impact of diet．

参考译文：注射胰岛素的2型糖尿病患者自我监控血糖的频率应高于口服用药患者；口服降糖药物患者应把血糖自我监控作为评价用药效果和饮食影响的一种手段。

本句是由并列连词and连接的并列句。前一个分句的主语是Individuals， than those on oral agents是比较状语从句；后一个分句的主语是those （individuals）被省略，as a means of assessing．．．是介词短语，做状语。句中who are taking insulin和who are on oral medications都是定语从句，分别修饰两个分句的主语individuals。

6．Devices for continuous blood glucose monitoring are the subject of intense investigation，as some systems have been approved by the FDA and others are in various stages of development．

参考译文：用于持续监测血糖的一些设备仍在接受严格调查，因为一些监测系统虽已通过（美国）食品与药物管理局审验批准，而另一些尚处于不同的研发阶段。

FDA：Food and Drug Administration［（美国）食品与药物管理局］

Exercises

Ⅰ．Answer the following questions．

1．What do education topics important for optimal diabetes care include？

2．What is the goal of MNT in the individual with type 1 DM？

3．What benefits does exercise have？

4．What should individuals with type 1 DM do to avoid exercise－related hyperglycemia or hypoglycemia？

5．How do continuous glucose monitoring systems measure the glucose？

Ⅱ．Decide whether the following statements are True or False．

1．As for the general population，a diet that includes fruits，vegetables，fiber－containing foods，and high－fat milk is advised．

2．Presently，evidence does not support supplementation of the diet with vitamins，antioxidants（vitamin C and Vitamin E），or micronutrients （chromium）in patients with diabetes．

3．Hypocaloric diets and modest weight loss（5％—7％）often result in rapid and dramatic glucose lowering in individuals with new－onset type 1 DM．

4．If the insulin level is too low，the rise in catecholamines may increase the plasma glucose excessively，promote ketone body formation，and possibly lead to ketoacidosis．

5．Devices for continuous blood glucose monitoring are the subject of intense investigation，as some systems have been approved by the FDA and others are in various stages of development．