首页 中华糖尿病杂志 2022年14卷09期 中国糖尿病医学营养治疗指南（2022版）
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ENGLISH ABSTRACT
中国糖尿病医学营养治疗指南（2022版）
中国医疗保健国际交流促进会营养与代谢管理分会 
中国营养学会临床营养分会
中华医学会糖尿病学分会
中华医学会肠外肠内营养学分会
中国医师协会营养医师专业委员会
作者及单位信息
·
DOI： 10.3760/cma.j.cn115791-20220704-00324
Chinese guidelines of medical nutrition therapy in diabetes (2022 edition)
Nutrition and Metabolic Management Branch of China International Exchange and Promotive Association for Medical and Health Care
Clinical Nutrition Branch of Chinese Nutrition Society
Chinese Diabetes Society
Chinese Society for Parenteral and Enteral Nutrition
Chinese Clinical Nutritionist Center of Chinese Medical Doctor Association
Chen Wei
Authors Info & Affiliations
Nutrition and Metabolic Management Branch of China International Exchange and Promotive Association for Medical and Health Care
Clinical Nutrition Branch of Chinese Nutrition Society
Chinese Diabetes Society
Chinese Society for Parenteral and Enteral Nutrition
Chinese Clinical Nutritionist Center of Chinese Medical Doctor Association
Chen Wei
Department of Clinical Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
·
DOI： 10.3760/cma.j.cn115791-20220704-00324
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摘要
医学营养治疗（MNT）是糖尿病综合治疗的基础，是糖尿病病程中任何阶段预防和控制必不可少的措施。2010年，由中国医师协会营养医师专业委员会联合中华医学会糖尿病学分会共同制定了中国首个糖尿病MNT指南，并于2015年更新。近7年来，糖尿病MNT和代谢治疗领域也取得了诸多突破性进展，由中国医疗保健国际交流促进会营养与代谢管理分会组织来自中国营养学会临床营养分会、中华医学会糖尿病学分会、肠外肠内营养学分会和中国医师协会营养医师专业委员会的相关领域专家，启动了《中国糖尿病医学营养治疗指南（2013）》的修订工作，内容涉及糖尿病营养预防、治疗、并发症防治、人工甜味剂及新型植物化学物、肠外肠内营养支持等诸多领域。指南制定过程中严格按照方法学的要求，参照《中国制订/修订临床诊疗指南的指导原则（2022版）》的要求，坚持基于患者问题为导向、证据级别与推荐并重、服务于临床的宗旨，结合中国临床实践提出问题及进行证据采集，形成了《中国糖尿病医学营养治疗指南（2022版）》，旨在指导和规范临床MNT。
糖尿病;医学营养治疗;膳食模式;营养支持;糖尿病前期;糖尿病并发症
引用本文
中国医疗保健国际交流促进会营养与代谢管理分会,中国营养学会临床营养分会,中华医学会糖尿病学分会,等. 中国糖尿病医学营养治疗指南（2022版）[J]. 中华糖尿病杂志,2022,14(09)：881-933.
DOI:10.3760/cma.j.cn115791-20220704-00324PERMISSIONS
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目录
第一章 医学营养治疗概述 885
第二章 糖尿病医学营养治疗流程 886
第三章 医学营养治疗中营养相关要素对糖尿病的影响 886
一、能量 886
问题1：糖尿病患者适宜的能量范围是多少？887
问题2：低热量饮食/极低热量饮食是否有助于T2DM患者的血糖管理？887
问题3：间歇性能量限制/持续性能量限制对T2DM患者糖脂代谢和体重有何影响？887
二、碳水化合物 888
问题4：摄入碳水化合物的量对于控制血糖、胰岛素水平及并发症危险因素有何影响？888
问题5：不同食物来源的碳水化合物对于控制血糖、胰岛素水平和并发症及其危险因素有无影响？888
问题6：膳食纤维（非补充剂或额外添加）的含量和来源对于控制血糖及并发症有何影响？888
问题7：特定碳水化合物（蔗糖、果糖）对于控制血糖、胰岛素水平等有何影响？889
三、脂肪 889
问题8：T2DM患者每日膳食总脂肪及各类脂肪酸的推荐摄入量是多少？889
问题9：糖尿病患者是否需要限制胆固醇摄入？889
问题10：补充ω-3多不饱和脂肪酸对T2DM是否有利？890
四、蛋白质 890
问题11：肾功能正常的糖尿病患者蛋白质摄入量占总摄入能量的比例是多少？增加蛋白质摄入是否有助于控制血脂和血糖？890
问题12：乳清蛋白、大豆蛋白对糖尿病患者血糖及体重有何影响？890
五、维生素及微量元素 890
问题13：补充维生素E对于糖尿病患者有何影响？891
问题14：补充叶酸对糖尿病患者有何影响？891
问题15：糖尿病前期人群及糖尿病患者补充维生素D有何影响？891
问题16：复合维生素及矿物质联合补充对T2DM患者有何影响？891
问题17：补充铬是否对糖尿病有益？892
六、甜味剂 892
问题18：营养性甜味剂对控制血糖、胰岛素等有何影响？892
问题19：非营养性甜味剂对控制血糖、胰岛素及体重有何影响？892
问题20：酒精及酒精饮料对血糖控制有何影响？893
七、植物化学物 893
问题21：植物化学物多酚对于T2DM患者调节血糖有何影响？893
问题22：大豆异黄酮对糖尿病患者的炎症及并发症有何影响？893
第四章 膳食结构 894
问题23：地中海饮食是否可以预防T2DM的发生，能否改善血糖、血脂控制，降低心血管疾病的风险？894
问题24：终止高血压膳食疗法饮食是否可以预防T2DM发生？能否改善T2DM的血糖和血脂，降低心血管疾病的风险？894
第五章 益生菌及益生元 894
问题25：补充益生菌对T2DM患者的糖代谢有何影响？895
问题26：补充益生元能否帮助T2DM患者改善血糖控制？895
问题27：补充合生元是否有利于T2DM患者改善血糖？895
问题28：补充益生菌/益生元/合生元对T1DM患者的血糖控制有何影响？896
第六章 糖尿病营养教育与管理 896
问题29：糖尿病教育对糖尿病发病风险是否有影响？896
问题30：糖尿病营养教育及运动指导对糖尿病患者体重及血糖控制是否产生影响？897
一、升糖指数及血糖负荷 897
问题31：低升糖指数/血糖负荷饮食是否有助于糖尿病患者控制血糖？897
问题32：低升糖指数/血糖负荷饮食是否有助于糖尿病患者并发症的控制？897
二、食物交换份 898
问题33：食物交换份法是否有助于糖尿病患者控制血糖水平？898
问题34：相较于传统食物交换份法，基于低血糖负荷的食物交换份法是否利于血糖控制？898
三、碳水化合物计数法 898
问题35：对于T1DM患者采用碳水化合物计数法能否有助于血糖控制？898
问题36：碳水化合物计数法对于T2DM患者的血糖控制是否有帮助？898
第七章 糖尿病特殊人群 899
一、儿童青少年糖尿病 899
问题37：儿童青少年T1DM患者中不同的饮食模式对血糖及代谢有何影响？899
问题38：蛋白质摄入对儿童青少年T1DM患者的代谢和胰岛素治疗有何影响？899
问题39：维生素D对于儿童青少年T1DM患者有何影响？900
问题40：营养减重干预对于超重和肥胖的儿童青少年T1DM和T2DM患者的血糖有何影响？900
二、妊娠期糖尿病 900
问题41：孕期补充叶酸是否有利于降低妊娠期糖尿病的风险？901
问题42：孕期摄入植物蛋白是否有利于降低妊娠期糖尿病的风险？901
问题43：低升糖指数饮食对妊娠期糖尿病血糖控制有何影响？901
问题44：糖尿病特定营养制剂能否改善妊娠期糖尿病的临床结局？901
问题45：妊娠期糖尿病患者是否需要补充膳食纤维？902
问题46：妊娠期糖尿病患者是否需要补充微量营养素？902
三、老年糖尿病 902
问题47：老年糖尿病患者应摄入多少能量为宜？902
问题48：增加蛋白质摄入对老年糖尿病患者有何影响？903
问题49：老年糖尿病患者是否需要补充维生素和微量元素？903
四、糖尿病前期 903
问题50：在糖尿病前期进行生活方式干预是否有助于延缓T2DM发病及并发症的发生？903
问题51：对于超重/肥胖的糖尿病前期人群，减重是否可以减少T2DM发生？903
问题52：在糖尿病前期人群中，精准营养治疗是否有利于血糖管理及预防T2DM发生？903
第八章 糖尿病相关并发症与医学营养治疗 904
一、代谢手术与营养 904
问题53：T2DM患者行代谢术后是否需要补充蛋白质？904
问题54：T2DM患者代谢术后是否需要补充铁？904
问题55：T2DM患者代谢术后是否需要补充钙和维生素D？904
问题56：T2DM患者代谢术后是否需要补充维生素B？904
问题57：T2DM患者代谢术后是否需要补充维生素A？905
问题58：T2DM患者如何预防代谢术后低血糖？905
问题59：如何通过围术期营养管理促进T2DM患者的代谢手术效果？905
问题60：T2DM患者代谢术后应如何进行长期营养管理？905
问题61：对于代谢术后糖尿病缓解效果不佳者，应如何进行营养管理？906
二、创伤及围术期血糖控制 906
问题62：合并应激性高血糖应选择何种营养支持方式？906
问题63：应激性高血糖可以使用糖尿病特定肠内营养制剂吗？907
问题64：危重症患者发生应激性高血糖时血糖目标应该控制在何种范围？907
三、肠外肠内营养支持 908
问题65：糖尿病住院患者的营养风险/营养不良高于非糖尿病住院患者吗？908
问题66：糖尿病特定肠内营养制剂对血糖的影响优于全营养型标准配方制剂吗？908
问题67：糖尿病实施特定肠内营养治疗是否有卫生经济学改善？908
四、糖尿病肾脏病及透析期 908
问题68：糖尿病肾脏病患者如何预防营养不良？909
问题69：合并营养不良的糖尿病肾脏病患者应该如何改善营养状况？909
问题70：合并高磷血症的糖尿病肾脏病患者如何改善血磷状况？909
问题71：糖尿病肾脏病需要常规补充维生素D或其类似物吗？909
五、糖尿病并发脂代谢紊乱 910
问题72：膳食脂肪酸来源对T2DM患者脂代谢有何影响？910
问题73：膳食来源的胆固醇对糖尿病患者心血管事件发生的影响？910
六、糖尿病合并神经病变 910
问题74：补充维生素B12衍生物（甲基钴胺素）是否对糖尿病神经病变有改善作用？911
问题75：α-硫辛酸是否对糖尿病神经病变有改善作用？911
问题76：补充维生素D是否对糖尿病神经病变有改善作用？911
七、糖尿病足 911
问题77：补充精氨酸等药理作用的氨基酸是否对糖尿病足溃疡愈合有影响？911
问题78：补充维生素D是否对糖尿病足溃疡愈合有影响？912
问题79：补充锌是否对糖尿病足溃疡愈合有影响？912
问题80：补充镁是否对糖尿病足溃疡愈合有影响？912
第九章 药物治疗与营养 912
问题81：GLP-1受体激动剂是否有助于合并肥胖/超重的T2DM患者减重？912
问题82：GLP-1受体激动剂影响机体的肌肉状况吗？913
问题83：SGLT2i可以降低体重吗？913
问题84：SGLT2i会影响机体的骨代谢吗？914
问题85：应用SGLT2i的糖尿病患者是否需要进行特殊的膳食管理？914
问题86：二甲双胍是否会引起维生素B12缺乏？914
参考文献 915
近50年来，全球糖尿病患病率以惊人的速度增长。根据国际糖尿病联盟2019年公布的数据，全球共有4.63亿人患有糖尿病，也就是平均每11个成人中就有1个糖尿病患者，预计到2045年糖尿病人数将跃升至7亿
［
1
］
。中华医学会糖尿病学分会发布的《中国2型糖尿病防治指南（2020年版）》中，根据2015至2017年全国流行病学调查结果报告，我国成人糖尿病患病率已达11.2%
［
2
］
，糖尿病已经成为严重影响国人身心健康的主要公共卫生问题。
医学营养治疗（medical nutrition therapy，MNT）是糖尿病综合治疗的基础，是糖尿病病程中任何阶段预防和控制都必不可少的措施。自1971年美国糖尿病学会（American Diabetes Association，ADA）首次颁布《糖尿病患者营养与饮食推荐原则》
［
3
］
以来，每年都会更新糖尿病个体化营养治疗原则。2010年，由中国医师协会营养医师专业委员会联合中华医学会糖尿病学分会共同制定了中国首个糖尿病MNT指南，并于2015年更新
［
4
］
。近7年来，糖尿病MNT和代谢治疗领域也取得了诸多突破性进展，由中国医疗保健国际交流促进会营养与代谢管理分会组织来自中国营养学会临床营养分会、中华医学会糖尿病学分会、肠外肠内营养学分会和中国医师协会营养医师专业委员会的相关领域专家，启动了《中国糖尿病医学营养治疗指南（2013）》的修订工作，内容涉及糖尿病营养预防、治疗、并发症防治、新型植物化学物、肠外肠内营养支持等诸多领域。编写组严格按照方法学的要求，通过系统的文献检索，收集支持证据并对证据进行质量和推荐意见分级（
表1
，
2
），还参照《中国制订/修订临床诊疗指南的指导原则（2022版）》
［
5
］
，完成了指南的国际注册。《中国糖尿病医学营养治疗指南（2022版）》依然坚持基于患者问题为导向、证据级别与推荐并重、服务于临床的宗旨，将推荐分级的评估、制定与评价（grade of recommendation assessment，developmentand evaluation，GRADE）协作网Ⅱ的标准作为质控标准，结合中国临床实践提出问题及进行证据采集。基于已获得的证据力度，结合研究设计、质量以及临床一致性和实用性的评估，形成推荐意见，对于有分歧的推荐意见，采用“德尔斐法则”，通过编写支持小组与各专业领域的专家们讨论，达成“循证共识”进而解决分歧。
| 文献检索信息 | 具体描述 |
|---|---|
| 文献时间 | 2000年1月1日至2021年12月31日 |
| 语言 | 英语，汉语 |
| 数据库 | 一级数据库包括Medline、EMBASE、Web of Science、中国生物医学文献数据库等，二级数据库包括Guideline Clearing House、Cochrane Library、Sum Search等 |
| 筛选项目 | 人类 |
| 文献出版类型 | 指南、Meta分析、系统评价、随机对照试验、观察研究、病例报告、共识意见 |
| 主要检索词 | diabetes、nutrition、糖尿病、营养。各章节根据内容进一步确定相关领域内的检索词 |
展开表格
证据检索信息
| 分级系统和推荐强度 | 具体描述 |
|---|---|
| 证据强度分级 | |
| 高（A） | 非常确信估计的效应值接近真实的效应值，进一步研究也不可能改变该估计效应值的可信度 |
| 中（B） | 对估计的效应值确信程度中等，估计值可能接近真实的效应值，但仍存在二者不相同的可能性，进一步研究有可能改变该估计效应值的可信度 |
| 低（C） | 对估计的效应值确信程度有限，估计值与真实的效应值可能大不相同，进一步研究极有可能改变该估计效应值的可信度 |
| 极低（D） | 对估计的效应值几乎没有信心，估计值与真实值很可能完全不同，对效应值的任何估计都很不确定 |
| 推荐强度分级 | |
| 强推荐 | 明确显示干预措施利大于弊或弊大于利 |
| 弱推荐 | 利弊不确定或无论质量高低的证据均显示利弊相当 |
展开表格
GRADE证据强度和推荐强度分级系统
注：GRADE为推荐分级的评估、制定与评价
本指南每一章节内容均按“背景-问题-推荐意见-证据简述”的基本框架进行阐述
［
4
，
6
］
。关键性临床问题部分按照“对象（patient，P）、干预措施（intervention，I）、对照（comparison，C）、结局指标（outcome，O）、研究类型（study，S），简称PICOS”格式进行定义：在何种人群，采用何种干预措施/诊断试验可能会带来怎样的结局，这种干预措施/诊断试验若存在其他的替代/对照措施，相比较之下是否更好/更差/相似。例如，针对“限制能量饮食是否有助于超重/肥胖2型糖尿病（type 2 diabetes mellitus，T2DM）患者的血糖和管理”这一问题，先根据临床问题检索证据并进行证据合成，形成推荐意见；再总结关键性临床问题的证据，并充分考虑卫生经济学效应后得出结论。当一项干预措施的益处超过其风险且经济上可负担时，推荐意见为“强推荐”；当获益减弱或风险增加时，推荐意见降级为“弱推荐”；反之，当风险大于益处或获益甚少而经济上负担甚大时，推荐意见为“强烈不推荐”或“不推荐”。当证据不足或高质量证据很少时，可以给出专家意见，同样需要考虑获益与风险及其经济负担。进行推荐时，不仅要考虑证据质量，还需要考虑利弊平衡、患者价值观以及经济成本，具体的因素分析及示例参照
表3
。
| 因素 | 解释说明 | 示例 | |
|---|---|---|---|
| 强推荐 | 弱推荐 | ||
| 证据质量 | 证据质量越高，越适合强推荐，反之亦然 | 短期内（<1年）限制能量饮食有助于超重/肥胖糖尿病患者的体重和血糖管理 | 推荐营养不良的糖尿病肾脏病患者口服肾病专用型营养补充剂 |
| 利弊平衡 | 利弊间的差别越大，越适合强推荐，反之亦然 | 血糖指数/负荷较高的饮食会显著增加健康人群患2型糖尿病的风险 | 极低热量饮食短期内有助于改善2型糖尿病患者的空腹血糖、胰岛素抵抗、糖化血红蛋白、体重等；因实施过程中可能出现不良反应，不推荐2型糖尿病患者长期接受极低能量（<800 kcal/d）的营养治疗 |
| 价值观或偏好 | 患者之间的价值观和偏好越趋同，越适合强推荐，反之亦然 | 糖尿病前期或糖尿病人群应常规进行医学营养治疗评估，并由具备经验的临床营养（医）师或糖尿病医师给予个体化医学营养治疗 | 基于集中教育，联合经济激励和行为干预实施群体减重 |
| 成本 | 干预措施的花费越少，消耗的资源越少，越适合强推荐，反之亦然 | 对糖尿病前期人群进行生活方式干预可延缓2型糖尿病的发病，降低心血管事件、微血管并发症以及心血管和全因死亡率 | 与饮食咨询或口服补充剂相比，透析中肠外营养对改善糖尿病肾脏病的临床结局并无明显优势 |
展开表格
影响推荐强度的因素及示例
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备注信息
A
陈伟，中国医学科学院 北京协和医学院 北京协和医院临床营养科，北京 100730，Email：
mocdef.aabnisiewnehcxt
B
中国医疗保健国际交流促进会营养与代谢管理分会, 中国营养学会临床营养分会, 中华医学会糖尿病学分会, 等. 中国糖尿病医学营养治疗指南（2022版）[J]. 中华糖尿病杂志, 2022, 14(9): 881-933. DOI: 10.3760/cma.j.cn115791-20220704-00324.
C
IPGRP-2021CN029
D
所有参编人员声明：未接受任何利益相关公司的赞助，未持有任何利益相关公司的股票，未持有任何与本指南涉及领域的专利，均无利益冲突
E
北京市科学技术委员会项目 (Z191100008619006)
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